Friday, May 4, 2018

CMS-HCC Coding Cards – 12 Pack

CMS-HCC Coding Cards – 12 Pack

You will love these 5x7 HCC Coding Cards!

This 12 pack is perfect your next risk adjustment project.


•ICD-10 Coding Tips (side 1) includes RAF

•Clinical Documentation Tips (side 2) includes RAF


•ICD-10 Coding Tips (side 1) includes RAF

•Clinical Documentation Tips (side 2) includes RAF

3.Heart Failure:

•ICD-10 Coding Tips (side 1) includes RAF

•Clinical Documentation Tips (side 2) includes RAF

4.Major Depressive Disorder:

•ICD-10 Coding Tips (side 1) includes RAF

•Clinical Documentation Tips (side 2) includes RAF

5.Malnutrition and Morbid Obesity:

•ICD-10 Coding Tips (side 1) includes RAF

•Clinical Documentation Tips (side 2) includes RAF

6.Complications with Internal Devices and Dependence:

•ICD-10 Coding Tips for Complications (side 1) includes RAF

•ICD-10 Coding Tips for Dependency (side 2) includes RAF

7. Infectious Disease:

•ICD-10 CDI / Coding Tips for HIV and Sepsis (side 1) includes RAF

•ICD-10 Coding Tips for Liver Disease (side 2) includes RAF

8. Heart Failure:

•ICD-10 Coding Tips (side 1) includes RAF

•Clinical Documentation Tips (side 2) includes RAF

9. Chronic Kidney Disease:

•ICD-10 Coding Tips (side 1) includes RAF

•Clinical Documentation Tips (side 2) includes RAF

10. Seizures and Neurological Disorders:

•ICD-10 Coding Tips (side 1) includes RAF

•Clinical Documentation Tips (side 2) includes RAF

11. Diseases of the Digestive System:

•ICD-10 ICD-10 Coding Tips (side 1) includes RAF

•ICD-10 ICD-10 Coding Tips (side 2) includes RAF

12. Primary and Secondary Neoplasms:

•ICD-10 ICD-10 Coding Tips (side 1) includes RAF

•ICD-10 ICD-10 Coding Tips (side 2) includes RAF

Post one to your bulletin board, stick one near the EHR or tape it to your workstation
HCC Coding Cards are made to last all year on thick 16 pt cardstock with a gloss finish.

Visit our store to see more risk adjustment tools.

Thursday, April 26, 2018

Advanced Risk Adjustment and HCC Coding

Are you looking for the best education available in risk adjustment?

Good News - You have found it!

Join us for a day of risk adjustment, catch up with colleagues over lunch, and get the best tools in the industry for FREE!

Do you need CMEs or CEUs? We have that too!

All Workshops are approved by the American Medical Association, American Academy of Family Practice and the American Academy of Professional Coders.

Register your team ( 3 or more) today to save 10% on Tampa and Ft. Lauderdale.

Take advantage of Early Bird pricing for Fall Workshops and Save $100!

Improve the Accuracy of your Risk Scores...

What is changing for risk adjustment in 2019? New ICD-10 codes and HCC categories are coming. What should your team be doing now to prepare?
Review the different risk adjustment models and their impact on medical practice management for 2019 and beyond.
Discuss the impact of shifting from RAPS to EDS. What does this mean for office based claims?
Take a deep dive into HCC Coding and Documentation.
Review real documentation examples to see what validates, what doesn’t, and why. 
Learn how to leverage frontline staff to be successful in the world of risk adjustment and value-based payments.

Who Should Attend?
Medical Coders and Billers
Providers, Managers and Frontline Staff
CDI Specialists
Executive Leaders
ACO, MSO and IPA Teams
Rural Health Centers
Health Alliance Members
Medicare, Medicaid and Commercial Plans

Fort Lauderdale, Florida
1451 W. Cypress Creek Road, Fort Lauderdale, FL, 33309

Wednesday - May 9, 2018
9:30 AM - 3:30 PM

Thursday November 8, 2018
9:20 AM - 3:30 PM
Early Bird Pricing $100

Tampa, Florida
4328 Garden Vista Drive, Riverview, FL 34747

Wednesday - October 24, 2018
10:00 AM - 4:00 PM
Early Bird Pricing $100

Visit for more details

Saturday, April 14, 2018

CMS-HCC ICD-10 and CDI Cards

You will love these 5x7 HCC Coding Cards!

This 6 pack includes all the basics to jump start you risk adjustment project.

ICD-10 Coding Tips (side 1) includes RAF
Clinical Documentation Tips (side 2) includes RAF

ICD-10 Coding Tips (side 1) includes RAF
Clinical Documentation Tips (side 2) includes RAF

3.Heart Failure
ICD-10 Coding Tips (side 1) includes RAF
Clinical Documentation Tips (side 2includes RAF

4.Major Depressive Disorder:
ICD-10 Coding Tips (side 1includes RAF
Clinical Documentation Tips (side 2) includes RAF

5.Malnutrition and Morbid Obesity:
ICD-10 Coding Tips (side 1) includes RAF
Clinical Documentation Tips (side 2) includes RAF

6.Complications with Internal Devices and Dependence
ICD-10 Coding Tips for Complications (side 1) includes RAF
ICD-10 Coding Tips for Dependency(side 2) includes RAF

Post one to your bulletin board, stick one near the EHR or tape it to your workstation!

HCC CodingCards are made to last all year on thick 16 pt cardstock with a gloss finish

Tuesday, April 3, 2018

CMS 2019 Final Call Letter

Announcement of Calendar Year (CY) 2019 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter    April 2, 2018

For payment year 2019, CMS will implement the updated CMS-HCC model without count variables that was provided in Part I of the Advance Notice for comparison.

"This model incorporates the proposed additional Chronic Kidney Disease, mental health, and substance use disorder conditions, updates the data years used to calibrate the model from 2013 diagnoses predicting 2014 cost to 2014 diagnoses predicting 2015 cost, and selects 2014 diagnoses for calibration with the CPT/HCPCS-based methodology that is used to select risk adjustment eligible diagnoses submitted to the encounter data system. "

See New Coefficients Below:

Encounter Data

CMS is also finalizing the proposal to calculate 2019 risk scores by adding 25% of the risk score
calculated using encounter data and FFS diagnoses (with inpatient RAPS data to supplement encounter data) and 75% of the risk score calculated using RAPS and FFS diagnoses.

 Download the entire Call Letter here

Friday, March 30, 2018

Is Your Team Risk Ready?

What will define those who claim victory and those who are defeated in the battle towards value based care? Will it be those organizations with the most money, power and seats at the table? Or will it be those who are nimble, flexible and open to change?

 I believe it will be both. As victory will not be defined by the owners and head coaches but instead by how the players execute on the field. It will be the game time decisions that matter most.

A quarterback who can read the defense and adjust accordingly will provide far greater value to the offense than the most athletic quarterback who misses the blitz every time.

Perhaps Napoleon said it best, “Battles are won by the power of the mind.” For in a game of inches, the winners and losers will be defined by those who can execute in the moments that matter most.

Prepare your team for victory with information at the point of care!

ERM Consulting has developed the industries best tools for players on the frontline.

This 42 page guide includes proper ICD-10 coding and clinical documentation for the most common diagnoses included in the risk models. A complete list of CMS-HCCs with RAF and demographics included. Order 1 for your entire team! Orders of 100 or more can be white labeled with your logo at no charge. Please email logo to after purchase.

This 36 page guide contains a list of the most common HCC codes in the Medicare (CMS-HCC) model. Includes both medical (HCC) and pharmacy (RxHCC) codes. Orders of 100 or more can be white labeled with your logo at no charge. Please email logo to after purchase. 

Visit our online store for a full list of available tools.

Tuesday, March 27, 2018

UHC Implements Mandatory Reviews of Level 4 and 5 ED Codes

Image result for emergency room

Three key takeaways from this effort by healthcare giant UnitedHealthcare
UnitedHealthcare (UHC) is continuing its quest to revamp many facets of our healthcare industry. Last year, they adapted mandatory policies for the use of the SA modifier to indicate that a professional service was performed as incident-to, and now the company is introducing a mandatory review of high-level ED facility-based service codes.
The newest UHC policy took effect March 1 and applies to both UHC’s commercial plans and its Medicare Advantage plans, as well as claims submitted to UHC from non-participating facilities.
Organizations that submit claims to UHC have begun to see a dramatic change in coding policy, with emergency department (ED) service codes of Level 4 and 5 now undergoing review for adjustment or outright denial.
Let’s review the policy change and the explanation posted by UHC, and then we will walk through concerns providers have including the following:
Simply selecting ED codes 99284 and 99285, which represent moderate-complexity and high-complexity cases, will result in the claim being reviewed by UHC using its Optum Emergency Department Claim (EDC) Analyzer tool, which is a software module that supposedly “systematically evaluates each ED visit level code in the context of other claim data (i.e., diagnosis codes, procedure codes, patient age, and patient gender) to ensure that it reasonably relates to the intensity of hospital resource utilization as required per CMS (Centers for Medicare & Medicaid Services) guidelines.”
UHC stated in its December 2017 bulletin, that the other ED codes, 99281-99283 (in the same family of codes) will not be subject to this automatic review by the EDC tool. UHC further stated that those facilities submitting claims with 99284 or 99285 will have those claims “adjusted” in level, which is to say downcoded, or completely denied, based on “the reimbursement structure within their agreements with UnitedHealthcare,”.
There are some exceptions to the automatic EDC review, which include:
  • Admissions from the ED;
  • Critical care patients;
  • Patients younger than 2 years of age;
  • Certain diagnoses requiring greater-than-average resource use when performed in the ED;
  • Patients who die in the ED; and
  • Facilities whose billing of Level 4 and 5 evaluation and management (E&M) codes does not abnormally deviate from Optum's EDC Analyzer tool determination.
Facilities that see either a reduction in their ED code levels or denials will be able to submit reconsideration or appeal requests if they disagree with the EDC analyzer’s findings and the subsequent “adjustments,” according to the UHC bulletin. The massive increase in scrutiny created by this new policy is needed, UHC said, to “support UnitedHealthcare’s commitment to the triple aim of improving healthcare services, health outcomes, and overall cost of care.”
 Now, let’s break it all down:
 Facility coding guidelines are different from professional coding guidelines. Therefore, although the codes used to bill and support the facility-based services are the same, the utilization of these codes are quite different. When reported for Facility services codes are chosen based on the volume and intensity of resources utilized by the facility to provide patient care. In fact, while physicians pay homage to documentation guidelines with every single service they provide, CMS has yet to create a standard by which facility ED codes are applied to an encounter.
ACEP has created a set of standards than many ED’s across the country have adopted, and therefore has become somewhat of an industry standard, but again- previously no formal process has been adapted. Therefore, many would stay that there is no definitive correlation between facility and professional coding and therefore no rational basis for the application of one set of codes for the determination of the other on a case-by-case basis.  However, when we begin to review the steps the EDC analyzer will evaluate the line between facility services, and the professional use of the code set begins to get lost in the sand.
According to the EDC analyzer (, Step one is a consideration of the level of risk of the patient’s presenting problem to drive the standard resource valuation for the presenting problems in that ED visit level and include the costs associated with the following:
  1. Nursing and ancillary staff time (for a routine arrival, triage, registration, basic patient/family communications, and a routine discharge)
  2. The room
  3. Creation of a medical record
  4. Coding and billing

These four resource valuations are driven by the risk associated with the patient’s presenting problem as referenced within the MDM scoring process for professional based services. So, while these coding systems are supposed to be different, we begin to see how the facility service is also driven by the complexity of care of the patient identifying their stated medical necessity. While medical necessity should be the determination of what is billed and why it should be reimbursed, the problem in UHC’s step one determination is the initial weighted costs related to the presenting problem.
For clarity, this methodology is better explained with an example. The weight of a patient presenting for a blood pressure check may seem anteriorly low, but if their blood pressure is severely high, then our presenting problem just increased 1-2 levels to a higher level of severity, which depending on the severity may pose imminent threat to support the highest cost weight category.
Step two within the EDC provides for a review of all line-level services on the claim to identify diagnostic tests as follows: 
  • Laboratory tests
  • X-ray tests (film)
  • EKG/RT/other diagnostic tests
  • CT/MRI/ultrasound tests
Consideration was allowed to provide for costs of creating orders, time and staffing to provide the testing, and communication with the patient. These cost weights are then added together per each category to find the total weighted consideration. WOW, this sounds much like the data and complexity section of MDM scoring of professional services but extending them beyond the scope of the physician service and realizing the facility burden associated with each category of service.
Step 3 will then take into all diagnoses assigned to the patient that may impact utilization of resources based on complicating factors, i.e., the risk imposed by the patients care level needed. UHC has indicated that they have Patient complexity cost weights that were developed for each complicating condition by analyzing the additional services typically provided to patients with that complicating condition. UHC provides examples of diagnoses and conditions that they have weighted. However, they do not provide the weighted costs associated with each.
UHC’s final step, once again, sounds suspiciously comparative to professional services as we will use the 3 categories to assess our service collectively. The formula they have published is the following:
Total Weight = Standard Cost Weight (Step 1) + Extended Cost Weight (Step 2) + Patient Complexity Cost Weight (Step 3)
Pricing = resources required based on presenting problem + resources expended based on Categories of service used + the potential resources consumed based on the diagnoses of the encounter
There is one curiosity that the EDC by UHC does not indicate and that is the weighted cost of each step. This information has been redacted from their website and not published, and therefore we do not know exactly the scoring process that has been implemented. At least on the professional services side, the scoring process of the medical decision making (MDM) —again comparative in nature— does provide us with the guidance of the weight of each element to support the overall service. However, UHC has chosen to keep this information confidential.
So let’s apply this to a condition. There are two words that when put together, escalate care in the ED: chest pain. I do realize that facilities have protocol requirements for this type of scenario, but before we engage in a debate, please be reminded that is a facility’s protocol and not the carrier’s. Unless the medical necessity can support the appropriateness of the services rendered, the carrier may decline reimbursements.
However, let’s proceed. Patient reports to the ED for chest pain and of course lab, radiology, and diagnostic testing is performed, but ultimately it is determined that the patient’s problem is merely heartburn and they are discharged to home. The UHC EDC would consider our formula as follows:
Remember your algebra rules for this one:
Total Weight = Chest pain + (lab + Radiology + EKG) + GERD
Pricing = Extensive resources needed for chest pain presenting problem + 3 categories of service line resources + a lower resource consuming formal diagnosis of the encounter

In conclusion, three final points:
  • Industry Modeling: UHC has created a “scoring methodology” through what they consider an analytics program, but what it really seems like is they have tried to use E&M Documentation Guidelines for Professional Services to create an industry modeling scoring of these facility-based services. Now come on, everyone knows how gray and ambiguous E&M Guidelines are, and let’s get serious… the MDM is one of the MOST troublesome parts! Therefore, it seems this may end up causing more confusion as opposed to providing valued guidance.
  • UHC Mandatory Automatic Reviews: This policy has provided some basis for facilities to better apply the proper ED service code, but it will likely raise overhead expenses on both sides. As we pointed out through this article, much of this scoring process is based on MDM related scoring principals which are gray and ambiguous at best and part of Marshfield Guidelines, which “technically” have never been formally adopted as part of the official guidelines. Now facilities will be required to produce proof to substantiate every single level 4 and 5 encounter through an appeal process. Additionally, UHC is now going to have to review every single appealed encounter. Who loses? Patients! This increased overhead will affect them on both sides: as a consumer and an insured.
  • Data Analytics Reviews: It’s the new buzz-phrase in healthcare. Not only has data analytics created new avenues in which carriers can track all services by facilities and providers, but more importanty, facilities and providers can now analyze their own risk and focus on their compliance dollars. However, analytics cannot assess medical necessity regardless of the type of service- be it facility or professional. Keep in mind that UHC essentially has an algorithm that raises red flags of alert, but that should only be a flag, as it truly takes a reviewer to analyze services for medical necessity.
Is the point of this policy to encourage undercoding? Maybe, but rather than point fingers in this way, let’s ponder for just a moment what this policy still does not do. It does not provide an avenue to educate the masses on the proper use of these codes. Instead, this policy will increase labor by driving unnecessary medical reviews.
We need the carriers to back educational efforts to help improve code usage, rather than introducing burdensome policies that increase healthcare costs to all involved.