Clinical Documentation Improvement Tips - HCC Coding

Clinical Documentation Improvement Tips - HCC Coding

* Clinical Documentation Improvement will be the key to a successful transition into ICD-10.

Over the last two years, I have been teaching medical professionals how to code and document compliantly - specifically HCC Documentation and Coding.

I have listed below the most common errors that I find when auditing medical records. 

• Don’t document “H/O” of any disease that currently exists.

– The statement “history of” in ICD-9 terms means that the patient no longer has this condition. However, “H/O” is ok when documenting some status conditions such as an Amputation, Old MI or Cancer

• Rule of thumb in coding is

– If a patient is on a medication for a condition and if the medication were to be stopped, would the condition resume, and the answer is mostly likely or yes, then you still code the condition.

Examples

– H/O CHF – pt is on lasix 428.0

– H/O Angina – pt has nitroquick 413.9

– H/O COPD – pt is on Advair 496

• This also applies to a pacemaker for SSS or Complete or 3^rd degree heart block…if the SSS or Heart Block is documented you can still code it 427.81 or 426.0

ALCOHOL AND DRUG DEPENDENCE

• Alcohol dependence, Chronic alcoholism or Alcoholism in remission 303.90 & 303.93

• Drug dependence or Drug dependence in remission

• (opiate, anxiolytic, sedative, hypnotic, hallucinogen or amphetamine) 304.90 & 304.93

• Patient has arrived at a stage of physical dependency and would experience physical signs of withdrawal with sudden cessation

 **Alcohol abuse and drug abuse are not HCC’s 305.XX

Major Depression 296.XX

– PHQ9 score >10

– 5 of 9 DSMIV criteria

– Medication

– Following with a mental health provider

– **if only “Depression” 311 is documented…it is not an HCC code!

Neoplasms

Must have current treatment to the site

Treatment to the site is considered:

• Chemotherapy, Radiation or Adjunct therapy

• Or if patient elects not to have any treatment

Breast Ca (174.9) – on Tamoxifan, Arimidex, Femara etc. would be considered adjunct therapy

• Documentation needs to say “Breast Ca onTamoxifan”

• If not then H/O Breast cancer V10.3

Prostate Ca (185) – on Lupron, Casodex or Zoladex would be considered adjunct therapy

• Documentation needs to say “Prostate Ca on Lupron”

•If not then H/O Prostate Ca. V10.46

METASTATIC CANCER

• Mets is the highest HCC $17,753 – only if the site it has metastasized to is documented

– H/O Breast Ca with Mets to lung V10.3 & 197.0

– Prostate Ca on Lupron with bone Mets 185 & 198.82

– H/O Colon Ca with Mets to the liver V10.05 & 197.7

• If you document like this the highest HCC opportunity will be missed

– Metastatic Breast Ca $1622 (if Breast ca is under treatment) 174.9 & 199.1

– Metastatic Colon Ca $1622 (if Colon ca is under treatment) 154.0 & 199.1

– Lung Ca with Mets $8213 (if Lung ca is under treatment) 162.9 & 199.1

– H/O Lung Ca with Mets $1622 V10.11 & 199.1

CVA

Acute condition that can only be documented and coded during the initial episode of care – 434.9X

– Once the patient is discharged from hospital documentation should reflect:

  “h/o CVA, s/p CVA or Old CVA V12.54”

UNLESS THEY HAVE A LATE EFFECT!

• Late effects of CVA should be documented and coded as such

– CVA with hemiplegia/hemiparesis 438.20

– CVA with dysphagia 438.82

DVT

Acute DVT (initial episode of care)

– 453.40

• Chronic DVT (on an anti-coagulant)

– 453.50

• H/O DVT (not on an anti-coagulant)

– V12.51

Need to document “chronic DVT” if patient is on an anti-coagulant

*** Same guidelines for Pulmonary Embolism

COMMON OMISSIONS YEAR OVER YEAR

• Artificial openings

– Gastrostomy V44.1

– Colostomy V44.3

– Tracheostomy V44.0

– Ileostomy V44.2

• Amputations

– BKA V49.75

– AKA V49.76

– Foot V49.73

– Toe V49.71 or V49.72

• AAA – Abdominal aortic aneurysm – 441.1 (w/o repair)

• Aortic Atherosclerosis – 440.0

Contact Kameron Gifford, CPC at ERM Consulting for a free Revenue Risk Assessment 
877-938-9232

www.ermconsultinginc.com