Recently, I have had a couple questions about different kinds of non- face-to-face visits and whether ICD-9 codes could be used for risk adjustment.

I have never seen any guidance from CMS to suggest that telephone visits were acceptable sources of risk-adjustment data.  Similarly, it is not acceptable for a remote, third-party physician to review lab results or some other kind of clinical summary and then submit new ICD-9 codes that were not captured during a proper face to face encounter with the patient.

From page “6-6” of the 2008 CMS Risk Training Guide-

“Co-existing conditions include chronic, ongoing conditions such as diabetes (250.XX, HCCs 15-19), congestive heart failure (428.0, HCC 80), atrial fibrillation (427.31, HCC 92), chronic obstructive and pulmonary disease (496, HCC 108). These diseases are generally managed by ongoing medication and have the potential for acute exacerbations if not treated properly, particularly if the patient is experiencing other acute conditions. It is likely that these diagnoses would be part of a general overview of the patient’s health when treating co-existing conditions for all but the most minor of medical encounters.

Co-existing conditions also include ongoing conditions such as multiple sclerosis (340, HCC 72), hemiplegia (342.9X, HCC 100), rheumatoid arthritis (714.0, HCC 38) and Parkinson’s disease (332.0, HCC 73). Although they may not impact every minor healthcare episode, it is likely that patients having these conditions would have their general health status evaluated within a data reporting period, and these diagnoses would be documented and reportable at that time.”

From the CMS ICD-9-CM Coding Guidelines…

“J. Chronic diseases

Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s)

K. Code all documented conditions that coexist

Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (V10-V19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment. “

For those of you who have not already read the CMS Impact study of ICD-10 on the Medicare space (July, 2009 by Nobilis), I wanted to present the Medicare Advantage/ risk adjustment related sections.

Download as .pdf file   ICD10_Impact_on_Risk_Adjustment

One of the most frequent questions to this blog is whether or not health plans can abstract ICD-9 codes from diagnostic radiology reports for risk-adjustment reporting.  The public guidance from CMS has been that such sources, whether institutional or professional-component are not acceptable for risk-adjustment.

“The following CPT codes indicate diagnostic radiology and other diagnoses that should not be submitted as risk adjustment data: 70010 through 76999 and 78000 through 78999″

“It is important for MA organizations to note that regardless of the type of diagnostic radiology bill (outpatient department or physician component), the services are not acceptable for risk adjustment.”

“CMS will not accept medical records for diagnostic radiology regardless of the type of bill (outpatient department or physician component) as support for data submission of a diagnosis. CMS recommends plans locate the medical record from the referring physician and determine if the diagnosis in question is based on the physician’s documentation in the medial record.”

*Quotes extracted from 2008 Risk Training guide and Feb 2008 CMS User Group Notes.

From yesterday’s CMS April 5, 2011 Announcement, pg. 2:

“Part C Risk Adjustment Model. Based on our interpretation of Congressional intent regarding changes in Part C payment methodology, CMS will not implement the new CMS-HCC and CMS-HCC ESRD dialysis risk adjustment models or the recalibrated frailty factors in 2011. CMS will implement these new models in 2012. To reference the factors in the CMS-HCC risk adjustment model that will be used in 2011, see the 2009 Rate Announcement (published in April 2008). To reference the factors in the CMS-HCC ESRD risk adjustment model that will be used in 2011, see the 2008 Rate Announcement (published in April 2007).”

Link to 2011 Announcement:

http://www.cms.gov/MedicareAdvtgSpecRateStats/AD/list.asp#TopOfPage

I am hearing from several of my readers that the 2011 HCC model codes will implemented starting payment year 2011.  This means that the new code crosswalk (to be finalized April 5th by CMS) will be implemented during the following dates of service windows.  The January 2011 preliminary payment rates will be set by the July, 2009 to June, 2010 12 month dates of service window using the new codes.  The July 2011 payment rates will be set by dates of service in CY2010 using the new codes.

I did a quick comparison of the ICD9s in the current  2010 Payment Year HCC-ICD9 crosswalk to the ICD9s mapped to the preliminary release of the 2011 CMS and found about 250 “newly added” ICD-9 codes that are not in previous models.  Again, this is a prelim release, so treat this file as an FYI that may change.  On tab 2 of the excel are the 100 or so ICD9s slated for deletion for PY2011.  Say goodbye to everyone’s favorite “412 Old Myocardial Infarction”.

2011_HCC_changed_ICD9s(PRELIM) XLS (excel)

Been getting lots of questions lately on which ICD-9 code sets are valid for a particular payment year.  CMS issued guidance on this in their 2009 Advance Notice.

“Starting with payment year 2009, RAPS will only accept valid ICD-9-CM codes for two fiscal years — the fiscal year that begins prior to the payment year and the fiscal year that begins during the payment year — for the CMS-HCC, ESRD, and RxHCC risk adjustment models. For example, for diagnoses codes to be used in 2009 final payment, i.e., for diagnoses from service dates between January 1, 2008 and December 31, 2008, RAPS will only accept codes that are valid for Fiscal Year 2008 and Fiscal Year 2009. (Please note that for the initial risk score run for payment year 2009, CMS will use valid diagnosis codes from FY 2007 and FY 2008 — services dates between July 1, 2007 and June 30, 2008.)”

Advance2009 PDF

According to the 2009 Risk User Group Q&A session, signature logs are acceptable to use if they were part of the health plan contractual arrangement with that provider during the time of service in question.

Here are the notes from the meeting – see highlights pg.3:  Jan2009_User_group_sig_logs (PDF)

CMS announced in the Oct 22, 2009 Fed Register that they plan to audit 110 MA plans total during the two year period of 2010-2011. All plans will have a 12-week deadline to submit the one best medical record to substantiate an HCC. Typically 700 HCCs will need to be validated on an approximate sample size of 200 patients. Discrepancies will be extrapolated on the plan level for that discrepant HCC rather than as formerly done on the individual beneficiary level.