Thursday, August 6, 2020

Newly Unsealed FCA Suit Targeting Cigna Medicare Advantage

By Jeff Overley

Law360 (August 5, 2020, 9:39 PM EDT) -- Cigna Corp. overbilled Medicare Advantage by more than $1.4 billion by persuading nurses to diagnose policyholders with exaggerated medical problems, according to a newly unsealed suit that joins a growing list of False Claims Act cases targeting Medicare Advantage insurers.

The whistleblower suit made public Tuesday in New York federal court alleges that from 2012 to 2017 a company division called Cigna-HealthSpring billed for medical conditions that "did not exist, were not recorded in any medical records and were not based on any clinically reliable information."

Whistleblower Robert A. Cutler, an employee of Cigna contractor Texas Health Management LLC, filed the complaint under seal in 2017.

Whistleblower complaints under the FCA are usually unsealed only after the 
U.S. Department of Justice has announced whether it will intervene in the case. An order in February from U.S. District Judge Kenneth Karas said that the DOJ had declined to intervene in some of the allegations and would not intervene for the time being in the remaining allegations. The same order called for the complaint to be unsealed in April, but it only hit the docket on Tuesday for reasons that were not immediately clear.

Law360 on Wednesday afternoon asked DOJ representatives at the 
U.S. Attorney's Office in Manhattan to clarify whether the government would be intervening. Within 40 minutes, the entire case docket was again placed under seal on Pacer. A DOJ representative late Wednesday declined to comment on the status of intervention or the resealing of the case.

In a short statement Wednesday, Cigna also didn't say whether the federal government had decided to join the case.

"We are proud of our industry-leading Medicare Advantage program and the manner in which we conduct our business," the company said. "We will actively defend Cigna against unjustified allegations."

Cutler, who represented himself when filing the case, didn't immediately respond to an email and voicemail seeking comment on Wednesday.

Cutler's complaint focuses primarily on Cigna's arrangements with contractors that sent nurse practitioners to patient homes for health screenings.

"On numerous occasions, THM managers made clear to executives at Cigna-HealthSpring" that nurses couldn't definitively diagnose serious conditions, but Cigna went ahead and billed Medicare Advantage as if the assessments were "confirmed medical diagnoses," the complaint alleges, referring to Texas Health Management.

Cutler's suit describes one instance of billing codes being added for dementia and chronic obstructive pulmonary disease even though a nurse practitioner reported that a patient's mental and respiratory functions were normal. In another section, the suit describes Cigna training contractors to diagnose rheumatoid arthritis based solely on fatigue, weight loss and certain symptoms of pain and stiffness.

The government was "unaware that these claims were false and fraudulent," and it "overpaid Cigna-HealthSpring by more than $1.4 billion," the complaint said of claims submitted over the five-year period.

Cigna paid $3.8 billion in 2012 to acquire HealthSpring Inc., which at the time had 340,000 Medicare Advantage enrollees. There are 22 million enrollees nationwide among all Medicare Advantage insurers, and Cigna is a relatively small player in the space, according to the Kaiser Family Foundation.

Medicare Advantage insurers are paid more than $200 billion annually, and FCA litigation against them by the DOJ is a relatively new phenomenon. The DOJ joined two whistleblower cases in 2017 against 
UnitedHealth Group Inc., which has defeated one of those cases and trimmed allegations in the other one. More recently, the DOJ in March hit Anthem Inc. with allegations of Medicare Advantage fraud.

All the cases involve allegations that insurers overstated the severity of illnesses to get more money from the government. Cigna noted in its most recent annual report that the DOJ "is conducting an industrywide investigation of Medicare Advantage" billing by insurance companies. Cigna added that it was "currently responding to ... civil investigative demands received from the ... U.S. Attorney's Offices for the Eastern District of Pennsylvania and the Southern District of New York."

Counsel information for the government and Cigna were not immediately available.

The case is U.S. ex. rel. Cutler v. Cigna Corp. et al., case number 
7:17-cv-07515, in the U.S. District Court for the Southern District of New York.

--Editing by Jill Coffey.


Download Case Documents Here

Tuesday, August 4, 2020

Congress Considers Timeline as Accelerated and Advance Payment Recoupment Looms

Monday, August 3, 2020

To provide additional financial support for Medicare providers responding to COVID-19, and pursuant in part to CARES Act requirements, the Centers for Medicare & Medicaid Services (CMS) expanded the Accelerated and Advance Payment Programs for providers and suppliers. CMS used existing rules that allow providers and suppliers to receive an advance on Medicare claims payments if they have experienced financial difficulties due to a delay in payments or in other exceptional situations.

Now, approximately four months after the first accelerated and advance payments were distributed, early applicants are approaching the date when Medicare will begin recouping payments through zeroed out claims, absent congressional action. These repayments are coming due at a time when providers still face critical financial challenges and reduced patient volume due to the pandemic.

Accelerating Medicare Payments to Providers

COVID-19 placed significant financial pressure on hospitals, physician practices and other providers and suppliers. Some were overwhelmed by a dramatic increase in COVID-19 patients, while others sat empty as non-emergency procedures were cancelled and patients under stay-home orders delayed care. CMS used the Accelerated and Advance Payment Programs to provide cash flow to affected providers. Unlike the Provider Relief Fund, the Accelerated and Advance Payment Programs provide loans that must be repaid.

For providers and suppliers who participate in the Accelerated and Advance Payment programs, claims recoupment via withheld claims begins 120 days after issuance of the payment. For suppliers, repayment of the full balance is due 210 days after the issuance of the payment; most hospitals have a full year to repay the balance. For both the Accelerated and the Advanced Payment Programs, unpaid balances due at the end of the repayment period are subject to the private consumer rate of interest rate, currently 9.5%.

CMS paused both programs on April 26, 2020, citing other funds available to the provider community.

Payments Come Due for Hospitals, Physicians and Suppliers. Physician practices and other suppliers had 120 days from the date CMS issued their payment. At least one MAC has indicated recoupment began July 27, 2020.

Legislation Could Extend Repayment Timeline

Given the state of COVID-19 recovery, it seems likely that Congress will extend the recoupment period for loan recipients. In May 2020, the US House of Representatives passed the Health Economic Recovery Omnibus Emergency Solutions (HEROES) Act, which would extend the timeline for recoupment and repayment of the loans. On July 27, 2020, Senate Republicans introduced the Health Economic Assistance, Liability Protection and Schools (HEALS) Act, which also would extend the repayment and recoupment terms, although for a shorter period. HEROES would take the additional steps of reducing the interest rate and reducing the amount of clHT NNaims recoupment. HEALS does not include parallel proposals affecting interest rates or recoupment amounts.

Some provider groups are pursuing legislation that would forgive these loans altogether. H.R.7292, introduced in June, would, among other things, forgive debts arising under these programs for providers, suppliers and physicians meeting certain criteria and conditions. This bill has over 74 cosponsors as of July 31st, and support from both Republican and Democratic Representatives. Senate Democrats introduced a version of forgiveness in May. S. 3750 would grant CMS the authority to waive repayment for Accelerated and Advance payments for providers facing significant hardship for at least two years. Full forgiveness has not appeared in either HEROES or HEALS, making it a long-shot to be included in a negotiated compromise this month.

Leadership from both parties continues to work toward a deal on broad stimulus and relief legislation that also would address this program. Final agreement is anticipated sometime in the next few weeks, but it is unlikely that an agreement will be finalized before some providers’ and suppliers’ repayment periods commence.

How Will the MACs Respond? Practical Considerations for Providers

Seven MACs are tasked with administering accelerated and advance payments and taking initial actions to recoup Medicare funds. In general, CMS instructs MACs on how to adhere to the agency’s guidance and regulatory requirements. MACs therefore may need clear instructions from CMS to alter their recoupment process in response to any legislative change. It is unlikely that CMS will take any such action in the absence of legislation. Providers and suppliers that obtained advance or accelerated payments therefore may experience a few bumpy weeks as MACs implement a large-scale recoupment program under shifting instructions from CMS, and as CMS awaits final stimulus legislation. Early recipients of advance or accelerated payments may be subject to claims reductions that start and stop as a result of the shifting policy environment and current lack of clarity for MACs.

Providers and suppliers may wish to take steps now to advocate for a smoother approach and to prepare operationally for a period of uncertainty. Providers and suppliers can communicate with their MACs to request information on how they will handle recoupment of advance and accelerated payments, and to request a brief grace period to account for the legislative process on Capitol Hill. Providers and suppliers also should continue to share feedback with CMS and the MACs regarding the internal disruption that could result from recoupment processes being started and stopped, and to urge CMS and the MACs to hold off on recouping funds until the timeline is finalized legislatively.

Finally, providers and suppliers can continue to put pressure on Congress to resolve this matter legislatively as quickly as possible. In the meantime, providers should take operational steps to prepare for recoupment to begin.

Wednesday, July 22, 2020

Six Reasons Your Risk Scores are Inaccurate

By Kameron Gifford, CPC

As we enter the third quarter of 2020, healthcare organizations have been struggling for months to balance priorities and resources while navigating new technologies and processes to keep employees and patients safe during the coronavirus.

The AAFP and MGMA both recently reported, “Medical group practices of all sizes and specialties have felt the direct and indirect financial impact... On average, patient volumes have dropped 60% nationally since the start of the pandemic attributing to a 55% decrease in fee-for-service revenues.  

Medical practices are not alone, hospital revenue is dropping by an average of $1.4 billion per day as COVID-19 continues to impact patient volumes, according to Crowe RCA Benchmarking analysis.

Risk Scores and Value-Based Payments
As more and more healthcare organizations are moving away from traditional fee-for-service payment models, how will this decrease in utilization impact risk scores and value-based payments in the future?

According to Avalere, the deferral of care has resulted in fewer claims and diagnoses among Medicare Advantage (MA) enrollees, which will likely lead to a 3%–7% reduction in 2021 risk scores and lower plan payments.

Mitigating the Impact to Risk and Quality
Inaccurate risk scores not only impact payments to Medicare Advantage plans, but also skew the costs in ACOs and hinder performance in value-based contracts. This further underscores the need to capture an accurate health status on every patient.

What steps can organizations take today to achieve accurate risk scores and mitigate future losses?

Common Errors Leading to Inaccurate Risk Scores
The 2020 ICD-10-CM code set includes 72,184 diagnoses and the 2021 ICD-10-CM code set includes 72,616 diagnoses. With less than 14% of ICD-10-CM codes mapping to an HCC, lack of specificity is the most common cause of inaccurate risk scores.  

Review the six most common coding errors below that lead to inaccurate risk scores and payments.

E11.9 – Type 2 Diabetes without Complications

According to the most recent data released by MedPAC on July 17, 2020, 28.2% of Medicare beneficiaries had a diagnosis of diabetes on a claim in 2019. Roughly 70% of these mapped to HCC 18, Diabetes with chronic complications, while 30% of these mapped to HCC 19, Diabetes without complications.

How does your coding for diabetes compare to MedPAC data? What percentage of patients are coded as E11.9 by primary care providers? What percentage are coded as E11.9 by specialists such as hospitalists and endocrinologists?

Per ICD-10 Guidelines, approximately 30 conditions have an assumed relationship with type 2 diabetes. Meaning, they are always coded as a complication unless the medical record explicitly states otherwise.

Examples include:
  • Type 2 Diabetes with CKD, E11.22
  • Type 2 Diabetes with dermatitis, E11.620
  • Type 2 Diabetes with foot ulcer, E11.621
  • Type 2 Diabetes with gastroparesis, E11.43
  • Type 2 Diabetes with hyperglycemia, E11.65
  • Type 2 Diabetes with hypoglycemia, E11.649
  • Type 2 Diabetes with mononeuropathy, E11.41
  • Type 2 Diabetes with myasthenia, E11.44
  • Type 2 Diabetes with nephropathy, E11.21
  • Type 2 Diabetes with neuralgia, E11.42
  • Type 2 Diabetes with neuropathy, E11.40
  • Type 2 Diabetes with PAD, E11.51
  • Type 2 Diabetes with periodontal disease, E11.630
  • Type 2 Diabetes with polyneuropathy, E11.42
  • Type 2 Diabetes with retinopathy, E11.319

Review 5 – 10 encounters per provider. What percentage of encounters coded as E11.9, had a complication documented in the medical record? Target education, prospective chart checks and pre-billing review per the results.

How it Happens
Several factors contribute to the high error rate related to coding for E11.9. The two most common reasons are failure to update the diagnosis as the disease progresses and failure to follow the ICD-10 Guidelines for “with”.

Why it Matters
The 2020 CMS-HCC RAF for HCC 19 is 0.105 and the 2020 CMS-HCC RAF for HCC 18 is 0.302. That is a loss of 0.197 per error. This adds up quickly across populations, accounting for annual average losses of $60,000 - $130,000 per 1000 MA beneficiaries.

F32.9, Major Depression, Single Episode, Unspecified

According to the most recent data released by MedPAC on July 17, 2020, 11.3% of MA beneficiaries were diagnosed with a condition mapping to HCC 59, Major Depressive, Bipolar or Paranoid Disorders.  

According to CMS, mood disorders (mainly MDD and bipolar disorder) are the second leading cause of disability in Medicare patients under the age of 65. Depression is a major predictor of the onset of stroke, diabetes, and heart disease; it raises patients’ risk of developing coronary heart disease and the risk of dying from a heart attack nearly threefold.

Overall, the economic burden of the disease is significant to managed care organizations, with direct medical costs estimated at $3.5 million per 1000 plan members with depression.

Identify Errors and Opportunities

From a coding perspective, MDD is classified by episode, severity, and remission.
According to AMJMED, 75% to 90% of patients experience >1 episode of depression. This suggests that only 10 - 25% of MDD diagnoses would be assigned to F32 with the remaining 75 – 90% being classified as F33.

Analyze your coding for MDD. What percentage of MDD diagnoses are single episodes (F32.x) vs. recurrent episodes (F33.x) What percentage of single episodes are classified as “unspecified” (F32.9) when a PHQ-9 was completed and/or the documentation supported a more specific diagnosis? What percentage of patients taking an SSRI or other antidepressant have a current diagnosis to support medical necessity?

Review 5-10 encounters per provider with a diagnosis of F32.9. Was the correct diagnosis assigned? Target education, prospective chart checks and pre-billing review per the results.

Why it Matters
From a risk adjustment perspective, F32.9, is the only MDD diagnosis that does not map to an HCC. The 2020 CMS-HCC RAF for HCC 59, Major Depressive, Bipolar and Paranoid Disorders is 0.309. Missed opportunities relating to the use of F32.9 average 20% across populations accounting for an average annual loss revenue of $77,500 per 1000 members.

How it Happens
Two factors contribute to the high use of this code. First, the GEM files mapped the ICD-9 code 311 to the ICD-10 code F32.9 and these files were widely used by EHR vendors. The second factor involves the number of boxes providers must check in their EHR to get to the more specific MDD diagnosis.

One way to avoid these extra clicks is by typing the diagnosis code directly into the search box of your EHR. For example, typing F32.0 (MDD, single episode, mild) vs depression will reduce clicks from 13 to 4 and reduce search results from 800+ to 1. Searching for F33.0 (MDD, recurrent, mild) vs recurrent depression will save even more clicks with the same results.

I25.9, Chronic Ischemic Heart Disease and I25.10, CAD without Angina

According to the NIH, an estimated 10 million adults in the United States carry the diagnosis and ischemic heart disease remains the number one cause of death for male as well as female patients. Furthermore, the increasing survival with the use of modern therapies has produced an aging population where more than 20% of women and 35% of men above the age of 80 have coronary artery disease.

Identify Errors and Opportunities
From a coding perspective, chronic ischemic heart disease is classified to category I25 and CAD is further classified as with or without angina.

Analyze your coding of chronic ischemic heart disease (I25.9) and CAD without angina (I25.10). Depending on your results you may also want to include old MI (I25.2) and chest pain (R07.9) in your search.

Review 5-10 encounters per provider. How many of these patients had evidence of angina documented, history of CABG and/or a current prescription for nitroglycerin? Target education, prospective chart checks and pre-billing reviews per the results.

How it Happens
The term stable ischemic heart disease (SIHD) is often used synonymously with chronic coronary artery disease (CAD) and encompasses a variety of conditions. Many EHR’s include an IMO to assist providers in searching for codes. This “tool” adds multiple code descriptions for each ICD-10 code and can increase search results by 70%. Many providers do not have the time to search dozens of code descriptions for multiple diagnoses prior to closing their note. This often results in the selection of the first or second result, even when a more specific diagnosis is supported by the documentation.

Why it Matters
From a risk adjustment perspective, I25.9 and I25.10 are included in the Rx-HCC Model V05, but not in the CMS HCC Model V24. However, CAD with Angina (I25.110 – I25.119) and Angina (I20.0 – 120.9, I23.7) are all included in the CMS HCC Model V24. The 2020 RAF for HCC 87 is 0.195 and HCC 88 is 0.135.

According to the CMS Chronic Disease Warehouse, 10,238,321 (or 17.1%) Medicare beneficiaries had a diagnosis of ischemic heart disease. While the most recent MedPAC data published on July 17, 2020 reveals only a 4% prevalence rate among MA beneficiaries in the same year.

Missed opportunities relating to the use of I25.9, I25.10, I25.2 and/or R07.9 average 25% across populations accounting for an average annual loss of $64,638 - $93,366 per 1000 MA members. 

I49.9, Cardiac arrythmia, unspecified

According to the most recent data released by MedPAC on July 17, 2020, 11.4% of Medicare Advantage members had a diagnosis that mapped into HCC 96, Specified Heart Arrythmias.

In the CMS-HCC Model V24, 18 ICD-10 codes are mapped into HCC 96.

Examples include:
  • AV Block, Complete, I44.2
  • SVT, I47.1
  • Paroxysmal A. Fib, I48.0
  • A. Flutter, I49.92
  • Sick Sinus, I49.5

Identify Errors and Opportunities
Analyze your coding for cardiac arrythmias. What percentage of encounters/claims are coded with I49.9, Cardiac arrhythmia, unspecified when the medical record supported a more specific diagnosis? 

You may also want to include the use the ICD-10-CM code Z95.810, Presence of automatic (implantable) cardiac defibrillator, in your analysis. Target education, prospective chart checks and pre-billing reviews per the results.

How it Happens
AHA Coding Clinic recently updated their guidance on coding for sick sinus syndrome treated with a pacemaker. This change in guidance has led to an increased number of opportunities identified in HCC 96. Additional opportunities are identified from diagnostic test results and specialists’ reports.

Why it Matters
I49.9, Cardiac arrhythmia, unspecified is not included in the 2020 CMS-HCC Model V24.
Missed opportunities relating to HCC 96 average 20% across populations accounting for average annual lost revenue of $67,214 per 1,000 MA beneficiaries.

N18.9, CKD, unspecified

According to the CMS Chronic Condition Warehouse, there were 9,360,944 Medicare beneficiaries (15.6%) with a diagnosis of CKD on a claim in 2018. However, a review of the most recent data released by MedPAC on July 17, 2020, does not include CKD, meaning the prevalence for MA members in the same year was less than 1.5%.

Why Is Chronic Kidney Disease Important?

The total Medicare spending on both CKD and ESRD patients was in excess of $120 billion in 2017. For identified CKD (not ESRD) the total Medicare expenditure was $84 billion.

Identify Errors and Opportunities
Analyze your coding for CKD. What percentage of encounters/claims are coded with N18.9, CKD, unspecified, vs. a more specific code such as N18.3 and/or N18.4?
You may also want to include the ICD-10 code N28.9, disorder of kidney and ureter, unspecified, in your analysis.

Review 5-10 encounters per provider. What percentage of encounters/claims are coded with an unspecified diagnosis such as N18.9 and/or N28.9, when a more specific diagnosis is supported by the medical record? Target education, prospective chart checks and pre-billing reviews per the results.

How it Happens
There are several factors that contribute to this large opportunity. Lack of documentation is the most common reason. CKD must be staged by the provider. Pasting a copy of the patient’s most recent labs into the current encounter supports the provider’s medical decision making but does not replace the need for the stage to be documented.
The fluctuating nature of the disease also contributes to the lack of specificity in coding, as providers are less likely to update.  

Historically, multiple terms have been applied to chronic kidney disease (CKD), eg, chronic renal insufficiency, chronic renal disease, and chronic renal failure, the National Kidney Foundation Kidney Disease Outcomes Quality Initiative™ (NKF KDOQI™) has defined the all-encompassing term, CKD. This recent change in terminology also contributes to the size of the opportunity. The IMO search tool in EHR’s will lead providers using older terminology such as, renal insufficiency, to select a diagnosis of N28.9

CKD stage 3 was removed from the HCC model in 2014 and this likely contributed to the decrease in coding by MA plans as well. CMS reversed course in PY 2019, and added HCC 138, CKD stage 3, back into the model.

Why it Matters
Missed opportunities relating to HCC 138, CKD stage 3, average 60% across MA populations accounting for annual average lost revenue of $73,625 per 1000 members.

Want to learn more? Visit and

ERM Consulting Inc. works with healthcare organizations across the country to optimize their risk adjustment operations.

Thursday, July 16, 2020

Take a Deep Dive Into Substance Use Disorders

Approved by the AAPC for 4 hours of CEU:

This program meets AAPC guidelines for 4.0 CEUs. Can be split between Core A, CRC, CEMC, CHONC, CANPC, CDEO, CPCO and CPMA after successful completion of post-test for continuing education units.


When is it appropriate to code for opioid dependence versus long time use?

What documentation is needed to support a diagnosis of alcoholism in remission? 

Should I code sedative dependence for all of my patients taking a sleeping medication?

Is it appropriate to code cannabis abuse when the medical record states recreational marijuana use? 

These are some of the most frequently asked questions by physicians and coders. 

This course takes a deep dive into the classification, screening, coding and documentation of the four most frequently coded substances: alcohol, cannabis, opioids and sedatives and substance-induced disorders. 

Register now - Course is FREE until August 1, 2020

Key Objectives:

Substance Use Disorders

  • Introduction
  • Brief history of Substance Use
  • Important Definitions

Classification of Substance Use Disorders

  • Introduction to DSM
  • Brief History of the DSM
  • Drugs of Abuse
  • Substance-Induced Disorders

Screening, Brief Intervention and Referral for Treatment

  • CAGE
  • DSAT-10

Coding for Substance Use Disorders

  • AHA Coding Clinic
  • ICD-10 Coding for Substance Use Disorders
  • Alcohol Use Disorders
  • Cannabis Use Disorders
  • Opioid Use Disorders
  • Sedative, Hypnotic, or Anxiolytic Use Disorders

Coding for Substance-Induced Disorders

  • Substance-Induced Anxiety Disorders
  • Substance-Induced Bipolar and Related Disorders
  • Substance-Induced Depressive Disorders
  • Substance-Induced Neurocognitive Disorders
  • Substance-Induced Sexual Dysfunctions
  • Substance-Induced Sleep Disorders

Clinical Documentation Improvement for Substance Use Disorders

  • Ten Tips for Success
  • Clinical Documentation Examples

Quality Measures for Substance Use Disorders

  • 2020 HEDIS Codes
  • 2020 CMS QM

Tuesday, July 14, 2020

Save 50% on ALL Workshops and Coding Tools

Are you looking for the best education available in risk adjustment, value-based payments and/or CDI?

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 any 2020 Workshop!

Take advantage of Early Bird pricing and Save $100!

  • Vast changes are coming to the way we purchase healthcare.
  • What should your team be doing now to be successful in the world of value-based payments? 
  • How do HCCs impact benchmarks and quality scores?
  • Review the CMS-HCC Model V24 for risk adjustment in 2020 and 2021. 
  • Discuss the importance of managing HCCs year over year. What resources are available from CMS to help? 
  • Take a deep dive into the 20 most common HCCs per Medpac data. 
  • Common GAPS in claims and encounter data that lead to inaccurate risk scores. 

Who Should Attend?
-Providers - MDs, DOs, PAs, and NPs
-Medical Directors - Medicare Advantage, ACOs, CPC+ and Medicaid
-Hospitals and Academic Medical Centers
-Medical Coders, Billers and CDI Specialists
-Executive Leaders, Administrators, Directors and Managers
-MSO and IPA Teams
-Rural Health Centers, FQHCs and Community Health Centers
-Health Alliance Members and Medical Society Members
-Medicare, Medicare Advantage, Medicaid and Commercial Plans

Each Attendee will Receive ($130):
 - Color copy of the presentation
 - CME from AAFP and AMA
 - CEU from AAPC

Please email Kameron Gifford

Early Bird Pricing and Group Discounts
Register NOW to save $100 with Early Bird Pricing!
Bring the WHOLE TEAM!
 Register 3 and save 10% on your order!

Order HCC Coding Tools for your Team and Save 50% 

Is Your Team Risk Ready?
Arm Your Team For Combat This Risk Adjustment Season!

Friday, July 10, 2020

Pulmonary Hypertension - HCC 85

What is Pulmonary Hypertension?

Pulmonary hypertension, defined as a mean pulmonary arterial pressure greater than 25 mm Hg at rest or greater than 30 mm Hg during exercise, is often characterized by a progressive and sustained increase in pulmonary vascular resistance that eventually may lead to right ventricular failure.

Types of Pulmonary Hypertension

Pulmonary arterial hypertension (PAH): 
This type of PH is caused by the changes in the walls of the small arteries of the lungs.

Pulmonary venous hypertension (PVH): 
This type of PH is caused by problems related to the left side of the heart such as heart valve disease, congestive heart failure and cardiomyopathy.

Other conditions that contribute to the development of PH

  • Aortic valve disease
  • Chronic obstructive pulmonary disease “COPD”: a group of lung diseases that block airflow and make it difficult to breathe.
  • Congenital heart disease
  • Liver cirrhosis: a disease that occurs when healthy cells in the liver are damaged and replaced by scar tissue, usually as a result of alcohol abuse or chronic hepatitis.
  • Autoimmune disease: a condition in which your immune system mistakenly attacks your body (e.g. lupus, rheumatoid arthritis and scleroderma).
  • Mitral valve disease
  • Pulmonary fibrosis: a type of lung disease that occurs when lung tissue becomes damaged and scarred.
  • Sickle cell disease: a condition in which there aren't enough healthy red blood cells to carry adequate oxygen throughout your body.
  • Obstructive sleep apnea: a condition in which your breathing abruptly stops and starts while sleeping.

Symptoms of Pulmonary Hypertension
The signs and symptoms of pulmonary hypertension in its early stages might not be noticeable for months or even years. As the disease progresses, symptoms become worse and begin to show. Various symptoms include:

  •          Abdominal bloating
  •         Shortness of breath during routine activity
  •         Fatigue
  •         Heart palpitations: when you feel like your heart is racing, pounding or fluttering.
  •         Heart arrhythmias
  •         Chest pain
  •         Decreased appetite
  •         Pain in your right side of the abdomen
  •         Rapid heart rate (tachycardia) of more than 100 beats per minute.
  •         Lightheadedness/Fainting
  •         Swelling in your ankles, legs and abdomen
  •         Bluish lips or skin (cyanosis)

Classification of Pulmonary Hypertension

The cause of pulmonary hypertension is classified by the World Health Organization into five groups.

Group 1- Pulmonary arterial hypertension: This grouping is caused by:

  • Certain drugs
  • Conditions that affect veins and small blood vessels of the lungs.
  • Congenital heart disease
  • Autoimmune disease (e.g. lupus, rheumatoid arthritis and scleroderma) is a condition in which your immune system mistakenly attacks your body.
  • Genetic tests
  • HIV infection
  • Liver disease
  • Sickle cell disease
  • Unknown cause

Group 2- Pulmonary hypertension caused by left-sided heart disease: This grouping is caused by:

  • Aortic valve disease
  • Cardiomyopathy
  • Congestive heart failure
  • Mitral valve disease

Group 3- Pulmonary hypertension caused by lung disease: This grouping is caused by:

  • Chronic obstructive pulmonary disease (COPD)
  • Interstitial lung disease
  • Long-term exposure to high altitudes
  • Sleep apnea and other sleep disorders

Group 4- Pulmonary hypertension caused by chronic blood clots: This grouping is caused by:

  • Chronic blood clots in the lungs or general clotting disorders.

Group 5- Pulmonary hypertension associated with other conditions that have unclear reasons why the pulmonary hypertension occurs: This grouping is caused by:

  • Blood disorders such as polycythemia vera and essential thrombocythemia.
  • Metabolic disorders such as thyroid and glycogen storage diseases.
  • Systemic disorders such as sarcoidosis and vasculitis.
  • Tumors pressing against pulmonary arteries.

Patients with pulmonary hypertension are normally classified into 4 symptom-based (functional) classes also described by the World Health Organization.

  • Class I: Patients in this category show no limitation of physical activity. Ordinary physical activity does not cause fatigue, palpitation or shortness of breath.
  • Class II: Patients in this category show slight limitation of physical activity. No symptoms at rest.
  • Class III: Patients in this category show great limitation of physical activity. No symptoms at rest.
  • Class IV: Patients in this category are unable to carry on any physical activity without discomfort. There are symptoms at rest.

Risk Adjustment / HCC Coding FAQs


If both pulmonary hypertension and heart failure are coded, will both diagnoses be added to the patient’s risk score? 


No, both diagnoses map to HCC 85. Each 

HCC category is only added to the risk score once.  

HCC Category
Community       Non-Dual, Aged
Community            FB Dual, Aged
HCC 85

There are a total of 61 ICD-10 codes included in HCC 85. See the complete list below. 

ICD-10 Description     
A36.81 Diphtheritic cardiomyopathy
B33.24 Viral cardiomyopathy
I09.81 Rheumatic heart failure
I11.0 Hypertensive heart disease with heart failure
I13.0 Hypertensive heart and CKD with HF and stage 1 through 4 CKD
I13.2 Hypertensive heart and CKD with HF and with stage 5 CKD, or ESRD
I26.01 Septic pulmonary embolism with acute cor pulmonale
I26.02 Saddle embolus of pulmonary artery with acute cor pulmonale
I26.09 Other pulmonary embolism with acute cor pulmonale
I27.0 Primary pulmonary hypertension
I27.1 Kyphoscoliotic heart disease
I27.20 Pulmonary hypertension, unspecified
I27.21 Secondary pulmonary arterial hypertension
I27.22 Pulmonary hypertension due to left heart disease
I27.23 Pulmonary hypertension due to lung diseases and hypoxia
I27.24 Chronic thromboembolic pulmonary hypertension
I27.29 Other secondary pulmonary hypertension
I27.81 Cor pulmonale (chronic)
I27.83 Eisenmenger's syndrome
I27.89 Other specified pulmonary heart diseases
I27.9 Pulmonary heart disease, unspecified
I28.0 Arteriovenous fistula of pulmonary vessels
I28.1 Aneurysm of pulmonary artery
I28.8 Other diseases of pulmonary vessels
I28.9 Disease of pulmonary vessels, unspecified
I42.0 Dilated cardiomyopathy
I42.1 Obstructive hypertrophic cardiomyopathy
I42.2 Other hypertrophic cardiomyopathy
I42.3 Endomyocardial (eosinophilic) disease
I42.4 Endocardial fibroelastosis
I42.5 Other restrictive cardiomyopathy
I42.6 Alcoholic cardiomyopathy
I42.7 Cardiomyopathy due to drug and external agent
I42.8 Other cardiomyopathies
I42.9 Cardiomyopathy, unspecified
I43    Cardiomyopathy in diseases classified elsewhere
I50.1 Left ventricular failure, unspecified
I50.20 Unspecified systolic (congestive) heart failure
I50.21 Acute systolic (congestive) heart failure
I50.22 Chronic systolic (congestive) heart failure
I50.23 Acute on chronic systolic (congestive) heart failure
I50.30 Unspecified diastolic (congestive) heart failure
I50.31 Acute diastolic (congestive) heart failure
I50.32 Chronic diastolic (congestive) heart failure
I50.33 Acute on chronic diastolic (congestive) heart failure
I50.40 Unspecified combined systolic (congestive) and diastolic (congestive) heart failure
I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure
I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.810 Right heart failure, unspecified
I50.811 Acute right heart failure
I50.812 Chronic right heart failure
I50.813 Acute on chronic right heart failure
I50.814 Right heart failure due to left heart failure
I50.82 Biventricular heart failure
I50.83 High output heart failure
I50.84 End stage heart failure
I50.89 Other heart failure
I50.9 Heart failure, unspecified
I51.4 Myocarditis, unspecified
I51.5 Myocardial degeneration

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