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.

Visit ERM365 to learn more

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.

Visit ERM365 to learn more

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.

Visit ERM365 to learn more

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

Visit ERM365 to learn more.

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

Visit ERM365 to learn more

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

Visit ERM365 to learn more

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

Visit to learn more.

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 

Saturday, June 20, 2020

Coding for AAA s/p Repair


How would an AAA be coded s/p EVAR? Is the coding the same with an open abdominal repair?


Coding for an AAA s/p repair, will depend on the type of surgical procedure:
For patients with EVAR, assign codes:
 – I71.4, AAA, without rupture
 – Z95.828, presence of other vascular implants and grafts
In EVAR, the graft reinforces the weakened section of the aorta to prevent rupture of the aneurysm. Over time, the aneurysm will shrink because of the lack of pressure on it. Patients who have an endovascular stent-graft must have the position of the stent-graft regularly monitored by a CT scan.

For patients who had an AAA open abdominal surgery repair, assign code:
 – Z95.828, presence of other vascular implants and grafts
In an open abdominal surgery, the damaged section of the aorta is removed and replaced with a synthetic tube (graft). In this case, the aneurysm no longer exists and would not be coded per ICD-10 guidelines.

Wednesday, May 13, 2020

Engage and Educate Your Patients with Custom E-Visits and Virtual Check-Ins

Is your practice looking for ways to increase revenue while protecting vulnerable patients?
If so, mHealth Games can help!

We build custom e-visits, virtual check-ins, online assessments and patient education that can be launched from your patient portal.

In need of a patient portal?
We can help with that too! Our patient portals start at $2,500 and can be completed in 7-10 days.

Recent projects include:

  • COVID-19 – Real-time monitoring of symptoms with personalized instructions
  • Heart Failure – Monitor daily weight and BP to prevent exacerbations
  • Diabetes – Patient management and education
  • COPD – Patient management and education
  • Major Depression – Online assessment and daily check-in
  • Substance Use Disorder – Patient management and education
  • Dermatology – Assessment of patient submitted images of skin rashes and other lesions


In all types of locations including the patient’s home, and in all areas (not just rural), established Medicare patients may have non-face-to-face patient-initiated communications with their doctors without going to the doctor’s office by using online patient portals. These services can only be reported when the billing practice has an established relationship with the patient.

For these E-Visits, the patient must generate the initial inquiry and communications can occur over a 7-day period. The services may be billed using CPT codes 99421-99423 and HCPCS codes G2061-G2063, as applicable. The patient must verbally consent to receive virtual check-in services. The Medicare coinsurance and deductible would apply to these services.

Medicare Part B also pays for E-visits or patient-initiated online evaluation and management conducted via a patient portal. Practitioners who may independently bill Medicare for evaluation and management visits (for instance, physicians and nurse practitioners) can bill the following codes:

99421: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5–10 minutes

99422: Online digital evaluation and management service, for an established patient, for up to 7 days cumulative time during the 7 days; 11– 20 minutes

99423: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes.

Clinicians who may not independently bill for evaluation and management visits (for example – physical therapists, occupational therapists, speech language pathologists, clinical psychologists) can also provide these e-visits and bill the following codes:

G2061: Qualified non-physician healthcare professional online assessment and management, for an established patient, for up to seven days, cumulative time during the 7 days; 5–10 minutes

 G2062: Qualified non-physician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 11–20 minutes

G2063: Qualified non-physician qualified healthcare professional assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes.


Medicare pays for these “virtual check-ins” (or Brief communication technology-based service) for patients to communicate with their doctors and avoid unnecessary trips to the doctor’s office. These virtual check-ins are for patients with an established (or existing) relationship with a physician or certain practitioners where the communication is not related to a medical visit within the previous 7 days and does not lead to a medical visit within the next 24 hours (or soonest appointment available). The patient must verbally consent to receive virtual check-in services. The Medicare coinsurance and deductible would generally apply to these services.

Doctors and certain practitioners may bill for these virtual check in services furnished through several communication technology modalities, such as telephone (HCPCS code G2012). The practitioner may respond to the patient’s concern by telephone, audio/video, secure text messaging, email, or use of a patient portal.  Standard Part B cost sharing applies to both. In addition, separate from these virtual check-in services, captured video or images can be sent to a physician (HCPCS code G2010).

HCPCS code G2012: Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.

HCPCS code G2010: Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment.

RHCs and FQHCs

RHCs and FQHCs may bill G0071, payment for communication technology-based services for 5 minutes or more of a virtual (non-face-to-face) communication between an RHC or FQHC practitioner and RHC or FQHC patient, or 5 minutes or more of remote evaluation of recorded video and/or image by an RHC or FQHC practitioner, occurring in lieu of an office visit; (RHC or FQHC only). G0071 will be paid at $24.76 beginning March 1, an increase from the prior rate of $13.53.

RHCs and FQHCs may also bill the “messaging” codes 99421–99423, on-line digital services.

MACs will automatically reprocess claims with G0071 for claims processed after March 1. The new rate is a blended rate, based on the payment rates of 99421—99423, and the two HCPCS codes for virtual communication, G2012 and G2010.

Visit mHealth Games today or contact Kameron Gifford to learn more. 

Friday, April 24, 2020

Advanced Risk Adjustment for Value Based Payments

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 CMS-HCC Model V24 for risk adjustment in 2020 and NEW HCCs that have been added to the model. 
  • 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
 - 2020 CMS-HCC Quick Coder
 - Laminated HCC and CDI Tools
 - 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!
 Register 4 and use the code TEAM4 to save 20% on your order!