Monday, July 6, 2020
Saturday, July 4, 2020
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?
- Click here to download the ICD-10 to HHS-HCC Mappings for payment year 2021.
- Click here to download the HCC Coefficients for payment year 2021.
Thursday, July 2, 2020
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.
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
Saturday, June 27, 2020
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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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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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
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 www.ERM365.org to learn more.
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.
▪ Primary hyperaldosteronism – E26.0 (HCC 23)
▪ Secondary hyperaldosteronism – E26.1 (HCC 23)
- 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.
▪ 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 www.ERM365.org to learn more.
Monday, June 22, 2020
Saturday, June 20, 2020
Wednesday, May 13, 2020
Is your practice looking for ways to increase revenue while protecting vulnerable patients?
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We build custom e-visits, virtual check-ins, online assessments and patient education that can be launched from your patient portal.
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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.
Friday, April 24, 2020
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