for the Coder/Biller Amber Condren, BS, B Ed, CPC, CEMC, CHA, CMDP - - PowerPoint PPT Presentation

CDI and Risk Adjustment for the Coder/Biller

Amber Condren, BS, B Ed, CPC, CEMC, CHA, CMDP AHIMA ICD-10-CM/PCS Approved Trainer Senior Managing Consultant

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The speaker has no financial relationship to any products or services referenced in this program. The program is intended to be informational only. The speaker is not an authoritative source by

• law. Attendees are advised to reference payer specific provider

manuals, on-line or otherwise, for verification prior to making changes to their coding, documentation and/or billing practices.

Disclaimer

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Agenda

For this session:

• We will discuss the importance of risk adjustment codes and how to

accurately capture them in both the inpatient and outpatient setting.

• Cover best-practices for compliant queries to perpetrate the accuracy

and of quality of documentation to ensure that all codes are documented and reported to their highest level of specificity.

• And explore options for how coders and the CDI experts can work

together to achieve the goals of the organization.

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What We Know About Risk Adjustment

• Risk Adjustment (RA) is a statistical process that takes into account the

underlying health status and health spending of the enrollees in an insurance plan when looking at their health care outcomes or health care costs.

https://www.healthcare.gov/glossary/risk-adjustment/

• Risk adjustment is an actuarial tool used to calibrate payments to health

plans or other stakeholders based on the relative health of the at-risk populations.

• A well-designed risk-adjustment system is one that properly aligns incentives, limits

gaming, and protects risk-bearing entities (e.g., insurers, health plans).

https://www.actuary.org/pdf/health/Risk Adjustment Issue Brief Final 5-26-10.pdf

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Why is RA Important?

• Predictive modeling – An analytical review of know data elements to

establish a hypothesis related to the future health care needs of a patient with varying certainty.

• Risk Adjustment is a method to evaluate and measure all patients on an

equal scale – levels the playing field

• Analyzes and reviews current and past medical conditions to predict future

costs.

• Concept was introduced to minimize the incentive to choose enrollees

based on their health status and encourage competition among health plans based on quality, efficiency, and premium stabilization.

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Important Items to Remember

• There is more than one risk-adjustment model.
• Each model may contain different HCCs.
• You must look at each model.
• Must be familiar with ICD-10-CM guidelines
• Must be familiar with how to look up ICD-10-CM codes in either the

alphabetic or tabular index.

• And when reporting RA codes, sequencing does not apply.

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Acronym Description Definition

RAF Risk Adjustment Factor Total score of all risk factors for one patient for a total year. It is used to predict future healthcare costs for health plan enrollees. HCC Hierarchical Condition Categories A value that contributes to an aggregated reimbursement that reflects the severity of the patient’s illness, to pay for resources projected for patient care. RADV Risk Adjustment Data Validation Random or targeted review of MA plans CDI Clinical Documentation Improvement Ensuring the content of the medical record accurately represents the status of the patient’s health. RAPS Risk Adjustment Processing System The systems through which risk adjustment data is processed EDPS Encounter Data Processing System CMS is transitioning from RAPS to EDPS which will allow for risk adjustment payments to include more detailed records

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How Does This Affect Reimbursement?

• Each patients entire risk profile must be documented in the medical
• record. These will be completely coded on the claims and any other

encounter data.

• RA will assist in improving the overall patient care.
• May affect the financial health of the practice and/or the facility.
• Using a predictive analysis to predict future costs and reimbursement.
• Will be used to forecast trends and future needs of patients.

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Preparation Steps

• Standardize Processes
• For medical record documentation, coding, queries, etc. This will help

minimize disruption and keep the process flowing.

• Develop Internal Checkpoints
• Theses checkpoints should be for the most common documentation and

coding errors/questions. They should be set up prior to processing claims or submitting documentation. CDI’s are valuable in this area.

• Utilize Tools and Resources
• This will help identify incomplete coding and/or documentation. CDI’s can

also assist in this area.

• Review
• Reviewing documentation for errors, specificity for capturing the complete
• code. This area most pertains to the CDI’s.

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Patient Risk Scoring

In order to accurately reflect a patient’s risk profile, more than the standard ICD codes, commonly seen in current billing practices, are required. HCC

Categories

ICD-10-CM codes that report to HCC categories

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Audit & Compliance

• Review audits to verify:
• The accuracy and specificity of the diagnosis codes for submission.
• The documentation supports the diagnoses codes.
• Verify the providers signature
• The providers credentials (MD, DO, PA, NP, LCSW, OT, PT, etc.)

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Coding Guidelines

Please Note: The inpatient coding guidelines are only referred to when a full inpatient record is being reviewed as one encounter (one stay). Outpatient coding guidelines are used if stand-alone documents such as discharge summaries, inpatient consults, etc., are for the provider and coded separately as single encounters.

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Inpatient Coding Guidelines

General guidance applicable to coding inpatient facility records using inpatient coding guidelines.

• 1. Confirm the admission and discharge dates are evident in the record.

These should typically appear on the Discharge Summary.

• 2. Confirm that the encounter was ordered as an “admission.” Encounters

that are ordered as an “observation” should be coded using outpatient coding guidelines with the admission date as the from/thru date (even if the discharge occurred 1-2 days later). Observation encounters are not classified as true admissions and must be coded as an outpatient encounter.

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Inpatient Coding Guidelines

• 3. In order for the record to be supported as an inpatient record, confirm

that a minimum set of inpatient documents are present (admission record, discharge summary, history & physical, physician orders/physician progress notes/consultation reports, procedure reports [if applicable]).

• 4. Confirm the Discharge Summary is compliantly signed (see Signature

guidance pages 7-8).

• 5. Code capture all current conditions listed on the discharge summary that

meet inpatient coding guidelines and received treatment.

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Inpatient Coding Guidelines

• 6. Uncertain diagnosis. If the diagnosis at the time of discharge is qualified as

“probable,” “suspected,” “likely,” “questionable,” “possible,” “still to be ruled

• ut,” or other similar terms indicating uncertainty, code the condition as if it

existed or were established. The basis for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis. Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term, and psychiatric facilities. (Per ICD-10-CM guidelines Section

• II. H.)
• a. Ruled-out conditions upon discharge should not be coded

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Inpatient Coding Guidelines

• 7. When applicable, code any chronic conditions that received treatment and

met requirement.

• 8. When applicable, further specificity of a condition that is listed as a final

diagnosis may be obtained from procedure or pathology reports. Ex. Femur fracture that is further specified to site and laterality on an x-ray)

• 9. Review all documents that are pertinent to the stay and query if further

clarification is needed.

• 10. A Discharge Summary report is not required for lengths of stay less than

48 hours. In lieu of a discharge summary, a final discharge progress note is acceptable when a list of final discharge diagnoses, final disposition and follow-up is documented by the attending physician.

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Outpatient Coding Guidelines

General guidance applicable to coding outpatient records using outpatient coding guidelines.

• 1. Only one date of service is an encounter. Unlike inpatient where the

entire stay is coded as one encounter.

• 2. There are 7 components of each encounter.
• History
• Exam
• Medical Decision Making
• Counseling
• Coordination of Care
• Nature of the Presenting Problem
• Time

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Outpatient Coding Guidelines

• 3. The History has 6 elements:
• History of present Illness (HPI)
• Review of Systems (ROS)
• Past Medical History
• Family History
• Social History
• Past, Family, Social Histories (PFSH)
• 4. ROS and PFSH may be recorded at an earlier encounter and does not

need to be re-recorded if there is evidence that the provider reviewed and updated the previous information. The date of the previous encounter should also be documented.

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Outpatient Coding Guidelines

• 5. The Chief Complaint (CC) is a concise statement stating the reason for the

encounter.

• 6. The HPI is a chronological description of the development of the patient’s illness.
• 7. The ROS is an inventory of the body systems to identify signs and/or symptoms

that the patient is or has experienced.

• 8. Past history are past illnesses, hospitalizations/operations, treatments, etc. that

the patient has experienced.

• 9. Family history is the medical events of the patient’s family, including those

conditions that are hereditary or are related to the patient's current condition.

• 10. Social history is an age appropriate review of past and current activities.

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Outpatient Coding Guidelines

• 11. The Exam is the specific abnormal and relevant findings of the

examination of the affecter area or areas. These should be thoroughly documented.

• 12. The Medical Decision Making has 3 elements
• The number and type of diagnosis
• The amount and complexity of data reviewed
• Risk of complications and/or morbidity/mortality
• 13. ‘Rule outs’, ‘suspected’, ‘probable's’, etc. are not coded for
• utpatient services only code definitive diagnosis. In lieu of a definitive

diagnosis, the signs and symptoms should be reported.

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Outpatient Coding Guidelines

• 14. Documentation for counseling/coordination of care using time have specific

rules.

• 15. Any conditions that are ‘ruled out’ should not be reported.
• 16. The assessment should have the diagnosis, their treatment plan and also

include any medications, tests, or other treatment options.

• 17. Provider must have a valid and timely signature
• 18. Date of service should be clearly stated.
• The date of service is the date of the face to face encounter and not the date of dictation,

date the documentation was signed or reviewed.

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Importance of Documentation

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Documentation Tips

“History of”

• “History of” means the patient no longer has the condition; it has resolved and is

not a current chronic or a controlled on-going problem.

• Incorrect documentation of “History of”:

❖Documenting chronic conditions that are not in an acute phase as “history of”. ❖Documenting previous resolved conditions as current and/or active. ❖There are few exceptions when documenting “history of” with certain status conditions.

• Documentation Examples:

❖Incorrect: Patient has a history of COPD that is well controlled with medication. ❖Correct: Patient has COPD and is well controlled with Spiriva

• Even though inpatient capture the chronic conditions listed in the past medical history,

best practices is to document them and any associated treatment in the assessment.

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Documentation Tips

A sample of some of the terminology that can be used to document chronic conditions:

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Assessment Plan of Care

Stable Discontinue Medication Improved Continue to Monitor Worsening Make a referral Medication (tolerating/not tolerating) Continue or Change Medication

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Documentation Tips

Outpatient

• All chronic conditions must be assessed

and reported annually

• COPD, DM, CHF
• Any co-existing acute conditions
• Insulin defendant, high blood sugars
• Active status conditions
• Dialysis
• Pertinent past conditions
• Other underlying medical condition

Inpatient

• Chronic conditions are reported per

inpatient stay.

• COPD, DM, CHF
• Co-existing acute conditions
• COPD w/ acute exacerbation
• Active status conditions
• HIV
• Other pertinent past conditions
• Old MI

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Documentation Tips

• Documentation should be concise in order to report the most specific diagnosis.
• For example:
• The documentation states severe depression, this could be better documented as major depression,

severe, recurrent.

• Linking terminology will assist in selecting the most specific diagnosis.
• ‘Due to’, ‘in conjunction with’, ‘related to’, etc.…
• Supporting terminology will also assist in selection of the most appropriate diagnosis.
• Stable, controlled, worsening, improving, severe, etc.
• Other terminology for specificity
• Signs and symptoms
• Test results (normal or abnormal)
• Reason they are being seen or admitted
• Acuity

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Documentation Tips

• Be graphic by fully illustrating the visit.
• The more specificity, the better.
• What are the thought processes that resulted in a final diagnosis?
• This is very helpful when ‘ruling out’ diagnosis.
• Make a case for the work performed.
• Use key terms.
• What were the results of treatment(s)?
• Document total time spent with patient
• Document time for counseling/coordinating care when applicable.

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Documentation Tips

• Avoid terminology that is vague or has more than one meaning.
• Comorbidities – cause and effect should be clearly documented
• Modifying factors should be clearly documented
• Re-read documentation to make sure there is no conflicting information.
• For example: The HPI states, patient reports back and knee pain. And the assessment back and

knee pain resolved.

• Documentation should be very specific and fully illustrate the visit/encounter.
• Needs to include details of what took place during the visit
• Documentation needs to be clear and concise but paint a good over all picture of the encounter.
• It’s all in the DETAILS!!

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Documentation and the CDI

• CDIs are not part of the treating team. They should not document

diagnosis, order treatments, order consults in the medical record.

• CDIs can not assume both roles even though their scope of practice

may allow this. It could be considered fraudulent.

• One job per “record”

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CDI and Coders

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Clinical vs Coding

• Clinical documentation and the documentation needed for the most

accurate coding have a disconnect.

• The same goes for the rules for correct coding and how providers are

taught to practice medicine.

• Though ICD-10 is more clinical than ICD-9 there are still a lot of areas

that are disconnected.

• This disconnect leads to frustration for both the providers and the

coder.

• Subsequently the CDI was developed to help bridge that

understanding gap.

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CDI’s

• Began in the 1990s
• ACDIS created the 1st nationally recognized CDI credential, May 2009
• ACDIS is the leading authority for CDI
• The official coding guidelines and cooperative party guidance applies

to CDI professionals

• AHIMA is the HIM coding authority
• There are now CDI certifications for the outpatient as well.

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CDI’s Role

• Though the original role of the CDI was for DRG validation their role

has expanded to include documentation enhancement for the most accurate coding, through:

• Continued monitoring
• Queries
• CMI (case mix index)
• Documentation accuracy & continuity
• Knowing the documentation rules
• Knowing the coding rules
• Assisting the coder and medical staff to translate the providers

documentation

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CDI Goals

• Facilitate a concise and accurate medical record by identifying and

clarifying vague and/or missing diagnosis. This reflects in a record that is:

• Accurately coded –
• Promote accurate reimbursement
• The quality of the care
• Severity of Illness (SOI)
• Coding that reflects the providers intent
• Appropriate profiles of the hospital and provider

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Coders Role

• To interpret the documentation into codes in order to submit for

payment.

• Verify POA (present on admission) for inpatient
• Medical Necessity
• Verify that the guidelines followed
• Verify clinical indicators in inpatient documentation
• Queries

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Coders

• Need the complete record to code accurately.
• Is the documentation sufficient to support the codes?
• The sequence of the codes
• Which code to assign with which clinical indicators.
• Guideline 19
• Chronic conditions that need to be reported.
• Have rigorous productivity metrics & accuracy rate is monitored
• Most inpatient coders have little if any interaction with the

providers/staff.

• And most outpatient coders do not have CDI’s for clarification.
• Coders have the final say on what codes are reported.

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Diagnosis codes are important.

• Misconception – Providers are not paid based on diagnosis codes
• Fact – Diagnosis codes trigger denials or improper payments based on

medical necessity

• Fact – Providers are scored based on the information on a claim.

Incorrect or unspecified codes can lead to incorrect scoring

• Fact – Payment methodologies are shifting. Diagnosis codes will play

a role in provider reimbursement. Here comes Risk Adjustment!

• Fact – Data used to determine new payment methodologies comes

from claims submitted now. Think RA

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Why are diagnosis codes important?

• Diagnosis codes that do not correlate with medical necessity result in

denials

• More payors are denying unspecified codes
• Sometimes unspecified codes are the only choice.
• Incorrect diagnoses codes could result in improper payments and

increase a provider’s chance for an audit by government and/or commercial payors.

• As diagnoses codes become part of payment methodology, RA, the

more payors will scrutinize accuracy.

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Collaboration

• Coders & CDIs need to work together to avoid duplication of work.
• Need to work collaboratively so that their work compliments each
• thers.
• Minimize provider confusion
• Have a process in place for queries

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The Physicians The Coders The CDI’s

The Clinical Documentation Team

Primary Focus

CDI – ensuring appropriate documentation to support code

• assignment. They do not assign the codes.

Coders – to assign the appropriate codes that are supported by the documentation to be reported.

Each one should have a clear and established mission that complements each

• ther.

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What is the purpose of a Query?

The purpose of a query is clarification.

It is to clarify documentation from provider language to coder ease and back again. For the most accurate documentation and coding of the medical record.

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Who is responsible for writing the Query?

The CDI Vs The Coder

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Who is responsible for writing the Query?

The CDI

• Most CDI’s have a clinical background
• Have worked in the clinical setting
• Have a working knowledge of correct documentation
• Most do not have a coding background

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Who is responsible for writing the Query?

The Coder

• Have many years of coding experience
• Have a working knowledge of correct documentation
• May or may not have worked in a clinical setting
• Most do not have a clinical background

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Who is responsible for writing the Query?

• Either the Coder or the CDI can write the query as long as all query

guidelines and rules are met.

• This pertains more to inpatient than outpatient because as of now there are

not rules for outpatient queries.

• The policies of the facility/practice will determine who should write

the query.

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Importance of a Query

Queries are a very important element in the documentation of a complete medical record. They clarify unspecified diagnosis, link information, and unite all the various parts of the record. This leads to the most accurate coding, which in turn, leads to the maximum revenue/reimbursement.

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A Leading Query

This would be a query that is worded in such away that the provider is lead to a specific diagnosis. Leading the provider to a specific diagnosis is not allowed!

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A Legal Query

A legal query is written for clarification purposes by stating what is documented and asking what is being treated, what indicators were used, etc. This can be done by an open-ended question or by giving the provider a list of options to choose from.

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What information should be included in a Query?

• Patient name
• DOS
• Patient MRN or Account number
• Date of Query
• Physician’s name
• Statement of the issue for the query
• Name and contact information of the person requesting the query

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Answered Queries

• The provider should sign and date the query upon answering
• Does the query need to be kept as part of the medical record?
• If the provider answers on the query form, then best practices is to have the

query attached to the documentation in questions.

• If the provider answers as an addendum to the documentation, then the

query may not need to be kept

• This is left to the facility/practice to establish
• Queries should be tracked for timeliness of answering for timely filing.
• The facility/practice needs to set up guidelines for answering queries.

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A Query should NEVER be used to question the judgment of a provider. Documentation clarification is the only reason for a Query.

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Diagnosis Codes

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Two Patients, Same Diagnosis, Different Care

• Many patients have the same diagnosis but different plans of care.

These are due to each patient's individual health status.

• Age
• Comorbidities
• Overall health of the patient
• The difference is Risk Adjustment.

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Health Status Codes

• Certain health status codes are important to assess, document and

code annually.

• Patients that are undergoing dialysis
• Amputation status
• HIV status
• Ostomy (specified site)

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Oncology

• Malignancies should only be documented when the patient has

evidence of current disease. If the patient had surgical intervention, radiation or chemotherapy and there is no evidence of current illness then the ‘history of’ code is reported.

• Examples:
• If the patient elected not to receive any treatment, then report as it is an

active disease, for instance patient decides on pain management verses intervention.

• If the patient completes treatment successfully then code as ‘history of’,

for instance mastectomy for breast cancer.

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Stroke Coding

• A stroke (CVA) is an acute event and should not be coded as active for

extended periods of time.

• Acuity (chronic or acute) should be documented
• After discharge, it should be coded as history of CVA with or without

residual effects

• Hemiparesis should documented as ‘due to’ CVA in order to be coded.
• Additional codes should be used to identify
• Hypertension
• Alcohol abuse or dependence
• Tobacco use or dependence

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Myocardial Infarction

• Myocardial Infarction (MI)
• Documentation of an old MI implicates ongoing monitoring and treatment.

This is important for RA reporting.

• If the MI is less than or equal to 4 weeks, it is considered current.
• Additional codes should be used to identify
• Tobacco use/dependence

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Congestive Heart Failure

• Congestive Heart Failure (CHF)
• Is it acute, chronic, acute on chronic
• Systolic, diastolic
• Use additional codes to identify:
• Heart failure due to Hypertension
• Heart failure following surgery
• Heart failure due to Hypertension with CKD

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Hypertension

• HTN is it primary or secondary
• If it is secondary what is it ‘due to’?
• Hypertensive heart disease
• There are combo codes if the documentation supports the cause and effect
• If the cause and effect are not documented
• Query
• Code separately

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Chronic Kidney Disease

• Chronic Kidney Disease (CKD)
• Documentation needs to specify the stage; this information needs to be state

by the provider and not taken from lab reports.

• If the documentation states mild, moderate or severe, codes may be assigned

for the appropriate stage.

• Dialysis needs to be reported when appropriate

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Diabetes

• There are 2 types of Diabetes (DM)
• Type 1 – body does not make insulin, referred to as juvenile diabetes
• Type 2 – body does not make enough insulin or unable to use the insulin

made by the body

• One of the most common diseases that is under documented.
• Complications should be clearly documented with cause and effect
• DM with neuropathy
• DM and neuropathy (cannot be assumed to be related)
• A query can be sent

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Chronic Obstructive Pulmonary Disease

• Can also be referred to as COPD, emphysema, Chronic bronchitis,
• bstructive asthma
• Clarification would assist in the most accurate coding.
• COPD is an unspecified code, if there is no exacerbation and well controlled
• n meds, there is no other code choice.
• Acuity is important when reporting COPD
• Additional codes should be used to identify
• Tobacco use/dependence
• Exposer to secondhand smoke

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Asthma

• Specificity in documentation is necessary
• Intrinsic or extrinsic
• Is it obstructive? (COPD)
• Are there comorbidities, such as allergies?
• Acuity
• Additional codes should be used to identify
• Tobacco use/dependence
• Exposer to secondhand smoke

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Amputations

• Amputations must be coded at least annually for RA

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Hepatitis

• Hepatitis is the inflammation of the liver
• Acuity needs to be documented
• Hepatitis A, B, C, D, E

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BMI and Obesity

• Readings may be reported by a clinician
• Coders should only code the BMI when documented in the medical

record and should not calculate.

• If there are references to BMI related issues and the BMI is not calculated,

then a query can be sent.

• Obesity must be documented by the treating provider.
• Morbid obesity is risk adjusted

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Provider Coding

There can be challenges when the providers do their own coding.

• Most providers are not trained in coding or coding guidelines
• Most providers do not code and/or submit all diagnosis codes
• Sometimes the specificity is not reported
• Errors are rarely corrected

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Summing it Up

• Documentation must support medical necessity.
• Coding tells the patient’s story, the more detail, the better
• Working with providers on how to document to represent the severity of

the conditions.

• Open lines of communication are is crucial between coder and provider.
• Clear, concise and detailed documentation is key.
• Risk adjustment isn’t going away any time soon and will change every

year.

• Risk adjustment varies between MA, ACA and private payers.
• Don’t forget about status conditions.
• Coders and CDI’s need to form a collaborative working relationship.

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QUESTIONS QUESTIONS

Amber Condren, BS, B Ed, CPC, CEMC, CHA, CMDP AHIMA ICD-10 CM/PCS Approved Trainer acondren@thescbi.com

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