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Todd Gifford, MBA


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It has taken CMS more than 50 years, but the agency has finally proposed a regulatory definition for determining whether an item or service is "reasonable and necessary" for Medicare coverage purposes. Medicare Program; Medicare Coverage of Innovative Technology (MCIT) and Definition of "Reasonable and Necessary," 85 Fed. Reg. 54327 (Proposed Rule, September 1, 2020). This move comes in response to the President's October 3, 2019 Executive Order 13890 directing the Secretary of HHS to ensure that Medicare beneficiaries have access to new cures and technologies that improve health outcomes. While CMS simultaneously seeks to establish a Medicare coverage pathway for medical devices designated as breakthrough by the FDA in this proposed rule, the proposed regulatory definition, including a possible consideration of whether an item or service is covered in the commercial insurance market, marks some progress toward clarifying when Medicare coverage is available. Comments to the proposed rule must be received by November 2, 2020.

"Reasonable and Necessary"

CMS explains that it is proposing to establish in regulations the factors it has historically used in making "reasonable and necessary" determinations under Section 1862(a)(1)(A), with "some modification." 85 Fed. Reg. at 54329. It acknowledged that stakeholders have expressed interest in codifying this definition for many years and that the proposed definition is "familiar and functional." 85 Fed. Reg. at 54328. The factors used by CMS for this purpose are set forth in the Medicare Program Integrity Manual (MPIM) and state that:

An item or service is considered "reasonable and necessary" if it is

(1) safe and effective;(2) not experimental or investigational; and(3) appropriate, including the duration and frequency that is considered appropriate for the item or service, in terms of whether it isfurnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body member;furnished in a setting appropriate to the patient's medical needs and condition;ordered and furnished by qualified personnel;one that meets, but does not exceed, the patient's medical need; andat least as beneficial as an existing and available medically appropriate alternative.

MPIM, CMS 100-08, ch. 13, § 13.5.4.

In addition to codifying the above criteria, CMS is proposing to include a separate basis under which an item or service would be "appropriate for Medicare patients" based on commercial health insurers' coverage policies (non-governmental entities that sponsor health insurance plans). And, CMS states that an "item or service deemed appropriate for Medicare coverage based on commercial coverage would be covered on that basis without also having to satisfy the bullets listed above." 85 Fed. Reg. at 54328.

By considering commercial health insurer coverage policies, CMS states that it would bring together the expertise of private payers and the Medicare program. Under this separate basis, CMS proposes that an item or service would satisfy factor (3) above if it is "covered under a plan(s) coverage policy if offered in the commercial insurance market, unless evidence supports that differences between Medicare beneficiaries and commercially insured individuals are clinically relevant." 85 Fed. Reg. at 54332. Under this proposal, CMS would exclude Medicaid managed care, Medicare Advantage, and other government administered health care coverage programs from the types of coverage CMS would consider, as these enrollees are not in the commercial market. CMS believes this definition is a "significant step in meeting the E.O.'s directive to bring clarity to coverage standards."

CMS specifically seeks comment on a myriad of issues related to this proposed definition, which include, among others, the following:

The sources of data that could be used to implement this policy;The most appropriate source(s) for these coverage policies and best way to determine which commercial plan(s) it would rely on for Medicare coverage;Whether beneficiaries, providers, innovators, or others wishing to gain coverage for an item or service demonstrate that the item or service is covered by at least one commercial insurance plan policy. If they can provide CMS with evidence of commercial coverage or if CMS or its MACs identify such coverage from its review of compilations of health insurance offerings or data from other sources, CMS would consider factor (3) to be satisfied;Whether CMS should limit its consideration of commercial plan offerings or covered lives to a subset of the commercial market in the interest of simplicity, including looking at geographic subsets, subsets based on number of enrollees, subsets based on plan type (HMO, PPO, etc.), or other subsets of plans – including utilizing a singular plan; andWhether CMS should adopt the most or least restrictive coverage policy since commercial plans may impose certain restrictions on an item or service (related to clinical criteria, disease stage, or number and frequency of treatment).

85 Fed. Reg. at 54332-54333.

In sum, CMS is proposing to define the term "reasonable and necessary" based on the factors currently found in the MPIM, plus an alternative basis for meeting factor (3) based on any coverage in the commercial market. As CMS states, it is soliciting comment on this proposed definition of reasonable and necessary as well as other mechanisms or definitions it could establish for the term "reasonable and necessary" and the merits and drawbacks associated with each, including the potential impact on Medicare program expenses or complexity.

Key Takeaways

To be sure, CMS did not propose this regulatory definition in a vacuum. This definition, if finalized, would be codified within 42 C.F.R. Part 405, Subpart B, which addresses "Medical Services Coverage Decisions that Relate to Health Care Technology." In this proposed rule and not discussed in detail here, CMS also seeks national Medicare coverage for breakthrough devices that are FDA market-authorized and used consistent with the FDA approved or cleared indication for use. For these devices, CMS will deem coverage under the MCIT pathway "reasonable and necessary under section 1862(a)(1)(A) of the Act because the device has met the unique criteria of the FDA Breakthrough Devices Program." 85 Fed. Reg. at 54329.

What is markedly absent from this proposed regulatory definition is an explicit requirement that this new regulatory definition be used solely for medical devices participating in the MCIT pathway and/or the FDA Breakthrough Devices Program. In fact, CMS explains:

Further, under our proposal, each MAC would be responsible for reviewing commercial offerings to inform their LCDs or claim by claim decisions, which would include individual medical necessity decisions. We may also allow the MACs to develop approaches to address any or all of the considerations outlined above, parallel to their current practice of making coverage decisions in the absence of an NCD or national policy.

85 Fed. Reg. at 54332.

While it remains to be seen whether claim adjudicators may utilize this proposed regulatory definition for other services or items outside of the FDA Breakthrough Devices Program or MCIT pathway, this could be useful for individual consideration of Medicare claims since any additional clarification to the subjective "reasonable and necessary" is helpful.

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Effective Dates

The 2021 ICD-10-CM files below contain information on the ICD-10-CM updates for FY 2021. These 2021 ICD-10-CM codes are to be used for discharges occurring from October 1, 2020 through September 30, 2021 and for patient encounters occurring from October 1, 2020 through September 30, 2021.


2021 Coding Guidelines (PDF)

2021 POA Exempt Codes (ZIP)

2021 Code Descriptions in Tabular Order (ZIP)

2021 Addendum (ZIP)

2021 Code Tables and Index (ZIP)

2021 Conversion Table (ZIP)

Overview of Changes

The final update includes hundreds of new ICD-10-CM codes including (but not limited to):

128 additions to Chapter 19: Injury, poisoning and certain other consequences of external causes for adverse effects and poisoning by fentanyl and tramadol as well as other synthetic narcotics.125 additions to Chapter 20: External causes of morbidity, including more specific codes for collisions involving electric scooters and other nonmotor vehicle accidents.57 musculoskeletal codes, including several in category M24.- (other specific joint derangements) for other articular cartilage disorders, disorders of ligament, pathological dislocation, recurrent dislocation, contracture, and ankylosis.21 codes to describe withdrawal from substances including alcohol, cocaine, and opioids.18 detailed codes for sickle cell anemia. New codes such as D57.213 (sickle-cell/Hb-C disease with cerebral vascular involvement) and D57.431 (sickle-cell thalassemia beta zero with acute chest syndrome) specify complications related to the condition.Three codes to capture stage 3 chronic kidney disease (CKD) in two new sub-stages. The new Chapter 22: Codes for Special Purposes (U00-U85) so far includes just two codes: U07.0 (vaping-related disorder) and U07.1 (COVID-19), which took effect in the early part of this year.The final update deletes code Q51.20 (other doubling of uterus, unspecified) and all codes within subcategory T40.4X- (poisoning by adverse effect of and underdosing of other synthetic narcotics), without code replacements.Visit ERM365 to learn more


Why OIG Did This Audit

This audit involved individuals eligible for Medicare who were covered under traditional Medicare in one year but chose to enroll in Medicare Advantage (MA) the following year (transferred enrollees). The Centers for Medicare & Medicaid Services (CMS) maps certain diagnosis codes into Hierarchical Condition Categories (HCCs). For transferred enrollees who, while covered under traditional Medicare, receive a diagnosis that maps to an HCC, CMS makes higher payments to MA organizations for the following year.

Through data mining and discussions with medical professionals, we have identified several diagnosis codes that were at high risk of being miscoded and resulting in inaccurate payments. For this audit, we focused only on selected acute stroke diagnosis codes (which map to the Ischemic or Unspecified Stroke HCC) that were reported on one physician's claim without being reported on a corresponding inpatient claim.

Our objective was to determine whether selected acute stroke diagnosis codes submitted by physicians under traditional Medicare that CMS later used to make payments to MA organizations on behalf of transferred enrollees complied with Federal requirements.

How OIG Did This Audit

We reviewed 582 of 8,437 transferred enrollees (that we selected with a stratified random sample) who received one instance of a high-risk acute stroke diagnosis code during 2014 or 2015. We had reviews performed to determine whether the medical records supported the submitted diagnosis codes. We relied on these reviews as the basis for our conclusions.

What OIG Found

Almost all of the selected acute stroke diagnosis codes that physicians submitted to CMS under traditional Medicare and that CMS later used to make payments to MA organizations for 2015 or 2016 on behalf of the 582 transferred enrollees did not comply with Federal requirements. For 580 of the transferred enrollees, the medical records did not support the acute stroke diagnosis codes. Thus, the Ischemic or Unspecified Stroke HCCs were not validated.

These errors originated from physicians submitting incorrect acute stroke diagnosis codes on claims billed under traditional Medicare. However, these errors were unnoticed and caused inaccurate payments in MA because CMS did not have policies and procedures to (1) identify beneficiaries who transferred from traditional Medicare to MA, and (2) evaluate whether the acute stroke diagnosis codes submitted under traditional Medicare on their behalf complied with Federal requirements. As a result, we estimated that CMS made inaccurate payments of just over $14.4 million to MA organizations.

What OIG Recommends and CMS Comments

We recommend that CMS (1) educate physicians on how to correctly submit acute stroke diagnosis codes and how these diagnosis codes may impact the MA program, and (2) develop and implement policies and procedures to identify beneficiaries transferring from traditional Medicare to MA and evaluate whether the acute stroke diagnosis codes submitted under traditional Medicare comply with Federal requirements.

CMS concurred with our recommendations and described actions that it had taken or planned to take to address them. Specifically, CMS stated that it would continue to educate physicians on how to correctly submit acute stroke diagnosis codes, including updated information on how these codes may impact the MA program. CMS also stated that although our findings account for less than 0.5 percent of all transferred enrollees, it would review its existing policies and procedures to evaluate whether any further clarification is needed with regards to acute stroke diagnoses.

Filed under: Centers for Medicare and Medicaid Services


Key Takeaways:

Billions in estimated risk-adjusted payments supported solely though HRA’s raise concerns about the completeness of payment data, validity of diagnoses on HRA’s and quality of care coordination for beneficiaries.

OIG findings highlight concerns about the extent to which MAOs are using HRAs to improve care and health outcomes, as intended, and about the sufficiency of the oversight by the Centers for Medicare & Medicaid Services (CMS).

From an analysis of 2016 MA encounter data, the OIG found that:

Diagnoses that MAOs reported only on HRAs, and on no other encounter records, resulted in an estimated $2.6 billion in risk-adjusted payments for 2017.

In-home HRAs generated 80 percent of these estimated payments. Most in-home HRAs were conducted by companies that partner with or are hired by MAOs to conduct these assessments—and therefore are not likely conducted by the beneficiary’s own primary care provider.

Twenty MAOs generated millions in payments from in-home HRAs for beneficiaries for whom there was not a single record of any other service being provided in 2016.

Read the full report here

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 1948 - 2020

George Franklin Smith, M.D., 71, passed away on August 25, 2020 in Austin, Texas.

He was born November 25, 1948 in San Augustine, Texas.

George graduated with a Bachelor of Arts from the University of Texas at Austin, and then went on to earn his Masters of Science in Public Health from the University of Texas Health Science Center at Houston's School of Public Health.

He earned his Doctor of Medicine from the University of Texas Medical Branch at Galveston in 1977, where he was the presiding senior of the Phi Chi Medical Fraternity.

He practiced family medicine in Austin for a decade, during which time he held multiple leadership positions at St. David's South Austin Medical Center, including Chairman of the Board of Trustees. He then went on to serve as President of PCA Medical Group of Texas, P.A. and Vice President of Medical Affairs and then Executive Director of the Central Texas Market at PCA Health Plans of Texas, Inc./Humana, Inc. in Austin from 1990 through 1998, and then as Chief Medical Officer of HealthFirst HMO, Inc. in Tyler, Texas.

He rejoined Humana in San Antonio, Texas in 2001, where he served as Vice President and Chief Medical Officer for the South Texas market, and then as Regional President of Senior Products for the Southwest Region until his retirement in 2013.

He served in leadership positions in various professional organizations and was a great mentor to many colleagues. After his retirement he kept busy with consulting roles.

George lived life to the fullest. He had a passion for the outdoors, including hunting, fishing, hiking and gardening. He loved Texas Longhorns football and playing poker with dear friends. He also loved cooking for family and friends, hosting parties, and enjoying great food and wine with his fellow Chaine des Rotisseurs members. In his retirement, George spent much of his time traveling to new places near and far. A sixth generation Texan, descendant of The Old 300 and a member of the Sons of the Republic of Texas, he loved Texas and its history. He also had a passion for reading, and was taking seminar courses through the University of Texas's OLLI SAGE program.

He is predeceased by his parents, Leonard Louis Smith and Gladys Nichols Smith, and his first wife, Kelly Reynolds Smith. He is survived by his daughter Megan (Brad) Demicco of Dallas, son Garrett (fiancé Danelle Cantu) of Austin, grandchildren Andrew and Julia Demicco of Dallas, sweetheart Marilyn Davis of Austin, sister-in-law Morna Reynolds (Lee) Erwin of Knoxville, Tennessee, and many extended family members and dear friends. We will miss George's kind and generous spirit, great stories, and wonderful sense of humor.

In lieu of flowers, donations may be made to the University of Texas Medical Branch at Galveston or an animal rescue organization of your choice.

A celebration of George's life will be held at a later date.


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By Jeff Overley

Law360 (August 5, 2020, 9:39 PM EDT) -- Cigna Corp. overbilled Medicare Advantage by more than $1.4 billion by persuading nurses to diagnose policyholders with exaggerated medical problems, according to a newly unsealed suit that joins a growing list of False Claims Act cases targeting Medicare Advantage insurers. The whistleblower suit made public Tuesday in New York federal court alleges that from 2012 to 2017 a company division called Cigna-HealthSpring billed for medical conditions that "did not exist, were not recorded in any medical records and were not based on any clinically reliable information." Whistleblower Robert A. Cutler, an employee of Cigna contractor Texas Health Management LLC, filed the complaint under seal in 2017. Whistleblower complaints under the FCA are usually unsealed only after the U.S. Department of Justice has announced whether it will intervene in the case. An order in February from U.S. District Judge Kenneth Karas said that the DOJ had declined to intervene in some of the allegations and would not intervene for the time being in the remaining allegations. The same order called for the complaint to be unsealed in April, but it only hit the docket on Tuesday for reasons that were not immediately clear. Law360 on Wednesday afternoon asked DOJ representatives at the U.S. Attorney's Office in Manhattan to clarify whether the government would be intervening. Within 40 minutes, the entire case docket was again placed under seal on Pacer. A DOJ representative late Wednesday declined to comment on the status of intervention or the resealing of the case. In a short statement Wednesday, Cigna also didn't say whether the federal government had decided to join the case. "We are proud of our industry-leading Medicare Advantage program and the manner in which we conduct our business," the company said. "We will actively defend Cigna against unjustified allegations." Cutler, who represented himself when filing the case, didn't immediately respond to an email and voicemail seeking comment on Wednesday. Cutler's complaint focuses primarily on Cigna's arrangements with contractors that sent nurse practitioners to patient homes for health screenings. "On numerous occasions, THM managers made clear to executives at Cigna-HealthSpring" that nurses couldn't definitively diagnose serious conditions, but Cigna went ahead and billed Medicare Advantage as if the assessments were "confirmed medical diagnoses," the complaint alleges, referring to Texas Health Management. Cutler's suit describes one instance of billing codes being added for dementia and chronic obstructive pulmonary disease even though a nurse practitioner reported that a patient's mental and respiratory functions were normal. In another section, the suit describes Cigna training contractors to diagnose rheumatoid arthritis based solely on fatigue, weight loss and certain symptoms of pain and stiffness. The government was "unaware that these claims were false and fraudulent," and it "overpaid Cigna-HealthSpring by more than $1.4 billion," the complaint said of claims submitted over the five-year period. Cigna paid $3.8 billion in 2012 to acquire HealthSpring Inc., which at the time had 340,000 Medicare Advantage enrollees. There are 22 million enrollees nationwide among all Medicare Advantage insurers, and Cigna is a relatively small player in the space, according to the Kaiser Family Foundation. Medicare Advantage insurers are paid more than $200 billion annually, and FCA litigation against them by the DOJ is a relatively new phenomenon. The DOJ joined two whistleblower cases in 2017 against UnitedHealth Group Inc., which has defeated one of those cases and trimmed allegations in the other one. More recently, the DOJ in March hit Anthem Inc. with allegations of Medicare Advantage fraud. All the cases involve allegations that insurers overstated the severity of illnesses to get more money from the government. Cigna noted in its most recent annual report that the DOJ "is conducting an industrywide investigation of Medicare Advantage" billing by insurance companies. Cigna added that it was "currently responding to ... civil investigative demands received from the ... U.S. Attorney's Offices for the Eastern District of Pennsylvania and the Southern District of New York." Counsel information for the government and Cigna were not immediately available. The case is U.S. ex. rel. Cutler v. Cigna Corp. et al., case number 7:17-cv-07515, in the U.S. District Court for the Southern District of New York. --Editing by Jill Coffey.


Download Case Documents Here


Monday, August 3, 2020To provide additional financial support for Medicare providers responding to COVID-19, and pursuant in part to CARES Act requirements, the Centers for Medicare & Medicaid Services (CMS) expanded the Accelerated and Advance Payment Programs for providers and suppliers. CMS used existing rules that allow providers and suppliers to receive an advance on Medicare claims payments if they have experienced financial difficulties due to a delay in payments or in other exceptional situations.Now, approximately four months after the first accelerated and advance payments were distributed, early applicants are approaching the date when Medicare will begin recouping payments through zeroed out claims, absent congressional action. These repayments are coming due at a time when providers still face critical financial challenges and reduced patient volume due to the pandemic.Accelerating Medicare Payments to ProvidersCOVID-19 placed significant financial pressure on hospitals, physician practices and other providers and suppliers. Some were overwhelmed by a dramatic increase in COVID-19 patients, while others sat empty as non-emergency procedures were cancelled and patients under stay-home orders delayed care. CMS used the Accelerated and Advance Payment Programs to provide cash flow to affected providers. Unlike the Provider Relief Fund, the Accelerated and Advance Payment Programs provide loans that must be repaid.For providers and suppliers who participate in the Accelerated and Advance Payment programs, claims recoupment via withheld claims begins 120 days after issuance of the payment. For suppliers, repayment of the full balance is due 210 days after the issuance of the payment; most hospitals have a full year to repay the balance. For both the Accelerated and the Advanced Payment Programs, unpaid balances due at the end of the repayment period are subject to the private consumer rate of interest rate, currently 9.5%.CMS paused both programs on April 26, 2020, citing other funds available to the provider community.Payments Come Due for Hospitals, Physicians and Suppliers. Physician practices and other suppliers had 120 days from the date CMS issued their payment. At least one MAC has indicated recoupment began July 27, 2020.Legislation Could Extend Repayment TimelineGiven the state of COVID-19 recovery, it seems likely that Congress will extend the recoupment period for loan recipients. In May 2020, the US House of Representatives passed the Health Economic Recovery Omnibus Emergency Solutions (HEROES) Act, which would extend the timeline for recoupment and repayment of the loans. On July 27, 2020, Senate Republicans introduced the Health Economic Assistance, Liability Protection and Schools (HEALS) Act, which also would extend the repayment and recoupment terms, although for a shorter period. HEROES would take the additional steps of reducing the interest rate and reducing the amount of clHT NNaims recoupment. HEALS does not include parallel proposals affecting interest rates or recoupment amounts.Some provider groups are pursuing legislation that would forgive these loans altogether. H.R.7292, introduced in June, would, among other things, forgive debts arising under these programs for providers, suppliers and physicians meeting certain criteria and conditions. This bill has over 74 cosponsors as of July 31st, and support from both Republican and Democratic Representatives. Senate Democrats introduced a version of forgiveness in May. S. 3750 would grant CMS the authority to waive repayment for Accelerated and Advance payments for providers facing significant hardship for at least two years. Full forgiveness has not appeared in either HEROES or HEALS, making it a long-shot to be included in a negotiated compromise this month.Leadership from both parties continues to work toward a deal on broad stimulus and relief legislation that also would address this program. Final agreement is anticipated sometime in the next few weeks, but it is unlikely that an agreement will be finalized before some providers’ and suppliers’ repayment periods commence.How Will the MACs Respond? Practical Considerations for ProvidersSeven MACs are tasked with administering accelerated and advance payments and taking initial actions to recoup Medicare funds. In general, CMS instructs MACs on how to adhere to the agency’s guidance and regulatory requirements. MACs therefore may need clear instructions from CMS to alter their recoupment process in response to any legislative change. It is unlikely that CMS will take any such action in the absence of legislation. Providers and suppliers that obtained advance or accelerated payments therefore may experience a few bumpy weeks as MACs implement a large-scale recoupment program under shifting instructions from CMS, and as CMS awaits final stimulus legislation. Early recipients of advance or accelerated payments may be subject to claims reductions that start and stop as a result of the shifting policy environment and current lack of clarity for MACs.Providers and suppliers may wish to take steps now to advocate for a smoother approach and to prepare operationally for a period of uncertainty. Providers and suppliers can communicate with their MACs to request information on how they will handle recoupment of advance and accelerated payments, and to request a brief grace period to account for the legislative process on Capitol Hill. Providers and suppliers also should continue to share feedback with CMS and the MACs regarding the internal disruption that could result from recoupment processes being started and stopped, and to urge CMS and the MACs to hold off on recouping funds until the timeline is finalized legislatively.Finally, providers and suppliers can continue to put pressure on Congress to resolve this matter legislatively as quickly as possible. In the meantime, providers should take operational steps to prepare for recoupment to begin.Full Article
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By Kameron Gifford, CPC As we enter the third quarter of 2020, healthcare organizations have been struggling for months to balance priorities and resources while navigating new technologies and processes to keep employees and patients safe during the coronavirus. The AAFP and MGMA both recently reported, “Medical group practices of all sizes and specialties have felt the direct and indirect financial impact... On average, patient volumes have dropped 60% nationally since the start of the pandemic attributing to a 55% decrease in fee-for-service revenues.   Medical practices are not alone, hospital revenue is dropping by an average of $1.4 billion per day as COVID-19 continues to impact patient volumes, according to Crowe RCA Benchmarking analysis. Risk Scores and Value-Based Payments As more and more healthcare organizations are moving away from traditional fee-for-service payment models, how will this decrease in utilization impact risk scores and value-based payments in the future? According to Avalere, the deferral of care has resulted in fewer claims and diagnoses among Medicare Advantage (MA) enrollees, which will likely lead to a 3%–7% reduction in 2021 risk scores and lower plan payments. Mitigating the Impact to Risk and Quality Inaccurate risk scores not only impact payments to Medicare Advantage plans, but also skew the costs in ACOs and hinder performance in value-based contracts. This further underscores the need to capture an accurate health status on every patient. What steps can organizations take today to achieve accurate risk scores and mitigate future losses? Common Errors Leading to Inaccurate Risk Scores The 2020 ICD-10-CM code set includes 72,184 diagnoses and the 2021 ICD-10-CM code set includes 72,616 diagnoses. With less than 14% of ICD-10-CM codes mapping to an HCC, lack of specificity is the most common cause of inaccurate risk scores.   Review the six most common coding errors below that lead to inaccurate risk scores and payments. E11.9 – Type 2 Diabetes without Complications According to the most recent data released by MedPAC on July 17, 2020, 28.2% of Medicare beneficiaries had a diagnosis of diabetes on a claim in 2019. Roughly 70% of these mapped to HCC 18, Diabetes with chronic complications, while 30% of these mapped to HCC 19, Diabetes without complications. How does your coding for diabetes compare to MedPAC data? What percentage of patients are coded as E11.9 by primary care providers? What percentage are coded as E11.9 by specialists such as hospitalists and endocrinologists? Per ICD-10 Guidelines, approximately 30 conditions have an assumed relationship with type 2 diabetes. Meaning, they are always coded as a complication unless the medical record explicitly states otherwise. Examples include: Type 2 Diabetes with CKD, E11.22 Type 2 Diabetes with dermatitis, E11.620 Type 2 Diabetes with foot ulcer, E11.621 Type 2 Diabetes with gastroparesis, E11.43 Type 2 Diabetes with hyperglycemia, E11.65 Type 2 Diabetes with hypoglycemia, E11.649 Type 2 Diabetes with mononeuropathy, E11.41 Type 2 Diabetes with myasthenia, E11.44 Type 2 Diabetes with nephropathy, E11.21 Type 2 Diabetes with neuralgia, E11.42 Type 2 Diabetes with neuropathy, E11.40 Type 2 Diabetes with PAD, E11.51 Type 2 Diabetes with periodontal disease, E11.630 Type 2 Diabetes with polyneuropathy, E11.42 Type 2 Diabetes with retinopathy, E11.319 Review 5 – 10 encounters per provider. What percentage of encounters coded as E11.9, had a complication documented in the medical record? Target education, prospective chart checks and pre-billing review per the results. How it Happens Several factors contribute to the high error rate related to coding for E11.9. The two most common reasons are failure to update the diagnosis as the disease progresses and failure to follow the ICD-10 Guidelines for “with”. Why it Matters The 2020 CMS-HCC RAF for HCC 19 is 0.105 and the 2020 CMS-HCC RAF for HCC 18 is 0.302. That is a loss of 0.197 per error. This adds up quickly across populations, accounting for annual average losses of $60,000 - $130,000 per 1000 MA beneficiaries. F32.9, Major Depression, Single Episode, Unspecified According to the most recent data released by MedPAC on July 17, 2020, 11.3% of MA beneficiaries were diagnosed with a condition mapping to HCC 59, Major Depressive, Bipolar or Paranoid Disorders.   According to CMS, mood disorders (mainly MDD and bipolar disorder) are the second leading cause of disability in Medicare patients under the age of 65. Depression is a major predictor of the onset of stroke, diabetes, and heart disease; it raises patients’ risk of developing coronary heart disease and the risk of dying from a heart attack nearly threefold. Overall, the economic burden of the disease is significant to managed care organizations, with direct medical costs estimated at $3.5 million per 1000 plan members with depression. Identify Errors and Opportunities From a coding perspective, MDD is classified by episode, severity, and remission. According to AMJMED, 75% to 90% of patients experience >1 episode of depression. This suggests that only 10 - 25% of MDD diagnoses would be assigned to F32 with the remaining 75 – 90% being classified as F33. Analyze your coding for MDD. What percentage of MDD diagnoses are single episodes (F32.x) vs. recurrent episodes (F33.x) What percentage of single episodes are classified as “unspecified” (F32.9) when a PHQ-9 was completed and/or the documentation supported a more specific diagnosis? What percentage of patients taking an SSRI or other antidepressant have a current diagnosis to support medical necessity? Review 5-10 encounters per provider with a diagnosis of F32.9. Was the correct diagnosis assigned? Target education, prospective chart checks and pre-billing review per the results. Why it Matters From a risk adjustment perspective, F32.9, is the only MDD diagnosis that does not map to an HCC. The 2020 CMS-HCC RAF for HCC 59, Major Depressive, Bipolar and Paranoid Disorders is 0.309. Missed opportunities relating to the use of F32.9 average 20% across populations accounting for an average annual loss revenue of $77,500 per 1000 members. How it Happens Two factors contribute to the high use of this code. First, the GEM files mapped the ICD-9 code 311 to the ICD-10 code F32.9 and these files were widely used by EHR vendors. The second factor involves the number of boxes providers must check in their EHR to get to the more specific MDD diagnosis. One way to avoid these extra clicks is by typing the diagnosis code directly into the search box of your EHR. For example, typing F32.0 (MDD, single episode, mild) vs depression will reduce clicks from 13 to 4 and reduce search results from 800+ to 1. Searching for F33.0 (MDD, recurrent, mild) vs recurrent depression will save even more clicks with the same results. I25.9, Chronic Ischemic Heart Disease and I25.10, CAD without Angina According to the NIH, an estimated 10 million adults in the United States carry the diagnosis and ischemic heart disease remains the number one cause of death for male as well as female patients. Furthermore, the increasing survival with the use of modern therapies has produced an aging population where more than 20% of women and 35% of men above the age of 80 have coronary artery disease. Identify Errors and Opportunities From a coding perspective, chronic ischemic heart disease is classified to category I25 and CAD is further classified as with or without angina. Analyze your coding of chronic ischemic heart disease (I25.9) and CAD without angina (I25.10). Depending on your results you may also want to include old MI (I25.2) and chest pain (R07.9) in your search. Review 5-10 encounters per provider. How many of these patients had evidence of angina documented, history of CABG and/or a current prescription for nitroglycerin? Target education, prospective chart checks and pre-billing reviews per the results. How it Happens The term stable ischemic heart disease (SIHD) is often used synonymously with chronic coronary artery disease (CAD) and encompasses a variety of conditions. Many EHR’s include an IMO to assist providers in searching for codes. This “tool” adds multiple code descriptions for each ICD-10 code and can increase search results by 70%. Many providers do not have the time to search dozens of code descriptions for multiple diagnoses prior to closing their note. This often results in the selection of the first or second result, even when a more specific diagnosis is supported by the documentation. Why it Matters From a risk adjustment perspective, I25.9 and I25.10 are included in the Rx-HCC Model V05, but not in the CMS HCC Model V24. However, CAD with Angina (I25.110 – I25.119) and Angina (I20.0 – 120.9, I23.7) are all included in the CMS HCC Model V24. The 2020 RAF for HCC 87 is 0.195 and HCC 88 is 0.135. According to the CMS Chronic Disease Warehouse, 10,238,321 (or 17.1%) Medicare beneficiaries had a diagnosis of ischemic heart disease. While the most recent MedPAC data published on July 17, 2020 reveals only a 4% prevalence rate among MA beneficiaries in the same year. Missed opportunities relating to the use of I25.9, I25.10, I25.2 and/or R07.9 average 25% across populations accounting for an average annual loss of $64,638 - $93,366 per 1000 MA members.  I49.9, Cardiac arrythmia, unspecified According to the most recent data released by MedPAC on July 17, 2020, 11.4% of Medicare Advantage members had a diagnosis that mapped into HCC 96, Specified Heart Arrythmias. In the CMS-HCC Model V24, 18 ICD-10 codes are mapped into HCC 96. Examples include: AV Block, Complete, I44.2 SVT, I47.1 Paroxysmal A. Fib, I48.0 A. Flutter, I49.92 Sick Sinus, I49.5 Identify Errors and Opportunities Analyze your coding for cardiac arrythmias. What percentage of encounters/claims are coded with I49.9, Cardiac arrhythmia, unspecified when the medical record supported a more specific diagnosis?  You may also want to include the use the ICD-10-CM code Z95.810, Presence of automatic (implantable) cardiac defibrillator, in your analysis. Target education, prospective chart checks and pre-billing reviews per the results. How it Happens AHA Coding Clinic recently updated their guidance on coding for sick sinus syndrome treated with a pacemaker. This change in guidance has led to an increased number of opportunities identified in HCC 96. Additional opportunities are identified from diagnostic test results and specialists’ reports. Why it Matters I49.9, Cardiac arrhythmia, unspecified is not included in the 2020 CMS-HCC Model V24. Missed opportunities relating to HCC 96 average 20% across populations accounting for average annual lost revenue of $67,214 per 1,000 MA beneficiaries. N18.9, CKD, unspecified According to the CMS Chronic Condition Warehouse, there were 9,360,944 Medicare beneficiaries (15.6%) with a diagnosis of CKD on a claim in 2018. However, a review of the most recent data released by MedPAC on July 17, 2020, does not include CKD, meaning the prevalence for MA members in the same year was less than 1.5%. Why Is Chronic Kidney Disease Important? CKD and ESRD are very costly to treat. Nearly 25% of the Medicare budget is used to treat people with CKD and ESRD. The total Medicare spending on both CKD and ESRD patients was in excess of $120 billion in 2017. For identified CKD (not ESRD) the total Medicare expenditure was $84 billion. Identify Errors and Opportunities Analyze your coding for CKD. What percentage of encounters/claims are coded with N18.9, CKD, unspecified, vs. a more specific code such as N18.3 and/or N18.4? You may also want to include the ICD-10 code N28.9, disorder of kidney and ureter, unspecified, in your analysis. Review 5-10 encounters per provider. What percentage of encounters/claims are coded with an unspecified diagnosis such as N18.9 and/or N28.9, when a more specific diagnosis is supported by the medical record? Target education, prospective chart checks and pre-billing reviews per the results. How it Happens There are several factors that contribute to this large opportunity. Lack of documentation is the most common reason. CKD must be staged by the provider. Pasting a copy of the patient’s most recent labs into the current encounter supports the provider’s medical decision making but does not replace the need for the stage to be documented. The fluctuating nature of the disease also contributes to the lack of specificity in coding, as providers are less likely to update.   Historically, multiple terms have been applied to chronic kidney disease (CKD), eg, chronic renal insufficiency, chronic renal disease, and chronic renal failure, the National Kidney Foundation Kidney Disease Outcomes Quality Initiative™ (NKF KDOQI™) has defined the all-encompassing term, CKD. This recent change in terminology also contributes to the size of the opportunity. The IMO search tool in EHR’s will lead providers using older terminology such as, renal insufficiency, to select a diagnosis of N28.9 CKD stage 3 was removed from the HCC model in 2014 and this likely contributed to the decrease in coding by MA plans as well. CMS reversed course in PY 2019, and added HCC 138, CKD stage 3, back into the model. Why it Matters Missed opportunities relating to HCC 138, CKD stage 3, average 60% across MA populations accounting for annual average lost revenue of $73,625 per 1000 members. Want to learn more? Visit www.erm365.org and www.ermconsultinginc.com ERM Consulting Inc. works with healthcare organizations across the country to optimize their risk adjustment operations. ·
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Approved by the AAPC for 4 hours of CEU: This program meets AAPC guidelines for 4.0 CEUs. Can be split between Core A, CRC, CEMC, CHONC, CANPC, CDEO, CPCO and CPMA after successful completion of post-test for continuing education units. Overview: When is it appropriate to code for opioid dependence versus long time use? What documentation is needed to support a diagnosis of alcoholism in remission?  Should I code sedative dependence for all of my patients taking a sleeping medication? Is it appropriate to code cannabis abuse when the medical record states recreational marijuana use?  These are some of the most frequently asked questions by physicians and coders.  This course takes a deep dive into the classification, screening, coding and documentation of the four most frequently coded substances: alcohol, cannabis, opioids and sedatives and substance-induced disorders.  Register now - Course is FREE until August 1, 2020 Key Objectives: Substance Use Disorders Introduction Brief history of Substance Use Important Definitions Classification of Substance Use Disorders Introduction to DSM Brief History of the DSM Drugs of Abuse Substance-Induced Disorders Screening, Brief Intervention and Referral for Treatment SBIRT AUDIT CAGE CAGE-AID DSAT-10 SMAST-G Coding for Substance Use Disorders AHA Coding Clinic ICD-10 Coding for Substance Use Disorders Alcohol Use Disorders Cannabis Use Disorders Opioid Use Disorders Sedative, Hypnotic, or Anxiolytic Use Disorders Coding for Substance-Induced Disorders Substance-Induced Anxiety Disorders Substance-Induced Bipolar and Related Disorders Substance-Induced Depressive Disorders Substance-Induced Neurocognitive Disorders Substance-Induced Sexual Dysfunctions Substance-Induced Sleep Disorders Clinical Documentation Improvement for Substance Use Disorders Ten Tips for Success Clinical Documentation Examples Quality Measures for Substance Use Disorders 2020 HEDIS Codes 2020 CMS QM View the course on ERM365
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