Risk Adjustment Coding Guidelines

What is risk adjustment?

• The process by which health plans are reimbursed based on the health status of their members.
• The mechanism by which government programs adjust the revenue to health plans based on the health status of the covered population (members).
• Helps match payment to risk by estimating healthcare expenses based on the disease conditions attributed to the population.

Benefits of Risk Adjustment

• Identifies patients who may need disease management intervention.
• Identifies gaps in clinical documentation.
• Accurate and timely documentation allows for more meaningful data exchanges between health insurance plans and providers, which helps members by:
  • Identifying new problems early
  • Reinforcing self-care and prevention strategies
  • Coordinating care collaboratively
  • Avoiding potential drug/disease interaction
• Coded data translates into:
  • Quality reporting
  • Physician report cards
  • Reimbursement
  • Public health data

Physicians’ role

• Physician data is critical for accurate risk adjustment.
• Physicians are the largest source of medical data for the risk-adjustment models.
• Risk-adjusted payment relies on accurate diagnosis coding on claims and complete medical record documentation.
• Specificity of diagnosis coding is substantiated by the medical record.
• Contributes to the level of complexity for the patient encounter.
• Vital to a healthy revenue cycle and, more importantly, to a healthy patient.

What should you do?

• Follow general documentation requirements.
• Review official ICD-10-CM Guidelines for Coding and Reporting.
• Review E/M services guidelines regarding chronic conditions.
• Presenting problem(s) listed in the Table of Risk within Medical Decision addresses chronic conditions and may even justify a different E/M level.
• Each progress note must:
  • Support what is coded and billed (ICD-10-CM, CPT and HCPCS).
  • Stand alone.
  • Be complete and contain legible signature and credentials.
  • Show medical necessity.

THE GOLDEN RULE: Document for others as you would have them document for you.

Secure Provider Portal Registration

If you haven’t already done so, please go to SunshineHealth.com to register for our Secure Provider Portal. Functions on the portal include: verification of eligibility, submission of claims, entering authorizations, viewing patient care gaps, etc. Use of the portal is free for all services!

Electronic Funds Transfer/Electronic Remittance Advice

• Sunshine Health partners with PaySpan Health for EFT/ERA services.
• Register with PaySpan Health.

The Medical Record

Due to its simplicity and popularity, many medical records take on the SOAP format: Subject, Objective, Assessment and Plan. The SOAP format addresses patients’ complaints in an organized and consistent manner. Over time, patients’ chronic conditions may be overlooked, assumed or tacitly understood.

What does CMS say?

One of the documentation requirements, according to the May 9, 1992, HCFA (now CMS) bulletin for Associate Regional Medicare Administrators, Issue 9, progress notes should stand alone. This means that providers should code all documented conditions that coexist at the time of the encounter and require or affect patient care, treatment or management. This must be documented by the provider and cannot be inferred by coders.

One way to document chronic conditions is by using the acronym MEAT.

Examples of MEAT:

• Monitor
  • Symptoms
  • Disease progression/regression
  • Ordering of tests
  • Referencing labs/other tests
• Evaluate
  • Test results
  • Medication effectiveness
  • Response to treatment
  • Physical exam findings
• Assess/Address
  • Discussion, review records
  • Counseling
  • Acknowledging
  • Documenting status/level of condition
• Treat
  • Prescribing/continuation of medications
  • Surgical/other therapeutic interventions
  • Referral to specialist for treatment/consultation
  • Plan for management of condition

Additional tips

• Document each patient encounter as if it is the only encounter.
• Codes should be assigned for every condition documented in the chart note that has evidence of MEAT, not just the condition for which the patient came in.
• All chronic and complex conditions need to be coded annually.
  • Review and document conditions managed by a specialist.
  • This counts as MEAT and can be coded on the claim.
• When seeing a patient who comes in infrequently, ensure that chronic conditions are reviewed at the visit, even if they are only presenting for an acute issue.
• When refills are made outside of a visit, encourage patient to schedule a checkup so that the condition can be reviewed and managed at least once a year.
• Review and update the patient’s active problem list at each visit. If a condition is no longer active, either remove it from the list or add “History of.”
• Specify the basis for ordering additional testing/treatment.
• Show patient’s progress or lack of progress.
• Avoid using the words “History of” for a condition that is chronic but currently stable, such as COPD, DM or atrial fibrillation.

Attention Deficit Hyperactivity Disorder

Attention deficit hyperactivity disorder (ADHD) is a brain disorder marked by an ongoing pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development.¹ The symptoms differ person-to-person, but both children and adults can have ADHD. There are three types of ADHD: inattentive, hyperactive-impulsive and combined.² For a person to receive a diagnosis of ADHD, the symptoms of inattention and/or hyperactivity-impulsivity must be chronic or long-lasting, impair the person’s functioning and cause the person to fall behind normal development for his or her age.¹

Symptoms of ADHD

It is normal to have some inattention, unfocused motor activity and impulsivity. For people with ADHD, these behaviors can be more severe, occur more often and may interfere with or reduce the quality of how they function socially, at school or in a job. ADHD symptoms can appear as early as between the ages of three and six and can continue through adolescence and adulthood.¹

Treatment of ADHD

While there is no cure for ADHD, currently available treatments can help reduce symptoms and improve functioning. Treatments include medication, psychotherapy, education and training, or a combination of treatments.¹

Resources:

1. National Institute of Mental Health: Attention Deficit Hyperactivity Disorder (revised March 2016) 
2. WebMD: ADHD Health Center 
3. 2017 ICD-10-CM Expert for Physicians: The Complete Official Code Set, Optum360. 2016 Optum360, LLC

Asthma

Asthma, sometimes called bronchial asthma or reactive airway disease², is a chronic lung disease that makes it harder to move air in and out of the lungs.¹ It can be serious and life-threatening and can start at any age. With asthma, swollen airways become extra sensitive to things that one is exposed to in the environment every day—asthma “triggers.” When a trigger is breathed in, the airways create extra mucus and swell even more, making it harder to breathe.²

Symptoms of Asthma

Asthma symptoms include coughing (especially at night), wheezing, shortness of breath and chest tightness, pain or pressure.² Understanding the experiences or exposures that make the asthma flare up is a key step to better managing the disease.

Treatment of Asthma

Treatment for asthma may include inhalers, oral medications and drugs delivered in a nebulizer or breathing machine.² Making a plan to avoid or limit the environmental exposure to asthma triggers can eliminate asthma symptoms and help control the disease.¹

Resources:

1. American Lung Association
2. WebMD: Asthma Health Center 
3. 2017 ICD-10-CM Expert for Physicians: The Complete Official Code Set, Optum360. 2016 Optum360, LLC

Autistic Disorder

Autism is a brain disorder that limits a person’s ability to communicate and relate to other people.² Also known as autism spectrum disorder (ASD), the term “spectrum” reflects the wide variation in challenges and strengths possessed by each person.¹ Some people can navigate their world, some have exceptional abilities and some struggle to speak.²

Symptoms of Autism

Signs of ASD tend to appear between two and three years of age and can include repeated motions and/or words, avoiding eye contact or physical touch, delays in learning to talk and getting upset by minor changes.² Additionally, some people with autism can experience physical symptoms such as constipation, sleep problems, poor coordination of muscles and seizures.² These signs, however, can also occur in children without ASD and at any age.^1,2 It is important that caregivers talk with a healthcare provider to request a screening for autism.

Treatment of Autism

Treatment for ASD is dependent on screening results. A diagnosis of autism is not needed for people to begin receiving services related to developmental delays or learning challenges.¹ Treatments include behavior programs, individualized education programs (IEPs), medication, sensory processing, assistive technology and diet.²

Resources:

1. Autism Speaks: What is Autism?
2. WebMD: What is Autism? 
3. 2017 ICD-10-CM Expert for Physicians: The Complete Official Code Set, Optum360. 2016 Optum360, LLC

Conduct Disorder

Conduct disorder is a repetitive and persistent pattern of behavior in children and adolescents in which the rights of others or basic social rules are violated.¹ It is not uncommon for a child or teen to experience behavioral problems; however, the behavior is considered to be a conduct disorder when it is long-lasting and when it goes against accepted norms of behavior and disrupts the child’s or family’s everyday life.²

Symptoms of Conduct Disorder

Symptoms of conduct disorder vary depending on the age of the child and whether the disorder is mild, moderate or severe. In general, the symptoms fall into four categories: (1) Aggressive, (2) Nonaggressive or Destructive, (3) Deceitfulness, and (4) Violation of Rules.²

Treatment of Conduct Disorder

Treatment for conduct disorder is based on many factors, including the child’s age, the severity of the symptoms and the child’s ability to participate in and tolerate specific therapies.² Treatment usually consists of psychotherapy, medication and/or a family support group or organization. Appropriate treatment is individualized and should be done by a mental health professional, preferably one who is trained in children’s mental health.¹

Resources:

1. Mental Health America: Conduct Disorder 
2. WebMD: Mental health and Conduct Disorder
3. 2017 ICD-10-CM Expert for Physicians: The Complete Official Code Set, Optum360. 2016 Optum360, LLC

Bipolar Disorder

Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in mood, energy, activity levels and the ability to carry out day-to-day tasks.¹ People who have bipolar disorder can have periods in which they feel overly happy and energized and other periods of feeling very sad, hopeless and sluggish. In between those periods, they usually feel “normal.” One can think of the highs and the lows as two “poles” of mood, which is why it’s called “bipolar” disorder.²

Symptoms of Bipolar Disorder

People with bipolar disorder experience periods of unusually intense emotion, changes in sleep patterns and activity levels, and unusual behaviors. These distinct periods are called “mood episodes.”¹ A clinician would have to determine whether they may be the result of another cause (such as low thyroid or mood symptoms caused by drug or alcohol abuse).²

Treatment of Bipolar Disorder

Medication is the main treatment, usually involving “mood stabilizers.” Psychotherapy, or “talk therapy,” is often recommended, too.²

Resources:

1. National Institute of Mental Health: Bipolar Disorder (revised April 2016)
2. WebMD: A Look at Bipolar Disorder (reviewed November 2015) 
3. 2017 ICD-10CM Expert for Physicians: The Complete Official Code Set, Optum360. 2016 Optum360, LLC

Cancer

Cancer starts when cells grow out of control and crowd normal cells.² In all types of cancer, some of the body’s cells begin to divide without stopping and spread into surrounding tissues.¹ There are many types of cancer and the causes vary greatly.

Symptoms of Cancer

The signs and symptoms will depend on where the cancer is located, how big it is, and how much it affects the organs or tissues.² If a cancer has spread (metastasized), signs or symptoms may appear in different parts of the body. Some signs include noticeable changes such as changes in the skin, breast, or urination¹ while other signs are not known until the cancer has grown quite large.

Treatment of Cancer

There are many types of treatment that will depend on the type of cancer and how advanced it is. Common treatments include surgery, chemotherapy, radiation therapy, targeted therapy and immunotherapy.

Resources:

1. National Cancer Institute 
2. American Cancer Association 
3. Elsevier Clinical Solutions (Understanding the ICD10-CM Neoplasm Coding Guidelines)
4. ICD-10-CM Official Guidelines for Coding and Reporting (PDF)

Depression

Depression (major depressive disorder or clinical depression) is a common but serious mood disorder. It causes severe symptoms that affect how you feel, think and handle daily activities, such as sleeping, eating or working. To be diagnosed with depression, the symptoms must be present for at least two weeks.¹ Doctors aren’t sure what causes depression, but a prominent theory is altered brain structure and chemical function. Depression is not a sign of weakness or a negative personality. It is a major public health problem and a treatable medical condition.²

Symptoms of Depression

Some of the signs and symptoms of depression can be experienced most of the day, or nearly every day, for at least two weeks. These include feelings of sadness, anxiousness, hopelessness, irritability, guilt, decreased energy or fatigue, loss of interest, feeling restless, difficulty concentrating or sleeping, appetite changes and/or thoughts of death or suicide.¹

Treatment of Depression

Depression, even the most severe cases, can be treated. The earlier that treatment can begin, the more effective it is. Depression is usually treated with medications, psychotherapy or a combination of the two.¹ In addition to therapy and medication, research suggests pets and exercise are potent weapons against mild to moderate depression.²

Resources:

1. National Institute of Mental Health: Bipolar Disorder (revised October 2016) 
2. WebMD: Depression: What Is It? (reviewed May 07, 2016)
3. 2017 ICD-10CM Expert for Physicians: The Complete Official Code Set, Optum360. 2016 Optum360, LLC
4. Mental Health America: Depression Screening 

Diabetes

Diabetes is a disease that occurs when your blood glucose, or blood sugar, is too high, which can cause health problems over time.¹ Diabetes causes more deaths a year than breast cancer and AIDS combined and nearly doubles the chance of having a heart attack.² The main types of diabetes are type 1, type 2 and gestational.

Symptoms of Diabetes

Common diabetes symptoms include urinating often, feeling very thirsty, feeling very hungry even though you are eating, extreme fatigue, blurry vision, cuts/bruises that are slow to heal, weight loss even though you are eating more (type 1), and tingling, pain or numbness in the hands/feet (type 2).² Early detection and treatment of diabetes can decrease the risk of developing the complications of diabetes.

Treatment of Diabetes

Diabetes is a serious disease that cannot be treated on its own. A treatment plan may be developed by a provider that includes keeping a close watch over blood sugar levels with a combination of medications, exercise and diet.³

Resources:

1. National Institute of Diabetes and Digestive and Kidney Diseases 
2. American Diabetes Association 
3. WebMD: Diagnosis and Treatment 
4. ICD-10-CM Official Guidelines for Coding and Reporting (PDF)

When is oxygen therapy used?

According to the National Heart, Lung, and Blood Institute, doctors use oxygen therapy to treat the following conditions: Chronic Obstructive Pulmonary Disease (COPD), heart failure, pneumonia, severe asthma, cystic fibrosis, sleep apnea.¹

How is oxygen therapy administered?

Oxygen therapy is received from tubes resting in your nose, a face mask, or a tube placed in your trachea or windpipe. It can be given for a short or long period of time in the hospital, another medical setting or at home. Oxygen is stored as a gas or liquid in special tanks.¹

Resources:

1. National Heart, Lung and Blood Institute: Oxygen Therapy
2. SuperCoder
3. AHA Coding Clinic, 2002, Q4, Status V codes
4. Durable Medical Equipment (PDF) (pg195-198)
5. Pub Med
6. Medical PA Criteria Change V 2.9 (PDF)
7. CDC National Center for Health Statistics