Saturday, February 20, 2021

Opioid Use Disorder


Opioid Use Disorder is defined by the DSM-5 as a “problematic pattern of opioid use…”

  • A code of F11.20, opioid dependence, should not be assigned for patients taking pain medication as prescribed.
  • Instead a code of Z79.891, long term use of opiates, should be assigned.

Coders should always be mindful of ICD-10 Guidelines and Coding Clinic Guidance when assigning codes for substance use disorder.

2021 ICD-10 Guidelines (pages 43-44)

Chapter 5: Mental, Behavioral and Neurodevelopmental disorders (F01 – F99)

b. Mental and behavioral disorders due to psychoactive substance use

3. Psychoactive Substance Use, Unspecified
As with all other unspecified diagnoses, the codes for unspecified psychoactive substance use (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-, F15.9-, F16.9-, F18.9-, F19.9-) should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis (see Section III, Reporting Additional Diagnoses). These codes are to be used only when the psychoactive substance use is associated with a physical disorder included in chapter 5 (such as sexual dysfunction and sleep disorder), or a mental or behavioral disorder, and such a relationship is documented by the provider.

AHA Coding Clinic Guidance

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.

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

Learn more or download a copy of DSM-5 Criteria here

Saturday, February 13, 2021

Looking for an MRA Coding Tool?

2021 CMS-HCC Coding Tool Example

We have received several requests from physicians, coders and administrators for an “MRA Cheat Sheet”.

Many have asked for something that is a single page or similar in format to a “charge slip”. 

So, I wanted to share a simple example of one that could be used for primary care providers. 

Visit for more risk adjustment tools and information!

Sunday, January 24, 2021

Advanced Risk Adjustment and HCC Coding for Value Based Payments

Due to extremely high demand, new dates have been added for the 2021 workshops!


Vast changes are coming to Medicare risk adjustment in 2022 and beyond. Is your team ready?

What are the potential impacts to your revenue without RAPS?

Discuss the importance of managing HCCs year over year. What resources are available from CMS to help?

What are the components of a risk score and how is it calculated? What is the impact of the payment count?

Review NEW HCCs and see what documentation is needed to validate payment.

Simple steps for optimizing risk adjustment operations and associated revenue.

Take a deep dive into the grey areas and red flags of HCC coding and clinical documentation. See what your team should and should not be coding.


  • Physicians and Other Providers
  • Coders, CDI Specialists and Auditors
  • Nurses, Medical Assistants and Scribes
  • Medical Directors and CIOs
  • MA, Medicaid and Commercial Plans
  • ACO, MSO and IPA Teams
  • Hospitals and Academic Centers
  • Community Health, RHCs and FQHCs
  • Health Alliance Members


  • Color Presentation
  • CME / CEU / CE Certificate (Approved by the AAPC, AMA, AAFP and CCMC)
  • HCC Coding Tools Download
  • 25% off any HCC Tools ordered within 14 days of the event.


Register here for Friday, February 19, 2021

Register here for Friday, March 26, 2021

Register here for Friday, April 23, 2021

Register here for Friday, May 28, 2021


Tickets - $49  

Bring the Whole Team and SAVE 10% on 3 or more tickets!!


Visit ERM365 ( to learn more.

Download the agenda / flyer 

Saturday, January 9, 2021

Medicare Risk Adjustment Operations


APPROVED by the AAPC for 5 CEUs

Course Overview

Medicare Advantage (MA) is one of the fastest-growing and most complex health plan lines of business representing significant growth opportunities for payers. Launching and/or managing a successful MA market requires careful, strategic planning to meet requirements, ensure compliance, and maximize the program benefits for your organization.

Success in this market will depend on success in each of the following essential areas:

  • Value-based contracting
  • Clinical documentation and coding
  • Delivering high quality care
  • Managing utilization

This course will touch on all four essential areas of MRA Operations.

Learn more or Register here

Review the Agenda below:

Risk Adjustment Operations

  • Medicare Risk Adjustment Overview
  • History of Medicare Risk Adjustment
  • Key Concepts and Terms
  • Risk Adjustment Data
  • Risk Adjustment Process
  • Risk Adjustment Data Validation

CMS-HCC Risk Models

  • PY 2020 CMS HCC Risk Adjustment Model
  • PY 2021 CMS HCC Risk Adjustment Model
  • PY 2022 CMS HCC Risk Adjustment Model

Calculating Risk Scores and Payments

  • General Payment Rules
  • Data Submissions and Payments
  • PY 2020 Risk Score Calculations
  • PY 2020 CMS-HCC Payment Calculation Example
  • PY 2021 Risk Score Calculations
  • PY 2021 CMS-HCC Payment Calculation Example

Optimizing RA Operations

  • Network Adequacy Guidance
  • Medicare Star Ratings
  • Growth and Retention
  • Reports and Resources

Visit to see more courses. 

Friday, January 8, 2021

MIPS Extreme and Uncontrollable Circumstances Exception Application Deadline Extended to February 1, 2021

For the 2020 performance year, MIPS eligible clinicians, groups, and virtual groups can submit an application to the Centers for Medicare and Medicaid Services (CMS) asking the agency to re-weight one or more performance categories to 0% due to the COVID-19 public health emergency. This means if you have concerns about the impact of the COVID-19 public health emergency on your performance data – including cost measures – you can submit an application to CMS and cite COVID-19 as the reason for your application.

CMS has recently announced that it will be extending the deadline for COVID-19-related 2020 Merit-based Incentive Payment System (MIPS) Extreme and Uncontrollable Circumstances Exception applications to February 1, 2021.

If you have concerns about the effect the COVID-19 public health emergency will have on your performance data for the 2020 performance period, including cost measures,  submit an application now and make sure you cite COVID-19 as the reason for your application. The deadline to submit a MIPS Promoting Interoperability Performance Category Hardship Exception application or an Extreme and Uncontrollable Circumstances application not related to COVID-19 remained December 31, 2020. If you are already exempt from reporting Promoting Interoperability data, you don’t need to apply.

Once you have an approved application, you can still receive scores for the Quality, Improvement Activities and Promoting Interoperability performance categories if you submit data. If the Cost performance category is included in your approved application, you will not be scored on cost measures even if other data are submitted. It is important to note that you cannot submit an application to override data for program year 2020 that has already been submitted and any data submitted either before or after an application has been approved will be scored. 

MIPS Extreme and Uncontrollable Circumstances Exception Application Deadline Extended to February 1, 2021 – Policy & Medicine