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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Thursday, July 9, 2020

CMS Issues ABN Update

Are you using the most current ABN?

A new Fee-for-Service Advanced Beneficiary Notification of Non-coverage (ABN) form is now effective, with an expiration date of June 30, 2023. The use of the old ABN (version 03/2020) will be considered invalid after Aug. 31, 2020.

What’s Changed in the ABN?

Guidelines for dual eligible beneficiaries (patients with both Medicare and Medicaid coverage) have been added to the ABN form instructions. The changes were necessary to comply with billing prohibitions for patients in a Qualified Medicare Beneficiary (QMB) program. The QMB program helps pay Part A, Part B, or both program premiums, deductibles, coinsurance, and copayments.

Special Instructions Apply

Patients in a QMB program cannot be charged for Medicare cost sharing for covered Parts A and B services, nor can they elect to pay Medicare cost sharing. As such, special instructions apply when a provider issues an ABN to a dual eligible beneficiary:

Dually eligible beneficiaries must be instructed to check Option Box 1 on the ABN in order for a claim to be submitted for Medicare adjudication.

Strike through Option Box 1 as provided below:

□ OPTION 1. I want the D. [service or supply] listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN.

If Medicare denies a claim where an ABN was needed in order to transfer financial liability to the patient, the claim may be crossed over to Medicaid or submitted by the provider for adjudication based on state Medicaid coverage and payment policy.

Once the claim is adjudicated by both Medicare and Medicaid, providers may only charge the patient in the following circumstances:

If the patient has QMB coverage without full Medicaid coverage, the ABN could allow the provider to shift financial liability to the patient per Medicare policy.

If the patient has full Medicaid coverage and Medicaid denies the claim (or will not pay because the provider does not participate in Medicaid), the ABN could allow the provider to shift financial liability to the patient per Medicare policy, subject to any state laws that limit beneficiary liability.
These instructions should only be used when the ABN is used to transfer potential financial liability to the beneficiary and not in voluntary instances.

Find Out More About ABNs

More information on dual eligible beneficiaries may be found on the CMS website. Guidelines for issuing the ABN can be found beginning in Section 50 in the Medicare Claims Processing Manual, Pub. 100-4, Chapter 30. The revised ABN form may be downloaded from the CMS website.

Visit ERM365 to learn more.

Read more from the AAPC Blog

Wednesday, July 8, 2020

CMS-HCC to ICD-10 Mappings for 2021

CMS has released the initial ICD-10 Mappings and Software for 2021. 
 – The V24 (HCC) Model includes 9,757 ICD-10 Codes 
 – The V05 (RxHCC) Model includes 4,381 ICD-10 Codes
Click on a file below to download.

Monday, July 6, 2020

CMS Innovation Center COVID-19 Flexibilities

Centers for Medicare & Medicaid Services (CMS) has announced flexibilities and adjustments for current and future alternative payment models administered by the Center for Medicare and Medicaid Innovation (CMMI) to accommodate relevant participants, providers and stakeholders during the COVID-19 public health emergency. While CMS announced that additional details regarding model-specific flexibilities will be released on a rolling basis, CMS leadership authored a blog post and released a table that outlines the models and changes applicable to relevant models.
CMS has utilized existing flexibilities built into current bundled payment models, as well as aligned its additional adjustments with COVID-19 public health emergency flexibilities available on a Medicare fee for service basis. CMS also aimed to adjust financial methodology for performance-based rewards and repayment obligations during the public health emergency to accomplish the following:
  • Encourage continued participation in CMMI alternative payment models and ensure higher quality outcomes.
  • Create equity and consistency across models.
  • Reduce risk for model participants and the Medicare and Medicaid programs.
For example, certain models exclude COVID-19 cases or may reduce exposure for downside risk during the public health emergency. Other flexibilities offered by CMS involve quality reporting changes, including extending deadlines or implementing exceptions. Lastly, CMS announced adjustments to certain model timelines due to COVID-19. CMMI will extend timelines for certain existing models and delay starts for upcoming models.
A full version of the table outlining CMMI flexibilities is available here, which addresses the following models:
  • Bundled Payments for Care Improvement Advanced Model.
  • Comprehensive ESRD Care Model.
  • Comprehensive Care for Joint Replacement Model.
  • Direct Contracting Model.
  • Emergency Triage, Treat and Transport Model.
  • Oncology Care Model.
  • Home Health Value-Based Purchasing Model.
  • Independence at Home.
  • Integrated Care for Kids Model.
  • Kidney Care Choices.
  • Maternal Opioid Misuse Model.
  • Medicare Choices Model.
  • Medicare Diabetes Prevention Program Expanded Model.
  • Primary Care First Model.
  • Medicare ACO Track 1+ Model.
  • Next Generation ACO.
Additionally, in separate guidance, CMS published flexibilities in response to COVID-19 for the Medicare Shared Savings Program, available here.

Saturday, July 4, 2020

HHS Notice of Benefit and Payment Parameters for 2021 Final Rule


What are the HHS-HCC categories for 2021 and where can I find the risk adjustment factors? What ICD-10 codes map to an HHS-HCC for 2021?


Links to Important Resources

Regulations and Guidance – Includes model software
Registration not required.

REGTAP Registration for Technical Assistance Portal
Must register for a free account to access information.

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Thursday, July 2, 2020

Reducing the Burden of Clinical Documentation


What are the CMS documentation guidelines for who may elicit and document the patient’s history, including ROS, HPI and PFSH? Is it acceptable for my medical assistant to document the ROS, HPI and PFSH if I review the information?


Yes, as of 1/1/2019, CMS has modified previous rules relative to history discussion and documentation. As per CMS MLN11063, effective on 1/1/2019:

“For established patient office/outpatient visits, when relevant information is already contained in the medical record, practitioners may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed. Practitioners should still review prior data, update as necessary and indicate in the medical record that they have done so.

CMS is clarifying that for E/M office/outpatient visits, for new and established patients for visits, practitioners need not re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information.” 

The physician must still personally perform the physical exam and medical decision-making activities

Work Smarter, Not harder...

The single most common complaint when educating physicians on proper documentation for HCCs is the amount of time it takes to document a complete ROS and HPI. Up-training medical assistants and nurses to take and document the history components can significantly reduce the time physicians spend documenting and increase the time they spend taking care of patients. 

Visit ERM365 to learn more. 

Diabetes and Hypercoagulability


Can a diagnosis of  secondary hypercoagulable state, (D68.69) be assigned for an uncontrolled diabetic patient who is treated with 81 mg ASA QD?


Yes, as long as the documentation links the diabetes to the hypercoagulable state.

The coagulability of the blood is crucially important in ischemic cardiovascular events because the majority of MI and stroke events are caused by the rupture of atherosclerotic plaque and the resulting occlusion of a major artery by a blood clot (thrombus).

Up to 80% of patients with diabetes die a thrombotic death. Seventy-five percent of these deaths are the result of an MI, and the remainder are the result of cerebrovascular events and complications related to PVD.

The first defense against a thrombotic event is the vascular endothelium. Diabetes contributes to widespread endothelial dysfunction. The endothelium and the components of the blood are intricately linked, such that clotting signals initiated in the endothelial cell can activate platelets and other blood components, and vice versa.

Patients with diabetes exhibit enhanced activation of platelets and clotting factors in the blood. Increased circulating platelet aggregates, increased platelet aggregation in response to platelet agonists, and the presence of higher plasma levels of platelet coagulation products, such as beta-thromboglobulin, platelet factor 4, and thromboxane B2, demonstrate platelet hyperactivity in diabetes. Coagulation activation markers, such as prothrombin activation fragment 1+2 and thrombin–anti-thrombin complexes, are also elevated in diabetes. In addition, patients with diabetes have elevated levels of many clotting factors including fibrinogen, factor VII, factor VIII, factor XI, factor XII, kallikrein, and von Willebrand factor.

Conversely, anticoagulant mechanisms are diminished in diabetes. The fibrinolytic system, the primary means of removing clots, is relatively inhibited in diabetes because of abnormal clot structures that are more resistant to degradation, and also because of an increase in PAI-1.47

Clinicians attempt to reverse this hypercoagulable state with aspirin therapy, widely recommended for use as primary prevention against thrombotic events in patients with diabetes. However, numerous studies have suggested that aspirin in recommended doses does not adequately inhibit platelet activity in patients with diabetes.

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Tuesday, June 30, 2020

Coding for Diabetes with Complications


If a patient has multiple diabetic complications, will coding all of them have an impact on the risk score?


  • Credit is given once for each HCC category captured within the calendar year (after hierarchies are implied).
  • Depending on the specific complication, additional credit may be given for the HCC of the complication.

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Saturday, June 27, 2020

Coding for Morbid Obesity


When the BMI is below 40, but morbid obesity is documented by the anesthesiologist (no other documentation regarding the patient’s obesity is recorded in the health record), is it appropriate to code morbid obesity or is a query recommended?


Codes for overweight, obesity or morbid obesity are assigned based on the provider’s documentation of these conditions.

Therefore, if morbid obesity is documented, assign code E66.01, morbid (severe) obesity due to excess calories.

While the BMI is used as a screening tool for patients who are overweight or obese, there is no coding rule that defines what BMI values correspond to obesity or morbid obesity since the conditions are coded only when diagnosed and documented by the provider or another physician involved in the patient’s care.

AHA Coding Clinic, Fourth Quarter 2018, pp. 79 – 80

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Coding for Prescription Pain Medication


Medical record documentation indicates the patient is taking opioids prescribed by their physician for treatment of chronic pain. Does Guideline I.C.5.b.3. mean that codes cannot be assigned for the opioid use unless there is documentation of an associated physical, mental or behavioral disorder?


A code for the use of prescription opiates would not be reported because there is no associated physical, mental or behavioral disorder.

 – AHA Coding Clinic 2018 2nd Quarter, pages 11 and 12

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Coding for Recreational Marijuana Use


Should recreational marijuana use be coded when documented by the patient’s provider?


No, a code for the marijuana use is not assigned unless the provider documents an associated physical, mental, or behavioral disorder in accordance with ICD-10 Guideline I.C.5.b.3.

This guideline states “As with all other diagnoses, the codes for psychoactive substance use (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-, F15.9-, F16.9-) should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis (see Section III, Reporting Additional Diagnoses). The codes are to be used only when the psychoactive substance use is associated with a physical, mental or behavioral disorder, and such a relationship is documented by the provider.”

– AHA Coding Clinic 2018, Second Quarter, page 11

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Tuesday, June 23, 2020

Data Submission Deadlines for Medicare Advantage


When does CMS run the risk score model to calculate risk scores for Medicare Advantage? What is the deadline for submitting claims data? 


The chart above highlights when CMS will the risk model to calculate risk scores for the PY 2021 Initial Run. Dates of service included and data submission deadlines are also highlighted above.

Visit to learn more.

Coding for Hyperaldosteronism


How is hyperaldosteronism coded in ICD-10? Does the etiology impact code choice?


Hyperaldosteronism occurs due to the excess production of aldosterone from the adrenal gland.

Hyperaldosteronism can initially present as essential and refractory hypertension and can often go undiagnosed. This disorder can be of primary or secondary origin, both presenting similarly but differentiated by a set of lab values and diagnostic studies. Treatment is specific to the individual causes of hyperaldosteronism.

Its primary or secondary origin can differentiate hyperaldosteronism.

Primary hyperaldosteronism is due to the excess production of the adrenal gland, more specifically the zona glomerulosa. This can present more commonly as a primary tumor in the gland known as Conn syndrome or bilateral hyperplasia. Rarer forms are unilateral adrenal hyperplasia, ectopic aldosterone-secreting tumors, aldosterone-producing adrenocortical carcinomas, and familial hyperaldosteronism type 1.

Secondary hyperaldosteronism occurs due to excess activation of the renin-angiotensin-aldosterone system (RAAS). This activation can take the form of a renin-producing tumor, renal artery stenosis, or edematous disorders like left ventricular heart failure, pregnancy, cor pulmonale, or cirrhosis with ascites.

ICD-10 Codes

▪ Primary hyperaldosteronism – E26.0 (HCC 23)
▪ Secondary hyperaldosteronism – E26.1 (HCC 23)

Documentation Tips

  • Document the clinical findings which lead to the diagnosis of the primary condition responsible for the aldosteronism and the status, the diagnosis of secondary aldosteronism, and a plan of care.
  • As with most secondary diagnoses due to an underlying primary condition, the causal condition should be identified and documented, if known.

For Example:

▪ Secondary aldosteronism (E26.1) due to heart failure (I50.9)

▪ Alcoholic cirrhosis of liver with ascites (K70.31) and secondary hyperaldosteronism (E26.1)

▪ Aldosteronism, secondary (E26.1) due to severe renal artery stenosis (I70.1)

Download Quick Reference

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Monday, June 22, 2020

Coding for Chronic Orthostatic Hypotension


How is orthostatic hypotension coded in ICD-10? Does the pathophysiology or severity of OH impact the code choice?


Orthostatic hypotension (OH) can be divided into 2 pathophysiological subtypes: neurogenic and non-neurogenic.
In ICD-10, chronic neurogenic orthostatic hypotension is coded to G90.3 (HCC 78) and chronic non-neurogenic orthostatic hypotension is coded to I95.1 or I95.2, if OH is due to drugs. See ICD-10 Index below. 

Download Quick Reference:  Orthostatic Hypotension