By Holly J. Cassano, CPC
Accurate payment under the Centers for Medicare & Medicaid Services (CMS) risk adjustment reimbursement model depends on diagnosis code specificity and reporting all current chronic conditions. A leading cause of incorrect and/or insufficient reimbursement from Medicare Advantage (MA) plans is deficient hierarchal condition categories (HCC) code reporting.
CMS has been accepting up to eight diagnosis codes since 2007. Unfortunately, many physician practices are either not aware of this, or their electronic health record (EHR) and/or clearinghouses allow only four to six diagnosis code entries for claims submission. A practice can instruct its coders to submit all co-existing chronic diseases documented at the time of service, but this is of no help if your EHR or clearinghouses won’t accept all of the diagnoses submitted.
Too Many Diagnosis Codes Cause Confusion
A Coding Edge reader—understanding the importance of reporting all active chronic conditions that co-exist at the time of service (TOS)—recently asked about proper processes for submitting diagnoses in the EHR, and what to do if you have to submit more than eight diagnoses on a claim form. Specifically, the reader asked, what happens if and when:
- The physician treats patients with 10 or more diagnoses addressed during a visit?
- Coders validate the first eight diagnoses listed in lieu of sequencing?
- Providers do not sequence the diagnosis codes while listing more than eight diagnoses?
Educate the Vendor and Payer
First, contact your vendor and find out (verbally and in writing) the number of diagnosis codes the vendor will accept electronically per claim. Find out also if the vendor and payer will accept CPT® 99080 Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form, which may be used as an adjunct to a regular evaluation and management (E/M) office visit code to submit additional diagnosis codes for capturing chronic conditions.
Contact all MA plans with which the practice participates, and obtain in writing how many diagnosis codes each payer will accept. If the number is less than eight, ask if the payer will accept 99080 for the additional diagnosis codes (and get the reply in writing).
Inquire how many codes any commercial carriers accept in your practice to prevent future claims issues with the adoption of ICD-10, which will require even greater due diligence and coding specificity.
Sequencing Is Important
Sequencing can have a dramatic effect on payments if the nature of the presenting problem (NOPP) and subsequent co-existing conditions are either under-reported or incorrectly reported to an MA plan. The key to successful sequencing begins with an assessment and a plan. For example:
- Determine the primary diagnosis by identifying the primary focus of care.
- Determine which of the other diagnoses affect treatment and coexist at the TOS. Be sure to report these diagnoses (linking to other services isn’t necessary if only an E/M service is provided).
- All pertinent diagnoses must be listed to justify the services rendered.
The CMS risk adjustment model was implemented to promote specificity and discourage vague or unspecified coding. ICD-10 will promote this, as well. To ensure compliance and receipt of accurate payments through proper identification of chronic diseases, implement a strategy now. Be sure payers recognize all the diagnoses reported, so you don’t suffer potentially harmful consequences to your practice down the road.
Holly J. Cassano, CPC, has been involved in practice management, coding, auditing, teaching, and consulting for multiple specialties for the past 16 years. She served two terms as an AAPC local chapter officer, maintains an online column for Advance for Health Information Professionals, and writes for Justcoding.com. She is the CEO of ACCUCODE Consulting, LLC and blogs for medicalcodingandbilling.org via Consumer Media Network (CMN). She works for Preferred Care Partners as a CDI specialist, based out of The Villages, Fla. You can reach her at email@example.com and follow her on Twitter@hollycassano.
October 1st, 2012
The Centers for Medicare & Medicaid Services (CMS) released 25 corrections to the 2012 HCPCS Level II ANWEB file. The corrections, released Jan. 30, include description and ambulatory surgery center (ASC) indicator changes, removal of codes, updated Berenson-Eggers Type of Service (BETOS) information, and revised effective dates.
Terminated or Removed
C9716 Creations of thermal anal lesions by radiofrequency energy should be terminated effective Jan. 1, 2012.
G0449 Annual face-to-face obesity screening, 15 minutes will not be created. Remove from file.
G0450 Screening for sexually transmitted infections, includes laboratory tests for chlamydia, gonorrhea, syphilis and hepatitis B will not be created. Remove from file.
G0446 Long description Intensive behavioral therapy to reduce cardiovascular disease risk, individual, fact-to-face, >annual<, 15 minutes is revised effective Nov. 8, 2011.
G8553 Both short description (Prescrip transmit via ERx sy) and long description (Prescription(s) generated and transmitted via a qualified ERx system) are changed effective Jan. 1, 2012.
J1561 Short description Gamunex, Gamunex-C, Gammaked is changed effective Jan. 1, 2012.
Revised Effective Dates
G0442 Annual alcohol misuse screening, 15 minutes is now effective Oct. 14, 2011.
G0443 Brief face-to-face behavior counseling for alcohol misuses, 15 minutes is also effective Oct. 14, 2011.
K0743 Suction pump, home model, portable, for use on wounds is now effective July 1, 2011.
C1886 Catheter, extravascular tissue ablation, any modality (insertable)—Add ASC “YY” indicator, effective Jan. 1, 2012.
C9728 Placement of endorectal intracavitary applicator for high intensity brachytherapy—Add ASC “YY” indicator, effective Jan. 1, 2008.
C9732 Insertion of ocular telescope prosthesis including removal of crystalline lens—Add ASC “YY” indicator, effective Jan. 1, 2012.
G0448 Insertion or replacement of a permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber with insertion of pacing electrode, cardiac venous system, for left ventricular pacing—Change TOS to “2,” effective Jan. 1, 2012.
J2265 Injection, minocycline hydrochloride, 1 mg—Remove ASC “YY” indicator, effective Jan. 1, 2012.
Q4123 Alloskin RT, per sq cm—Remove ASC “YY” indicator, effective Jan. 1, 2012.
Q4125 Arthroflex, per sq cm—Remove ASC “YY” indicator, effective Jan. 1, 2012.
Q4126 Memoderm, per sq cm—Remove ASC “YY” indicator, effective Jan. 1, 2012.
Q4127 Talymed, per sq cm—Remove ASC “YY” indicator, effective Jan. 1, 2012.
Q4128 FlexHD or Allopatch HD, per sq cm—Remove ASC “YY” indicator, effective Jan. 1, 2012.
Q4129 Unite biomatrix, per sq cm—Remove ASC “YY” indicator, effective Jan. 1, 2012.
J8561 Everolimus, oral 0.25, mg—Change BETOS to “01E,” effective Jan. 1, 2012.
CMS recommends updating data files as well as noting changes in codebooks.
February 10th, 2012