The Note
(True or False) In the Physical Exam section, when using your provider’s template (or any template), it is imperative to remove any component of the exam that was NOT performed during that visit:
True
Which depression codes DO NOT risk adjust?
F32.9, F34.1, F34.0, F43.1
What is risk adjustment?
The actual process of using that clinical and demographic information to help predict medical cost(s) for the following year
What are the 3 different types of LE Exams that can be ordered in the note?
Diabetic foot assessment (GO245)
PAD Lower Extremity Exam (PAD)
LLEUU Lower Extremity Exam (LLEVU)
At which visits should you ‘address’ a suspected condition on the care report?
WRV, WV, PGV, PBV, PDV
In the Plan section of a Post Discharge Visit template, which CPT code indicates we reviewed a patient’s medication list from the hospital and compared it to what we have in Greenway (ie, a medication reconciliation was completed) AND what ICD-10 code is mapped?
1111F; Z79.899
How do providers typically make a COPD diagnosis?
FEV1/FVC less than 0.7 and/or clinical sxs
What are some examples of DM with Ophthalmic Disease
A CDQ score of what triggers a spirometry to be ordered/completed?
What is the type of visit called where a spirometry should be performed?
Pre/Post Dilation Spirometry Visit
What counts as ‘addressing’ a suspect?
Rejecting the suspect in the Care Report Registry because our provider has ruled out this condition, Assigning ‘follow up’ status in the Care Report Registry when we are waiting on records, a diagnostic, or lab result / vital sign for example, Documenting the suspected condition in the assessment section of a visit note with your provider
What are all the steps that must be checked as part of Superbill hygiene? (there are 7)
Ensure the visit is “linked”, The “Referring Provider” field is filled out accurately, Missing diagnosis codes are mapped, There are no V/W/X/Y codes OR Z00.00/Z00.01/Z00.8 mapped to the E&M or “visit” code, Modifiers are entered, All services not billable by OSH are marked as such, Superbill is changed from “Hold” to “Ready”
What can you NOT use to diagnosis COPD?
What are some examples of DM with Neurological Complication
Neuropathy unspecified, mononeuropathy, polyneuropathy, autonomic neuropathy, diabetic amyotrophy, or other neurologic manifestations
For the Depression Screening, what is the CIS' role?
During the visit ->If a positive screening result is obtained, document the discussion in the patient's note. Additionally, record any diagnoses related to depression or substance use disorder (SUD) as directed by the provider.
What is an HCC
A group of medical codes that represent diagnoses with similar clinical complexity and expected annual care costs
Coding BMI and weight status (overweight, obese, morbidly obese) is redundant. We should not code for both BMI and weight status.
False
What Heart Failure Codes DO NOT Risk Adjust?
Left Ventricular Hypertrophy (LVH), Right Bundle Branch Block (RBBB), Cardiomyopathy, Heart Disease, Benign Hypertensive Heart Disease, Systolic OR Diastolic Dysfunction
If a patient has type 2 diabetes mellitus and is prescribed Humalog 13 units TID, what ICD-10 do we need to add to the assessment in addition to the ICD-10 for the type 2 diabetes mellitus?
Z79.4 - Long term (current) use of insulin
What is the CIS role in our Internal Stars Program?
Day of Visit → Prompt provider to address gap during morning huddle if present on Huddle From.
Admin Time → Work through panel management lists assigned by PM/ PCP
What are some HCC coding best practices? (3)
Document and code all conditions that coexist at the time of the encounter and require or affect patient care treatment or management, Documentation of diagnoses must show MEAT, evidence the condition was monitored, evaluated, assessed or treated, and Document all relevant diagnoses at least once in a calendar year
Where should you document a diabetes foot exam that is completed at a visit? UPDATE
Physical Exam, Results Section, Assessment
What conditions require an additional diagnosis?
Diabetes, Cardiac and pulmonary conditions, Overweight, obesity, morbid obesity, etc.
An 80 yo F presents for a WV. She had an above the knee amputation of her right lower extremity (RLE) ~20 years ago. Which code should I prompt my provider to consider adding to the assessment?
Z89.611 - Acquired absence of right lower extremity above knee
What are the 3 main actions a CIS should take for gaps in A1c, BCS, KED, COL and EYE measures?
Check the Medical Records Exchange tab and/or external EMRs; move records over to patient chart
Update flowsheet
Identify patient who needs missing measure and create an action
Why was the Daily Accountability Tracker (DAT) introduced?
To ensure care teams follow through on all suspects in follow up at every visit and make progress to the next step for resolution/Include amendable language/action on suspects appropriately.
Why: This visit may be the last time we see the patient before the end of the year!