Comments for HCC Blog

Comment on hccblog by jmarino

jmarino — Wed, 18 Jan 2012 16:34:28 +0000

Hi Matt,
Sorry to see you go.
I for one have sure appreciated you being so open to sharing information on HCC.
Thank you for all the hours you commited to this Blog site.
I wish you a happy and healthy 2012!

Comment on Dentists correction by mistmi01

mistmi01 — Thu, 21 Jul 2011 14:39:54 +0000

All dentists are physicians under Medicare law (SSA 1861(r)1). Like all limited license practitioners, coverage of their services under Medicare is driven both by their scope of practice, and Medicare coverage guidelines. For risk adjustment purposes, they don’t have to be oral surgeons or oral maxillofacial surgeons, they just have to perform a service covered by Medicare–Medicare covers dental services that are an integral part of either a covered procedure (i.e., reconstruction of the jaw following accidental injury), or for extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw. Medicare also covers oral examinations,
but not treatment, preceding kidney transplantation or heart valve replacement, under certain circumstances.

Comment on Q & A of the day: Submitting ICD-9-CM codes – from claims only? by J. Matt Yuill, M.D., CPC

J. Matt Yuill, M.D., CPC — Mon, 16 May 2011 14:46:08 +0000

See pg. 2-2, and 7-3 of the risk training guide.

Comment on Q & A of the day: Submitting ICD-9-CM codes – from claims only? by Lmarie

Lmarie — Mon, 16 May 2011 14:30:53 +0000

Thank you for your quick response! Do you know where I might find this in either the Risk Adjustment training manual or on the CMS website?

Comment on Nursing notes by J. Matt Yuill, M.D., CPC

J. Matt Yuill, M.D., CPC — Mon, 16 May 2011 14:01:59 +0000

A health plan does not need a provider’s permission to submit documented ICD-9-CM codes to the RAPS database. Any documented chronic or acute condition that a certified coder could abstract from the proper face-to-face documentation (i.e. signed, dated, credentialed by acceptable specialty type) may be submitted for risk adjustment purposes. All of the chart auditing vendors and any coders working for a plan may abstract and code diagnoses that are properly documented and submit to the plan or submit to CMS on behalf of the plan.

Ideally, these additional codes would be submitted on claims in the first place for ease of processing, but you may submit ICD-9-CM codes to RAPS that have been collected in other means, such as a superbill, chart audit, etc.

Comment on Nursing notes by Lmarie

Lmarie — Mon, 16 May 2011 13:47:34 +0000

Does a health plan need the facility’s (clinic) permission to add a chronic condition to a claim when the evidence of evaluation and treatment is found in the documentation? Our problem is the very rural areas are coders who do not know anything about risk adjustment and are constantly disagreeing with out findings because they think you ONLY code the reason for the visit no matter what information I give them regarding the importance of coding chronic conditions when addressed/assessed and treated. Any guidance you can offer would be a great help!

Comment on Chronic Conditions coding guidance – for Outpatient Records by Karen Hylan

Karen Hylan — Fri, 25 Mar 2011 11:09:12 +0000

I agree there is a lot of confusion and conflicting information out there regarding documentation of chronic conditions to support an HCC. In the past we were told CMS would ‘accept’ certain chronic diseases such as DM, COPD, Parkinson’s ect without any supporting documentation of active management, treatment ect as it was ‘assumed’ that these conditions always influence care.

A speaker at a recent presentation on risk adjustment stated the physician’s note must ALWAYS have documentation that condition influenced care to hold up in RADV audit. This advice was quite different from past advice.

Coding Clinic, Third Quarter 2007 Page: 13 to 14 addresses chronic conditions and states: Chronic conditions such as, but not limited to, hypertension, Parkinson’s disease, COPD, and diabetes mellitus are chronic systemic diseases that ordinarily should be coded even in the absence of documented intervention or further evaluation. This advice applies to INPATIENT coding. For OUTPATIENT encounters/visits, chronic conditions that require or affect patient care treatment or management should be coded”.

Based on Coding Clinic clarification I would say chronic conditions in outpatient encounters such as a physician’s office require some evidence that condition was addressed in order to code. Thoughts?

I would greatly appreciate clarification on this issue especially regarding validation of an HCC in an RADV audit. Does anyone have first hand experience or knowledge of how CMS would regard documentation that was not substantiated? We see numerous physician notes in which provider simply documents ‘DM’ or ‘COPD’ with no further mention of assessment.

Comment on Changes to HCC model in 2012 by J. Matt Yuill, M.D., CPC

J. Matt Yuill, M.D., CPC — Mon, 14 Feb 2011 19:11:29 +0000

Agree – my understanding is that it is the former. 2012 New Model Changes will be based on Service Dates and ICD9 codes collected through 2011 calendar year.

Comment on Changes to HCC model in 2012 by JRF

JRF — Mon, 14 Feb 2011 16:19:31 +0000

Will the changes impact 2012 payment methodology or 2012 diagnostic service dates? If the former than these changes are already in place – that is 2011 DOS diagnoses are the basis for 2012 payment.

Comment on Chronic Conditions coding guidance – for Outpatient Records by LJ620

LJ620 — Wed, 12 Jan 2011 14:33:24 +0000

Our plan was just notified that we have been selected for RADV audit. One big concern I have is being able to substantiate chronic conditions. In the previous post the example of CHF is noted. Is it enough that it is mentioned in past history or does the note have to contain some concrete evidence that the provider considered this condition in the evaluation? Can these conditions be submitted when you review EHR notes and every note is virtually the same?