Compliance
A CMS audit of Part C HCCs to verify the diagnoses in the risk scores are supported by the documentation
What is RADV Audit
(Risk Adjustment Data Validation)
A patient is respirator dependent and has a tracheostomy in need of revision due to redundant scar tissue formation surrounding the site. Under general anesthesia and establishing the airway to maintain ventilation, the scar tissue is resected and then repair is accomplished using a layered closure. What ICD-10-CM codes are reported?
L90.5, Z43.0, Z99.11
Rationale: ICD-10-CM: Scar tissue is not a true complication of the stoma. In the ICD-10-CM Alphabetic Index look for Scar referring you to L90.5. Next, look in the Alphabetic Index for Attention to/tracheostomy directing you to Z43.0. ICD-10-CM guideline I.C.21.c.7. Aftercare indicates that aftercare codes should be used in conjunction with other aftercare codes or diagnosis codes to provide better detail on the specifics of an aftercare encounter visit, unless otherwise directed by the classification. The patient is ventilator dependent. In the Alphabetic Index look for Dependence/on/ventilator directing you to Z99.11. Verify all codes in the Tabular List
Commercial plans through healthcare exchanges use which risk adjustment model.
what is HHS-HCC
Health and Human Services Hierarchical Condition Category (HHS HCC)—Commercial, Individual, and Small Group
These categories are assigned for diagnoses that are costly to manage from a prescription drug treatment perspective
what are RxHCCs
While in the hospital, the patient developed an intra-muscular infection at the surgical site of a total knee replacement. The diagnosis is Staphylococcus sepsis. The Infectious Disease provider visits the patient to discuss the diagnosis and treatment plan. What ICD-10-CM codes are reported?
T81.42XA, T81.44XA, A41.2
Rationale: See ICD-10-CM Guideline I.C.1.d.5.b Sepsis due to a postprocedural infection. For such cases, a code from T81.40-T81.43 is reported for the site of the infection, followed by T81.44 for sepsis following a procedure. An additional code is reported to identify the infections agent.
Because the documentation does not state the infection is due to the prosthetic device but rather is at the deep (intramuscular) surgical site, look in the Alphabetic Index for Infection/postoperative wound/surgical site/deep incisional referring you to T81.42-. In the Alphabetic Index, look for Sepsis/postprocedural T81.44-. Both codes require a 7th character to identify the type of encounter. If a code that requires a 7th character is not already 6 characters in length, a placeholder X must be used to fill in the empty characters. There is a Use additional code note on T81.44- directing you to identify the sepsis. In the Alphabetic Index look for Sepsis/Staphylococcus, staphylococcal A41.2. Severe sepsis is not documented and R65.20 is not reported.
This model is also known as Medicare Advantage.
(Medicare HCC-C)
Medicare Hierarchical Condition Category, Part C
This type of review affects the following year instead of the current year?
Prospective
A 71-year-old presents to the outpatient clinic at the local hospital with COPD, congestive heart failure, and hypertension. After a comprehensive evaluation, the physician makes adjustments to the patient’s hypertension medication due to the hypertension being uncontrolled. The patient’s other conditions were documented as stable. The patient is to follow-up in two weeks. What ICD-10-CM codes are reported?
I11.0, I50.9, J44.9
Rationale: The provider does not document a cause and effect relationship between the heart failure and hypertension; however, guideline I.A.14 “With” indicates that when the word with appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List, with should be interpreted to mean associated with or due to. In the ICD-10-CM Alphabetic Index look for Disease, diseased/pulmonary/chronic obstructive referring you to J44.9. Next, look for Hypertension, hypertensive/with/heart failure (congestive) directing you to I11.0. There is no subterm for out of control. Next in the Alphabetic Index look for Failure/heart/congestive referring you to I50.9. Verify all the codes in the Tabular List. A note under I11.0 indicates to use an additional code to identify the type of heart failure (150.-). Final code to report is the COPD. Look in the ICD-10-CM Alphabetic Index for Disease/pulmonary/chronic obstructive J44.9.
This model is applicable to diagnoses captured in an inpatient setting.
Diagnosis Related Groups (DRG)—Inpatient
Using known data elements to establish a hypothesis related to the future health of patients
What is suspect logic
A patient with hypertensive heart disease sees the ophthalmologist for headaches and double vision. The ophthalmologist makes a diagnosis of bilateral hypertensive retinopathy of both eyes. What are the ICD-10-CM codes for this condition?
H35.033, I11.9
Rationale: ICD-10-CM Guideline I.C.9.a.5 Hypertension Retinopathy says subcategory H35.0, Background retinopathy and retinal vascular changes, should be used with a code from category I10-I15, Hypertensive disease to include the systemic hypertension. In the Alphabetic Index look for Retinopathy (background)/hypertensive H35.03-. Subcategory H35.03 requires a 6th character for laterality. Character 3 is used for bilateral. For hypertensive heart disease look for Hypertension, hypertensive/heart I11.9.
This model is known for outpatient
Adjusted Clinical Groups (ACG)—Outpatient
IVA
what is an Initial Validation Auditor (IVA)
The next patient is a 67-year-old gentleman with a history of prostate cancer receiving brachytherapy treatment. Following calculation, transrectal ultrasound guidance was provided for percutaneous placement of I-125 seeds into the prostate tissue. What ICD-10-CM coding is reported?
C61
Rationale: Look in the ICD-10-CM Alphabetic Index for Cancer referring you to see also Neoplasm, by site, malignant. Look in the ICD-10-CM Neoplasm Table for Neoplasm/prostate (gland)/Malignant Primary column guiding you to C61. Although the documentation states “history of,” the patient is receiving treatment making the history current.
This model is known for Medicaid line of business
Medicaid Chronic Illness and Disability Payment Systems (CDPS)