Medicare Choice Coding and Documentation for Encounters

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Medicare Choice Coding and Documentation for
Encounters

• Presented by
• Industry Collaboration Effort (ICE)
• Encounter Data Team

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Purpose

• To provide participants with the appropriate
  information and support needed to improve the
  quality and quantity of physician encounter data
  needed by your contracted health plans

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Objectives

• At the completion of this session participants
  will be able to
• Understand their role in the data collection
  process
• List the various uses of the data they provide
• Identify common coding errors
• Understand CMS plans for calculating
  reimbursement
• Know who to contact if you have any questions
• Ensure Train the Trainer sessions occur at the
  provider level.

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Introductions

• ICE - who are we?
• History of ICE
• Balanced Budget Act of 1997
• Goals
• Standardize processes and procedures where
  possible
• Create administrative efficiency
• Consistent regulatory compliance
• Education

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ICE Mission Statement

• Mission Statement/Scope of the ICE Encounter Data
  Team
• To collaboratively improve the collection and
  transmission of encounter data to CMS as required
  per the Balanced Budget Act of 1997, by
  identifying and resolving common issues by
  collectively working on provider communication
  and education by standardizing tools, processes,
  timeliness standards, and report formats by
  collaboratively regarding clearinghouse
  expectations and negotiations by collectively
  communicating with CMS for resolution of common
  issues.

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ICE Goals

• Goals of the ICE Encounter Data Team
• Successful efforts will result in increased
  volume of data submissions from providers, thus
  increased Medicare payments submission or
  transmission cost savings for hospitals due to
  standardization of health plan expectations cost
  saving for hospitals and health plans via
  collective negotiations with clearing houses
  improved customer relations between providers and
  health plans due to reduced expenses and
  increased revenues to hospitals, medical groups
  and health plans.

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Want more info about ICE?

• Go to ICE web site
• www.iceforhealth.org
• locate discussion forums
• become an ICE member
• online calendar of activities
• vast library of documents covering many topics

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Data Collection

• Physician data
• CMS1500
• Importance of clinical information
• Clinical information identifies the health status
  of your members
• Garbage in garbage out
• Hospital data
• UB92
• I/P O/P
• Clinical data is generally reliable

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Type of Data Collected

• Physician Data - result of face to face visit
• Hospital Inpatient Data
• Hospital Outpatient Data
• ______________________________
• Inpatient Excludes
• SNF Inpatient, Hospice, ICF
• Outpatient Excludes
• Lab, DME, Ambulance, ASCs, Prosthetics
  Orthotics

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Uses of Encounter Data

• Reimbursement from CMS
• Shared risk reporting
• HEDIS
• Performance measurements
• Utilization

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Financial ImpactPIP-DCG vs. CMS-HCC

• PIP-DCG model Principal Inpatient Diagnostic
  Cost Group
• beneficiaries are assigned to a disease group
  based on future cost to diagnosis
• a single most costly diagnosis is recognized from
  an inpatient stay greater than one day
• CMS-HCC model Hierarchical Condition Category
• incorporates multiple diagnosis codes from
  ambulatory data (outpatient physician)

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Financial Impact PIP-DCG Vs CMS-HCC
Female, 76 years old, Medicaid eligible, COPD,
CHF, vascular disease with complications
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ICD-9-CM Coding
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ICD-9-CM Coding

• The ICD-9-CM coding system translates written
  medical terminology into numeric and
  alpha-numeric codes
• The ICD-9-CM codes listed on your claim or
  encounter are intended to accurately reflect the
  patients condition as it relates to services
  rendered and documented during the encounter

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Best Practices in ICD-9-CM Coding

• The code selected should always be at the highest
  level of specificity
• The ICD-9-CM book is organized into three digit
  categories
• 250 Diabetes Mellitus
• 401 Essential Hypertension
• 480 Viral Pneumonia
• MOST diagnosis codes require a fourth/fifth digit
  to provide sufficient specificity
• A three digit code cannot be assigned if a
  category has fourth/fifth digits even if your
  billing or encoder system accepts it

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Best Practices in ICD-9-CM Coding (cont.)

• The fourth digit subcategory provides more
  specificity regarding
• Codes with a fourth digit of 9 are considered
  unspecified
• If another digit more accurately describes the
  condition, do not use 9

- Etiology Cause
- Site Specific area of the body
- Manifestation Characteristic signs, symptoms or processes of an illness
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Best Practices in ICD-9-CM Coding (cont.)

• Fifth-digit coding provides additional
  specificity
• You must code to the fifth-digit if the code has
  one
• Consider using a master problem list to track
  diagnoses over time
• Consider using random audits by certified coders
  to ensure coding accuracy

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Master Problem List

• Sample Documentation
• Problem 1 Resting angina coming on in morning,
  associated with dyspnea, no palpitations
• Problem 2 Pressure today is 125/76. She feels
  less tired on new medication. Will refill
• Problem 3 Allergies really bothering her. Eyes
  watering itching. Nasal mucosa irritated. Will
  prescribe antihistamine.

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Diabetes Coding

• Diabetes is a disease that is often miscoded,
  due to inadequate documentation.
• The three digit category for diabetes is 250
• Five digits are required for all diabetes codes
• 250.00 - The first three digits indicate the
  patient has diabetes
• 250.01 - The second 0 indicates there are no
  complications or other manifestations

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Diabetes Coding (cont.)

• If the physician specifically lists in the
  medical record any complications or
  manifestations of the diabetes that show the
  progression of the disease and/or response to
  treatment the additional documentation allows the
  biller/coder to select the proper fourth digit

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Diabetes Coding (cont.)

• Complications
• There are two acute complications of diabetes
  mellitus
• Diabetic ketoacidosis
• 250.1x
• 250.3x
• Hyperosmolar nonketotic coma
• 250.2x
• Other diabetic comas, such as hypoglycemic comas,
  are assigned to code 251.0

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Diabetes Coding (cont.)
Manifestations
Renal manifestations 250.4x
Ophthalmic manifestations 250.5x
Neurological manifestations 250.6x
Peripheral Circulatory disorders 250.7x
Other Specified manifestations 250.8x
Diabetes w/unspecified complications 250.9x
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Types of Diabetes

• It is critical to identify the type of diabetes
  in the medical record.
• If the physician states the level of control the
  patient is maintaining, this will allow the
  biller/coder to select the proper fifth digit.

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Types of Diabetes (cont.)
Type 1 (IDDM) Controlled 250.x1
Type 1 (IDDM) Uncontrolled 250.x3
Type II (NIDDM) Controlled 250.x0
Type II (NIDDM) Uncontrolled 250.x2

• Diabetes is NOT considered out of control unless
  the physician identifies it as such in the
  diagnostic statement and/or body of the record.

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Multiple Coding Techniques

• Used when more than one code number is needed to
  identify a given condition and provide a more
  complete picture of the diagnosis
• The use of multiple codes allows all of the
  components of a complex diagnosis to be
  identified
• The medical record must mention the presence of
  all the elements for each code number used

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Multiple Coding Techniques
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Multiple Coding Techniques (cont.)
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Diabetes Case Study

• A patient with Type I diabetes presents to the
  ophthalmologist for an evaluation of the
  progression of his diabetic cataracts. His blood
  sugar levels have been well controlled and he is
  following his diet and exercise plan according to
  his primary care physicians instructions.

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Diabetes Case Study
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Diabetes Case Study (cont.)
Renal Manifestations 4th digit 4 250.4x
Ophthalmic Manifestations 4th digit 5 250.5x
Neurologic Manifestations 4th digit 6 250.6x
Peripheral Circulatory Disorders 4th digit 7 250.7x
Other Specified Manifestations 4th digit 8 250.8x
Unspecified Manifestations 4th digit 9 250.9x
1. What is the proper fourth digit code for this
case?
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Diabetes Case Study (cont.)
2. What is the proper fifth digit for this case?
3. Are there any additional codes required?
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Diabetes Case Study (cont.)
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Diabetes Documentation

• Critical elements
• Type
• Level of control
• Manifestations and complications by category
• Manifestations and complications specified by site

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Impact of Specific Diabetes Coding on Risk
Adjustment

• Example Diagnosis of Diabetes with chronic
  renal failure
• In the first case
• Physician documents Diabetes
• Biller/coder codes 250.00
• Associated payment 475/yr

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Impact of Specific Diabetes Coding on Risk
Adjustment

• In the second case
• Physician documents Diabetes with chronic renal
  failure, insulin dependent
• Biller/coder codes 250.41 (diabetes with renal
  manifestations, insulin dependent
• Associated payment 1,852/yr
• Difference in payment due to insufficient
  documentation 1,377/yr

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Heart Failure Coding

• Heart failure coding has been expanded to 15
  codes for 2003
• Codes are now divided into
• Systolic heart failure (428.2x)
• Diastolic heart failure (428.3x)
• Combined systolic diastolic heart failure
  (428.4x)

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Heart Failure Coding

• Each subcategory is further subdivided by 5th
  digit
• 5th digit 0 unspecified
• 5th digit 1 acute
• 5th digit 2 chronic
• 5th digit 3 acute on chronic

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NEC vs. NOS

• NEC - Not Elsewhere Classifiable - NEC is used
  when the ICD-9-CM system doesnt have a code
  specific to the patients condition
• NOS - Not Otherwise Specified - NOS is used when
  the coder lacks sufficient information to code to
  a higher level of specificity. This is the
  equivalent of unspecified

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HCPCS / CPT Coding
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HCPCS - HealthCare Common Procedural Coding System
HCPCS
Local Codes (Level III)
CPT Codes (Level I)
National Codes (Level II)
Developed by local Medicare carriers
Developed by the AMA
Developed by CMS
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CPT Coding

• CPT stands for Current Procedural Terminology.
• It was developed by the American Medical
  Association (AMA) in 1966.
• It is a listing of five-digit, numeric codes for
  reporting medical services and procedures
  performed by physicians.
• CPT is revised and published annually by the AMA
  to keep pace with changes in medical practice.

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CPT Organization

• The procedures and services with their
  identifying codes are in numerical order within
  CPT with the exception of the Evaluation and
  Management services which are listed first.

Section Code Range
Evaluation and Management 99201 to 99499
Anesthesiology 00100 to 01999
Surgery 10040 to 69979
Radiology 70010 to 79999
Pathology and Laboratory 80002 to 89399
Medicine 90701 to 99199
Category III Codes 0001T to 0044T
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National Codes

• Are the Level II HCPCS codes.
• Published annually by CMS.
• Codes consist of five characters and are
  alpha-numeric.
• Were created because CPT describes only
  physicians procedures and services and CMS
  needed another method to code supplies,
  injections, and other procedures and services it
  recognized were not found in CPT. These codes
  are typically billed when services are provided
  in the medical office or in the Outpatient
  hospital setting.
• Example J0530 - Bicillin 600,000 Units

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Evaluation and Management Services

• CMS does not require a specific set of Evaluation
  and Management Guidelines for Medicare Choice
  provider.
• The code chosen by the physician must accurately
  describe the services rendered.
• In the Medicare fee-for-service program,
  physicians currently have the option of choosing
  the 1995 or the 1997 E M guidelines.

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Evaluation and Management Services

• We strongly suggest that you follow
  Fee-for-Service CMS guidelines when selecting an
  EM Code, and when coding encounters in general.
  CMS has notified Health Plans that physician
  encounter data will be subjected to Medical
  Records Review.

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Tips for Documenting Procedures

• Include narrative indications for surgery
• If the procedure is related to an injury include
  information regarding place and mechanism of
  injury
• If a repeat procedure is performed, provide the
  following information
• 1. Physician who performed the first procedure
• 2. Date the first procedure was performed
• 3. Brief narrative stating the reason(s) the
  procedure is being repeated

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Data Validation

• CMS will conduct data validation to ensure
  theres consistency between the claim and the
  medical records.
• As medical information is updated it is important
  that consistency exists between the claim and the
  medical record to ensure a successful data
  validation by CMS.

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Modifiers
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Modifiers

• Consist of 2 digits that are appended to
  procedure codes. Provides additional information
  as to how the procedure was different from the
  typical service described in CPT.
• The CPT system contains 33 modifiers.
• HCPCS modifiers are 2 digit alpha or alpha
  numeric.

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Modifiers May Be Used to Indicate

• A service or procedure has both a professional
  and technical component.
• A service or procedure was performed by more than
  one physician.
• A service or procedure has been increased or
  reduced.
• A bilateral procedure was performed.
• A service or procedure was provided more than
  once
• A secondary procedure was also performed
• Unusual events occurred

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Modifier - 25

• Significant Separately Identifiable Evaluation
  and Management Service by the Same Physician on
  the Same Day of a Procedure
• This modifier indicates that on a day a procedure
  or services identifier by a CPT code was
  performed, the patients condition required a
  significant, separately identifiable E/M service
  above and beyond the usual preoperative and
  postoperative care associated with the procedure
  that was performed. Assign the proper E/M code
  as appropriate for the services rendered.

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Modifier -25
Example A patient is seen in the office for
evaluation of his COPD, coronary artery disease
and diabetes. He is also complaining of swelling
in his knee which developed after he fell while
getting out of his car. The physician performs an
expanded, problem-focused history and examination
of his chronic illnesses along with his knee and
performs a joint aspiration of the knee.
Since there is a separately identifiable EM
service for the chronic illnesses, the office
visit is coded with modifier -25 appended to show
other services were rendered unrelated to the
joint aspiration
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Anesthesia Modifiers

• CMS requires that all anesthesia claims have
  modifiers
• Anesthesiologist Services
• AA - Anesthesia personally performed by the
  anesthesiologist
• AB - Medical direction of own employees (lt4
  employees)
• AC - Medical direction of other than own
  employees (lt4 individuals)
• AD - Medical Supervision by a physician more
  than 4 concurrent anesthesia procedures

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Anesthesia Modifiers

• CRNA Services
• QX - CRNA service with medical direction by a
  physician
• QY - Medical direction of one CRNA by an
  anesthesiologist
• QZ - CRNA service without medical direction

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Unlisted Procedures

• Every section of the CPT book has an unlisted
  procedure code.
• Used for procedures performed for which there is
  not a specific code listed in the CPT book.
• Often used for new procedures resulting from
  medical advances and research. NOTE Beginning
  with 2002 CPT, Category III codes are being
  developed. Check for a Category III code prior
  to using an unlisted code.
• Are NOT assigned when a more descriptive code is
  available.

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Miscellaneous Coding Information

• Anesthesia included in surgical procedure -
  anesthesia rendered by the surgeon is NOT
  reported separately.
• Separate procedures - procedure codes listed in
  the CPT as separate procedures are usually part
  of a more comprehensive service. If it is the
  only procedure done on a given date, then it may
  be billed separately.
• Designation of sex procedures - codes which
  include gender in their description cannot be
  billed for the opposite gender.

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Summary for Providers
Coding/Billing Staff

• If you are currently submitting Medicare
  fee-for-service claims, continue with that
  approach for Medicare Choice claims and
  encounters.
• If you are currently paying MC encounters or
  claims on behalf of a health plan, all data
  elements on a CMS 1500 or UB92 must be recorded
  and transmitted to the health plan.
• If you are new to filing a Medicare bill or
  encounter, we have given you training on best
  practices in coding to get you started.
• Physicians should provide sufficient
  documentation to enable accurate diagnosis coding
  by billers/coders.
• Use a documentation format that supports the
  level of evaluation and management service
  reported.
• Provide an Indications for Surgery narrative on
  operative reports.
• Provide information to the biller/coder when a
  modifier is necessary.

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Tips for Your Office or Facility

• Review your superbill to make certain that all
  codes are current.
• If diagnosis codes are printed on your superbill,
  allow enough code choices for the physician to
  accurately and completely describe that patients
  condition, to the highest level of specificity.
• Biller/coders make sure your codes are valid on
  a yearly basis.
• If you are having difficulty with a downstream
  providers format, please ask your health plan
  for assistance.
• Each procedure line may have a unique diagnosis.

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BBA DATA SUBMISSION DEADLINES AND CMS PAYMENT
SCHEDULE
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PIPDCG Payment Example

• 76 year old female
• Medicaid eligible
• COPD
• CHF
• Vascular disease with complications
• living in Los Angeles County, CA.
• 2003

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PIPDCG Payment Example

• Demographic Payment Calculation
• Monthly rate book for LA County
• Part A 400.33 Part B 323.21
• Jane Doe, Medicaid factor
• Part A 1.45 Part B 1.25
• Part A 400.33 x 1.45 580.48
• Part B 323.21 x 1.25 404.01
• Monthly demographic capitation payment (Part A
  plus Part B)
• 580.48 404.01 984.49 (100 demographic)

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PIPDCG Payment Example

• Risk Adjustment Payment Calculation
• Monthly rate book for LA County
• Part A 400.33 plus Part B 323.21 723.54
• Rescaling factor 0.989524
• Rescaling rate 723.54 x 0.989524 715.96

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PIPDCG Payment Example

• Risk factors
• Jane Doe, demographic base factor 0.588
• Medicaid 0.440
• CHF (PIPDCG 16) 2.438
• Total risk factor 0.588 0.440 2.438 3.466
• Monthly risk adjusted capitation (100 risk
  adjusted payment)
• 715.96 x 3.466 2,481.52

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PIPDCG Payment Example

• Blended Risk Adjustment Payment Calculation
• 90/10 Blend
• Demographic 984.49 x 0.9 886.04
• Risk 2,481.52 x 0.10 248.15
• Total Monthly Blended payment 886.04
  248.15 1,134.19
• Annually (if she lives and stays enrolled in an
  MC plan) 13,610.32

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CMS-HCC Payment

• Female, 76 years old, Medicaid eligible, COPD,
  CHF, vascular disease with complications, LA
  County, 2004
• Payment estimation
• 76 year old female (0.483)
• Medicaid (0.183)
• COPD (0.376)
• CHF (0.417)
• Vascular disease with complications (0.677)
• CHF with COPD (0.241)
• 2.377 (relative risk factor)

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CMS-HCC Payment

• 2.3725 x 715.96 1,701.84 (100 risk)
• 984.49 (100 demographic)
• 70 demographic (689.14)
  30 risk (510.55)
  total blended payment (1,199.69)
• Annual 14,396.34

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Risk Adjustment Factor New vs. Old
Female, 76 years old, Medicaid eligible, COPD,
CHF, vascular disease with complications

• HCC (new risk adj model)
• 70 demographic 689.14
• 30 risk 510.55
• Total Monthly Blend payment 1,199.69
• Annualized 14,396.34

• PIP-DCG (current model)
• 90 Demographic 886.04
• 10 Risk
• 248.15
• Total Monthly Blended payment 1,134.19
• Annualized13,610.32

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Coding Adjustments

• As indicated in the previous examples, accurate
  coding impacts reimbursement.
• Please follow-up with the Medicare Encounter Data
  Report contact in your plan (listed on Health
  plan contact list in the ICE Web-site) on how to
  adjust previously submitted claims or encounters.

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Submitting Your Data
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Tips for Your Office or Facility

• Paper Submission
• Direct to Health Plan
• Vendor (i.e. Clearinghouse)
• TPA, IPA, or Medical Group
• Refer to Resource Guide to complete CMS 1500 and
  UB92
• Electronic Submission
• Direct to Health Plan
• Vendor

For questions -- Please refer to the Where to
submit guide
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Final Check List

• Charge/Fee Tickets/Super Bill
• Cheat Sheets - Specialists
• Claims Systems
• Training for Physicians

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Resource Guide

• The resource guide included in your handout today
  contains a number of web-sites where you can
  obtain more coding and billing guidance.

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QUESTIONS?