Provider Policies and Procedures
On this page:
- Compliance with Policy/Protocol
- Provide Timely Notice of Demographic Changes
- Prohibited Billing Practices
- After Hours Care
- Delay in Service
- Medical Record Requirements
- Risk Adjustment Information
- Informing Members of Advance Directives
- Referrals and Prior Authorization Requests
- Member Rights and Responsibilities
Compliance with Policy/Protocol
According to your provider agreement, you will comply with and be bound by Trinity Health Plan New York’s policies and protocols, including those contained in this manual. Failure to comply with such policies and protocols will be reviewed by Trinity Health Plan New York and may result in appropriate action in accordance with your provider agreement, such as denial of payment, financial penalties and modifications to your reimbursement or other terms of your agreement with us, or ineligibility to participate in recognition programs.
You are not permitted to bill our members for any amounts not paid due to your failure to comply with our policies and protocols.
Provide Timely Notice of Demographic Changes
You must notify us within 30 days of any changes to demographic and participation information that differs from the information reported with your executed provider agreement. These include, but are not limited to: tax ID changes (W9 required), office or remittance address changes, phone numbers, suite numbers, additions or departures of health care providers from your practice, ability of individual practitioners to accept our members or any other changes that affect availability to our members and new service locations.
If a provider is associated with a group that is delegated for credentialing, please verify that credentialing is not affected by contacting the Provider Service Center at 1-800-991-9907.
Prohibited Billing Practices
Balance Billing
Prohibited Billing of Qualified Medicare Beneficiary (QMB) Individuals and Medicare Assignment
Medicare-covered services, also covered by Medicaid, are paid first by Medicare because Medicaid is generally the payor of last resort. Medicaid may cover the cost of care that Medicare may not cover or may partially cover (such as nursing home care, personal care, and home- and community-based services).
Federal law prohibits all Medicare providers from billing QMB individuals for all Medicare deductibles, coinsurance or copayments. All Medicare and Medicaid payments the provider receives for furnishing services to a QMB individual are considered payment in full. The provider is subject to sanctions if you bill a QMB individual for amounts above the sum total of all Medicare and Medicaid payments, even when Medicaid pays nothing.
In addition, all Medicare providers must accept assignment for Part B services furnished to dual eligible beneficiaries. Assignment means that the Medicare-allowed amount (Physician Fee Schedule amount) constitutes payment in full for all Part B-covered services provided to beneficiaries.
What to do:
- Ensure that you are checking the eligibility of your patients. Some Medicare enrollees may qualify for both Medicare and Medicaid services. These members are called Dual Benefits Members.
- You may confirm a member’s eligibility for Medicaid through Medicaid Information Technology System (MITS).
What not to do:
- The QMB program is a state Medicaid benefit that covers Medicare deductibles, coinsurance and copayments, subject to state payment limits.
- Medicare providers may not balance bill QMB individuals for Medicare cost-sharing, regardless of whether the state reimburses providers for the full Medicare cost-sharing amounts.
- Further, all Original Medicare and MA providers—not only those that accept Medicaid—must refrain from charging QMB individuals for Medicare cost- sharing. Providers who inappropriately balance bill QMB individuals are subject to sanctions. Federal law bars Medicare providers from balance billing a QMB beneficiary under any circumstances.
See Section 1902(n)(3)(B) of the Social Security Act, as modified by Section 4714 of the Balanced Budget Act of 1997.
Non-Covered and/or Not Medically Necessary Services, Integrated Denial Notice (IDN) Required
If you have any reason to believe that Trinity Health Plan New York will not cover a service, in whole or in part, you must contact our Utilization Management team prior to performing the services and obtain a Prior Authorization determination. The utilization management team will review the request and, if the service is not covered under the member’s benefit plan and/or “medically not necessary,” issue an IDN to the member. The member must receive the IDN in advance of receiving the service and must have sufficient time to decide if they want to proceed with the non-covered and/or “medically not necessary” service, at which time the member could be billed.
Failure to obtain an IDN for a non-covered and/or “not medically necessary” service will result in an administrative denial, for which you may not seek any reimbursement from Trinity Health Plan New York or the member.
You should know or have reason to know that a service may not be covered if:
- The service is expressly excluded from coverage in the member’s Summary of Benefits and Evidence of Coverage.
- We have provided general notice either that we will not cover a particular service or that particular services are only covered under certain circumstances.
- We have made a determination that planned services are not covered and/or are “not medically necessary” services and have communicated that determination to you.
Member Responsibility: Nothing herein or in your agreement with Trinity Health Plan New York prohibits you from collecting any coinsurance, deductible, or copayments specifically identified in the member’s Evidence of Coverage.
You may not bill our members for non-covered services if you do not comply with this policy.
After Hours Care
Our members are instructed to contact their PCP before any form of care is rendered. Therefore, the PCP may receive telephone calls outside routine office hours. It is incumbent upon you to determine whether the requested care is of an emergency nature. Every reasonable and medically appropriate attempt should be made to give advice and arrange for the member to be seen during regular office hours. As the provider, you should consider:
- Meeting the member at the emergency room or directing the member to the nearest urgent care center or emergency room, where appropriate.
- Meeting the member at your office.
- Directing the member to your pre-arranged, network PCP on-call.
Delay in Service
Facilities that provide inpatient services must maintain appropriate staff, resources and equipment to ensure that covered services are provided to our members in a timely manner. A delay in service is defined as a failure to execute a physician order in a timely manner that results in a longer length of stay. A delay in service may result for any of the following reasons:
- Equipment needed to execute a physician’s order is not available.
- Staff needed to execute a physician’s order is not available.
- A facility resource needed to execute a physician’s order is not available. Facility does not discharge the patient on the day the physician’s order is written. Payment to facilities may be affected for delays in service.
Medical Record Requirements
Follow Medical Record Standards
Medical record requests may be made by Trinity Health Plan New York and/or its designated vendor for a variety of reasons. Requests for medical records may be necessary in any of the following circumstances:
- Additional information is required before Trinity Health Plan New York can process a claim.
- A complaint or allegation of possible fraud, waste or abuse of the Medicare program which requires investigation.
- Any complaint alleging possible quality of care, service or access to care.
- Review of an established or new physician or practitioner is warranted, before or after a claim is paid, based on analysis of data.
- Payment retraction.
- Data collection for HEDIS.
- Risk adjustment purposes that include, but are not limited to: verifying the accuracy of coding, ensuring all diagnosis codes are properly supported by relevant medical records, medical record review to identify any conditions not captured through claims or encounter data, and to comply with CMS requests for records when conducting any Improper Payment Measure audits or Risk Adjustment Data Validation (RADV).
- CMS request for records (Trinity Health Plan New York performs health care operations for CMS).
- Additional information is required to support delegation oversight monitoring and auditing activities to ensure compliance with CMS guidelines.
In all cases, it is extremely important that requested records are provided to the proper entity within the timeframe specified.
It is understandable that there are concerns about patient confidentiality, but the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule permits disclosure of protected health information without a patient’s authorization when the information is necessary to carry out treatment, payment or health care operations.
When Medicare Beneficiaries enroll in one of our plans, they are informed of Trinity Health Plan New York’s use of their protected health information to carry out health care operations. Providing the requested documentation does not violate HIPAA and does not require additional beneficiary authorization.
Your cooperation is a legal obligation as outlined in the Social Security Act, the law governing Medicare (Section 1842), as well as a contractual requirement of your participation in Trinity Health Plan New York. CMS requires Trinity Health Plan New York, as one of its contractors, to report suspected fraud. Failure to forward records that substantiate service may force Trinity Health Plan New York to consider this action.
If you choose to charge the Plan for medical records, Plan shall reimburse physician for records requested by the Plan at the Medicare rate, plus postage when applicable. Payment shall be made by the Plan to physician upon the Plan’s receipt of the requested records.
General Documentation Guidelines
We also expect you to follow these commonly accepted guidelines for medical record information and documentation:
- Date all entries and identify the author.
- Make entries legible. If signatures are illegible, you may be required to provide an attestation or signature log.
- Cite medical conditions and significant illnesses under history of present illness, past medical history, and/or assessment and plan.
- Give prominence to notes on medication allergies and adverse reactions. Also note if the member has no known allergies or adverse reactions.
- Make it easy to identify the medical history and include chronic illnesses, accidents
- and operations.
- For medication records, include name of medication and dosages. Also, list over-the- counter drugs taken by the member.
- Code all ICD-10 codes to the highest specificity.
- Document these important items:
- All member conditions that are currently being treated or monitored.
- Blood pressure.
- Height/weight and body mass index (BMI). Tobacco items, including advice to quit.
- Alcohol use and substance abuse. Immunization record.
- Family and social history.
- Preventive screenings and services.
Demographic Information
The medical record for each member should include:
- Member name and/or ID number on every page.
- Gender.
- Age or date-of-birth.
- Address.
- Marital status.
- Occupational history.
- Home and/or work phone numbers.
- Name and phone number of emergency contact.
- Name of spouse or relative.
- Insurance information.
Member Encounters
When you see our members, document the visit by noting:
- Member’s complaint or reason for the visit.
- Physical assessment.
- Unresolved problems from the previous visit(s).
- Diagnosis and treatment plans consistent with your findings.
- Member education, counseling or coordination of care with other providers.
- Date of return visit or other follow-up care.
- Review by the primary physician (initialed) on consultation, lab, imaging, special studies and ancillary, outpatient and inpatient records.
- Consultation and abnormal studies are initialed and include follow-up plans.
Clinical Decision and Safety Support Tools in Place to Ensure Evidence-Based Care is Provided
Examples of clinical decision and safety support tools include, but are not limited to:
- ALT/AST laboratory test done if member taking statins.
- Immunization tracking sheet.
- Flow sheet for chronic diseases.
- Member reminder system.
- Electronic medical records.
- E-prescribing.
Risk Adjustment Information
In 1997, CMS created a new payment methodology for Medicare Advantage plans. The new methodology uses the health status of Medicare beneficiaries to determine accurate payment rates.
Physicians and other health care providers play an important role in risk adjustment because CMS looks at provider encounter data (extracted by Trinity Health Plan New York from claims) to determine payment rates. Encounter data you submit to Trinity Health Plan New York must be accurate and complete.
- Risk adjustment is based on ICD-10 diagnosis codes, not CPT codes. Therefore, it is critical for your office to refer to an ICD-10-CM coding manual and code accurately, specifically and completely when submitting claims to Trinity Health Plan New York.
- Diagnosis codes must be supported by the medical record. If it is not documented in the medical record, Trinity Health Plan New York has the right to not submit the diagnosis code to CMS through EDPS or submit a delete through EDPS. Medical records must be clear and complete.
- Never use a diagnosis code for a "probable" or "questionable" diagnosis. Instead code only to the highest degree of certainty.
- Be sure to distinguish between acute vs. chronic conditions in the medical record and in coding. Only choose diagnosis code(s) that fully describe the member’s condition and pertinent history at the time of the visit.
- Be sure that the diagnosis code is appropriate for the member’s gender.
- Always carry the diagnosis code all the way through to the correct digit for specificity. A code is invalid if it has not been coded to the full number of characters required for that code, including the 7th character where applicable. (Where place holders exist, "X" must be used for the code to be valid).
- Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist.
- To ensure complete and accurate diagnosis codes are submitted to CMS, Trinity Health Plan New York will conduct internal data validation audits by reviewing a sample of provider medical records to ensure coding accuracy. You may be contacted by Trinity Health Plan New York requesting medical records for data validation. In order for a chart to be valid the following criteria must be met:
- Complete patient demographic information
- Date of Service
- Valid Signature
- Illegible provider signature will require a signature attestation per CMS guidelines
- Documentation must indicate the diagnoses are being monitored, evaluated, assessed/addressed, or treated (MEAT).
- Trinity Health Plan New York will add any diagnosis codes documented within the record but they were not coded or coded to the highest specificity at the time of the visit. In addition, Trinity Health Plan New York will delete any diagnosis codes that were coded at the time of Trinity Health Plan New York is a registered trade name of Mount Carmel Health Plan, Inc., the visit but not fully supported within the medial record to CMS through EDPS.
Coding Tips
An Abdominal Aortic Aneurysm (AAA) is an enlarged area in the lower part of the aorta. It is very important to monitor this condition, as they can become fatal if not monitored properly. A specialist often diagnoses and treats this condition, but it is important to capture all chronic conditions on an annual basis.
- There are two procedures that can be done to treat AAA:
- If there has been an open repair, it is important to note that this can no longer be coded as current
- If an endovascular repair has been done and there are stents put in place, AAA is still coded as active
- There should be annual imaging done to monitor the condition
Acceptable Documentation
70-year-old male in for annual wellness exam. Patient has history of AAA and recently had imaging done to monitor. Imagining showed 3.4cm.
Code: I71.4 – Abdominal aortic aneurysm, without rupture
According to The National Institute on Alcohol Abuse and Alcoholism, Alcohol Use Disorder is a chronic relapsing brain disorder characterized by an impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences.
Important Coding Information
When the provider documentation refers to use, abuse and dependence of the same substance, only one code should be assigned to identify the pattern of use based on the following hierarchy:
- IF both use and abuse are present, assign only the code for abuse
- IF both abuse and dependence are present, assign only the code for dependence
- IF use, abuse and dependence are all present, assign only the code for dependence
- IF both use and dependence are present, assign only the code for dependenc
Alcohol Use Disorders
- F10.1_ Alcohol Abuse
- F10.2_ Alcohol Use
- 0. Alcohol Dependence
Subcategories
- _1 Alcohol Abuse
- _2 In remission
- _3 With intoxication
- _4 With withdrawal
- _5 With induced mood disorder
- _6 Psychotic disorders
- _7 Persisting amnestic disorder
- _8 Persisting dementia
- _9 Other induced disorders
- _10 Unspecified induced disorder
Angina usually occurs during exertion, severe emotional distress or after a heavy meal. In general, the presence or absence of angina is used to predict the risk of morbidity and mortality in patients with coronary artery disease (CAD). Patients with CAD, who have stable angina and use sublingual nitrates or long acting nitrates, are at higher risk than patients with CAD and no angina. Therefore, the provider should specify in their documentation the presence of stable angina independent of the diagnosis of CAD itself.
When documenting CAD with angina, ICD-10 has combination codes for CAD with or without angina pectoris. A causal relationship can be assumed in a patient with both CAD and angina pectoris unless the documentation indicates the angina is due to another condition. If angina is not linked with or due to CAD, it needs to be stated as so. This would include angina listed in the assessment, along with supporting documentation stating it is not due to CAD.
Documentation requirements
Cite: Native artery and/or bypass graft (autologous vein, autologous artery, non-autologous). Angina: With (angina pectoris, unstable angina pectoris or angina pectoris and spasm) or without
Acceptable documentation for independent conditions:
- 68 year old female with CAD native artery, follows up with cardiologist and working on changing eating habits.
- Patient also has stable angina, unrelated to CAD, being treated with Nitrostat.
- ICD-10-CM Codes:
- I2510 – atherosclerotic heart disease of native coronary artery without angina pectoris.
- I209 – angina pectoris, unspecified
Acceptable documentation for related conditions:
- 68 year old female with CAD native artery, follows up with cardiologist and working on changing eating habits.
- Patient has angina, being treated with Nitrostat.
- ICD-10-CM Code:
- I25119 - atherosclerotic heart disease of native coronary artery with unspecified angina pectoris
Atrial fibrillation is an irregular and often rapid heart rate that can cause poor blood flow to the body and could pose a threat of a stroke. There are three types of atrial fibrillation: Paroxysmal, Persistent and Chronic (permanent).
- Paroxysmal – two or more episodes or irregular cardiac rhythm, that last for more than 30 seconds, which go away spontaneously in seven days or less
- Persistent – irregular cardiac rhythm episodes that fail to go away within seven days
- Chronic (permanent) – irregular cardiac rhythm that has been present for more than 12 months
Important Coding Information
In order to properly code Atrial Fibrillation there needs to be supporting documentation, including a valid treatment plan. Treatment plans can include:
- Medications
- Diet
- Referrals, and
- Diagnostic exams
Common signs and symptoms are as follows, and can also be used as supporting documentation:
- Irregular heartbeat
- Palpitations
- Tachycardia
- Fatigue
- Weakness and dizziness
- Shortness of breath
- Chest Pain
DSM-5 Diagnostic criteria for Bipolar Disorder, mixed episode.
Bipolar [mood] disorders are a class of psychiatric disorders that are very challenging to manage due to the dynamic, chronic and fluctuating nature of the disease. These disorders cause unusual shifts in mood, energy and activity levels. The DSM-5 diagnostic criteria is used by mental health providers to diagnose mental disorder. Bipolar disorder, mixed episode, requires at least one week of fulfilling criteria for both mania and depression. The following are the some of the common signs of manic episode and major depressive episode:
- Impaired concentration/focus/thinking.
- Low energy.
- Significant, unintentional, weight loss or gain.
- Inflated self-esteem and self-confidence.
- Reduced need for sleep.
- More talkative than usual.
- Racing thoughts.
- Distractibility.
- Increase in activity directed toward a specific goal.
- Doing a lot of things that give pleasure or are risky (e.g. sexual or financial)
Examples of ICD-10 Documentation requirements for Bipolar disorder
- Diagnosis:
- Bipolar disorder
- Current Episode:
- Hypomanic
- Manic
- Depressed or Mixed
- Symptoms, Findings, Manifestations:
- Mild, moderate, or severe
- With psychotic features/without psychotic features
- Remission Status:
- Full vs partial remission, and
- Most recent episode as hypomanic, manic, depressed or mixed
Documentation Example
A 30-year old women presents with history of depression who has been feeling very sad and empty for the past week. She is losing interest in daily activities and has a hard time getting out of bed. But, some days, she states she feels like she has to keep moving. Is currently on Prozac, but mood swings tend to be worsening. Scored high on mood disorder questionnaire (MDQ).
Assessment/Plan
Diagnosis of bipolar disorder, current episode mixed, mild can be given due to depression and manic symptoms. Discontinue Prozac. Placed on Seroquel 100 mg. Will check up in a 3 months. Psychotherapy is recommended.
ICD-10 Code: F3161 – Bipolar disorder, current episode mixed, mild
Breast cancer occurs when cells within the breast tissue grow out of control. These overgrown cells usually form a tumor, which may be felt as a lump or seen on an x-ray. Breast cancer occurs in women, and although less common, can also occur in men.
There are various treatment options, including surgery, chemotherapy, hormonal therapy, and radiation therapy.
Important Coding Information
Active breast cancer for both male and female are under ICD-10 code category C50. According to the ICD-10-CM Coding Guidelines, “When a primary malignancy has been previously excised or eradicated from its site, there is no further treatment of the malignancy directed to that site, and there is no evidence of any existing primary malignancy, a code from category Z85 Personal history of malignant neoplasm, should be used to indicate that former site of the malignancy.
” Personal history of breast cancer should be coded as Z85.3
Code Selection
C50.- Malignant Neoplasm of Breast
- C50.0 – Nipple and areola
- C50.1 – Central portion
- C50.2 – Upper-inner quadrant
- C50.3 – Lower-inner quadrant
- C50.4 – Upper-outer quadrant
- C50.5 – Lower-outer quadrant
- C50.6 – Axillary tail of breast
- C50.8 – Overlapping sites
- C50.9 – Unspecified site
These codes require 5th and 6th digits:
- 5th digit specifies gender: 1 – Female; 2 – Male
- 6th digit specifies laterality: 1 – Rights; 2 – Left; 9 – Unspecifie
In ICD-10-CM, there is an assumed causal relationship in a patient with both coronary atherosclerosis and angina pectoris. Combination codes are used for these two conditions unless the documentation states explicitly the angina pectoris is due to some other condition or disease process besides atherosclerosis. Do not code angina and CAD separately. The combination codes reflect the vessel location and form of angina.
Without angina:
- Atherosclerosis of the native coronary artery, without angina: I25.10.
- Atherosclerosis of other coronary vessels, without angina: I25.81.
With angina:
- Atherosclerosis of the native coronary artery, with angina, requires a specific code based on the form of angina. Use the appropriate combination code:
- I25.110 (with unstable angina pectoris).
- I25.111 (with angina pectoris with documented spasm).
- I25.118 (with other forms of angina pectoris).
- I25.119 (with unspecified angina pectoris).
- Atherosclerosis of other coronary vessels, with angina: I25.7.
- I25.71: autologous vein bypass graft.
- I25.72: autologous artery bypass graft.
- I25.73: non-autologous biological bypass graft.
- I25.75: native coronary artery
Treatments are needed as supporting documentation for atherosclerosis and include the following:
- Procedures:
- Angioplasty.
- Stents.
- Cardiac Catheters.
- Coronary artery bypass graft (CABG)/transplanted heart.
- Medications – Statins.
- Lifestyle modifications – exercise regularly, work on diet, smoking cessation
The increasing complexity of medicine has created increasing complexity in medical documentation. We hope you find our monthly coding tips of benefit.
When under current treatment or initial diagnostic work-up, document malignant neoplasms as "active." Treatments include:
- Surgery.
- Chemotherapy.
- Radiation.
- Bone marrow or stem cell transplantation.
- Hormonal therapy.
- Immunotherapy.
- Prolonged adjuvant therapy, e.g. Tamoxifen or Arimidex for breast cancer and Lupron or Casodex for prostate cancer is considered active treatment.
When all treatments have been completed and the patient is under monitoring or surveillance-only, document malignancy as "history of." Exception: hematological malignancies (leukemia, lymphoma and multiple myeloma) should be documented as "active" even when in remission and the patient is under surveillance-only.
Acceptable Documentation
Active treatment:
- 67 year-old female with breast cancer currently being treated with Tamoxifen. Patient being seen by oncology.
- Assessment: improving.
- Plan: continue current treatment plan.
- ICD-10 code for breast cancer: C50.919.
Refusing cancer treatment:
- 54 year old male with lung cancer.
- Assessment: patient refuses treatment for lung cancer.
- Plan: continue current care.
- Code for active lung cancer, even though member refuses treatment, as long as the provider documents that patient has the conditions but is refusing treatment.
- ICD-10 Code for lung cancer C34.90.
Correct reporting of a cancer diagnosis requires documentation of whether the cancer has been eradicated or is currently being treated.
Important Coding Information
- CMS considers a patient to be cancer free if:
- Condition has been eradicated by surgery/radiation/chemo
- If hormonal related cancers such as prostate cancer or breast cancer, have been physically eradicated, but patient is on hormonal therapies (i.e. Tamoxifen, Lupron etc.) these cancers can still be coded as active since there is an active treatment
- Even if the patient refuses treatment, as long as the provider documents that treatment was refused, it can be coded as active cancer.
Acceptable Documentation
- Cancer is coded as “active” if the patient is currently receiving treatment or if the patient has refused treatment
- 66-year-old female with Breast Cancer currently on Raloxifene and following with Oncology.
- Assessment: stable. C50.919 - Malignant neoplasm of unspecified site of unspecified female breast
- Provider documented an active treatment for the condition and being treated by specialist).
Unacceptable Documentation
- There is not a treatment or indication of cancer being active
- 65-year-old male with prostate cancer following up with Urologist yearly.
- Assessment: Prostatectomy 2 years ago. Stable.
- Unable to code active cancer, there is not a treatment listed and follow-ups can be considered surveillance for cancer.
When documenting cardiomyopathy, be sure to include these specifics.
Types of Cardiomyopathy
- I42.0 Dilated Cardiomyopathy.
- I42.1 Obstructive hypertrophic cardiomyopathy.
- I42.2 Other hypertrophic cardiomyopathy.
- I42.3 Endomyocardial (eosinophilic) disease.
- I42.4 Endocardial fibroelastosis.
- I42.5 Other restrictive cardiomyopathy.
- I42.6 Alcoholic cardiomyopathy.
- I42.7 Cardiomyopathy due to drug and external agent.
- I42.8 Other cardiomyopathies.
- I42.9 Cardiomyopathy, unspecified
Treatment Plans
- Lifestyle: increase physical activity, avoiding alcohol, losing excess weight.
- Medications: Beta-blockers, ACE inhibitors, anticoagulants.
- Procedures: Pacemaker implantation, Defibrillator implantation.
- Monitoring: EKG.
Documentation
- Dilated cardiomyopathy (I42.0). Patient came in for 6-month follow-up. No new symptoms and should continue Ramipril
There has been additional guidance and clarification provided by the American Hospital Association (AHA) on how to code Carotid Artery Disease in their 2021 Q1 Coding Clinic.
With this update, as long as bilateral carotid artery disease is documented with occlusion and stenosis, code I65.23 (Occlusion and stenosis of bilateral carotid arteries) should be used. If stenosis and occlusion is not documented with carotid artery disease, code I77.9 (Disorder of arteries and arterioles, unspecified) should be the assigned.
Documentation Example 1
Assessment/Plan:
Carotid Artery Disease due to occlusion and stenosis – continue statin and will continue to monitor Correct code: I65.23, Occlusion and stenosis of bilateral carotid arteries
Documentation Example 2 Assessment/Plan:
Carotid Artery Disease – continue statin and will continue to monitor Correct code: I77.9, Disorder of arteries and arterioles, unspecified
Important Coding Documentation for CVA
A cerebrovascular accident (CVA) is an interruption of blood flow to the brain. When there is poor blood flow to the brain it results in cell death, which then can cause late or long-term effects. Due to this, it is very important that there is proper documentation.
Cerebral Infarction codes I63.00-I63.9 are used to report the acute phase of the CVA during the episode of care when the actual CVA is occurring. These should be coded during inpatient encounters.
Subsequent episodes of care would be coded to the history of CVA (Z86.73) or to the late effects (I69.3xx) based upon documentation.
Coding Example
70-year-old female is seen today for hospital follow up for CVA. It is apparent patient has residual left side hemiplegia as a result. Will send referral for neurology. Labs are normal and the patient’s only complaint today is weakness of the left arm.
Z86.73 - Personal history of transient is-chemic attack and cerebral infarction without residual deficits.
I69.354 - Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side
Chronic kidney disease (CKD), also known as chronic kidney failure and chronic renal failure, involves a gradual loss of kidney function over time.
Hypertension and Diabetes are often caused and linked to Chronic kidney disease. If either of these conditions are present and uncontrolled, it can lead to further progression in CKD.
Important Coding Information
When documenting the diagnosis or progression of CKD, there are two tests that are typically used: •
- Albumin-to-Creatinine Ratio (ACR)
- Estimated Glomerular Filtration Rate (eGFR) Provider documentation must specifically state the stage of CKD, the ACR and GFR test results are not sufficient documentation alone. Since CKD is often caused by Hypertension and/or Diabetes, it is important to code these conditions if they are linked:
- Diabetic CKD (E08.22, E09.22, E10.22, E11.22, E13.22)
- Hypertensive CKD (I12-, I13-)
Code Selection
Stage
- 1
- 2
- 3 (unspecified)
- 3a
- 3b
- 4
- 5
- End Stage Renal
GFR
- >90 N18.1
- 60-89 N18.2
- 30-59 N18.30
- 44-59 N18.31
- 30-44 N18.32
- 15-29 N18.4
- <15 (without dialysis)
- <15 (on dialysis)
ICD-10-CM Code
- N18.1
- N18.2
- N18.30
- N18.31
- N18.32
- N18.4
- N18.5
- N18.6
Important Coding Documentation for CHF
Heart failure occurs when the heart cannot pump enough blood to meet the body’s needs, and it typically develops after other conditions have weakened or damaged the heart. Considered a chronic condition, it tends to develop slowly over time. However, patients may experience a sudden onset of symptoms, which is known as acute heart failure. In order to assign the appropriate diagnosis code, physician must fully document the types of heart failure whether it is acute or acute on chronic as well as the affected side of the heart. It is also important to document the association between CHF and the diastolic/ systolic dysfunction. Like any other documentation, it is important that the diagnostic statement matches the assigned code. Below is a common mistake when documenting systolic and diastolic heart failure.
Unacceptable documentation
- Diagnostic statement: Left ventricular diastolic dysfunction
- Assigned code: I50.30 Unspecified diastolic congestive heart failure
- Test order: Electrocardiogram
- Correct code: I51.9 Heart Disease Unspecified
Acceptable documentation
- Diagnostic statement: Diastolic congestive heart failure
- Assigned code: I50.30 Unspecified diastolic congestive heart failure
- Test order: Electrocardiogram
COPD is the name for a group of diseases that restrict air flow and cause trouble breathing. It is a general term used to describe a variety of conditions that result in obstruction of the airway. There are three diseases that fall under this category – emphysema, chronic bronchitis and chronic asthma.
When coding COPD, there are supporting tests and findings that need to be documented in order to capture the appropriate code:
- Spirometry screening.
- Chest x-ray.
- Treatment (medications, seeing a specialist, etc.).
Acceptable Documentation for COPD with Chronic Asthma:
Fifty-eight year old female presents with a history of COPD. Mild persistent asthma, current smoker, recommended smoking cessation program. Takes Advair and Symbicort, as needed.
- Code: J44.9 - chronic obstructive pulmonary disease, unspecified.
- Code J45.30 - mild persistent asthma, uncomplicated.
- Code: Z72.0 – tobacco (nicotine) use.
When coding COPD with asthma:
- Include the specific type of asthma - additional J45-category code may be required.
- Exception: COPD with unspecified asthma. Only J44.9 – chronic obstructive pulmonary disease should be coded.
According to CMS, physicians should code all documented conditions that co-exist at the time of the encounter/visit and require, or affect, patient care treatment or management. Co-existing conditions include chronic, ongoing conditions such as COPD.
Deep Vein Thrombosis (DVT) is a condition that occurs when a blood clot forms in the deep veins of the body. This is a serious condition as the blood clot can travel through the bloodstream and cause blockages in other parts of the body such as the lungs, causing a pulmonary embolism (PE)
It is important to specify in documentation whether the DVT is acute, chronic, or history of since there is not a specific timeframe that distinguishes acute from chronic. If coding an acute condition, it can only be coded during the initial encounter. Typically, once the thrombosis is diagnosed, the patient is then put on anticoagulation therapy for several months for prophylactic reasons. After the initial encounter, including while the patient is on prophylactic therapy, it must be documented and coded as history of.
According to AHA Coding Clinic, “Query the physician for clarification whether the Coumadin is being given prophylactically to prevent recurrence of DVT or as treatment for chronic DVT. The patient may not have active disease but is being managed because of susceptibility for recurrence. Unfortunately, “history” as used in physician documentation can be a vague term that can have different meanings. According to the Official Guidelines for Coding and Reporting, “personal history codes explain a patient’s past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require monitoring.”
Acceptable Documentation for Acute Condition:
- 70-year-old female present with severe pain in right leg. Ultrasound of right lower extremity showing deep vein thrombosis.
- Acute DVT of right leg: Heparin flush. Coumadin at 5mg/day.
- Will check INR test in 4 days.
- Code: I82401 - Acute embolism and thrombosis of unspecified deep veins of right lower extremity.
- Code: Z7901 – Long term (current) use of anticoagulants.
Acceptable Documentation for History of Condition:
- 70-year-old female here for follow-up anticoagulation meds. Was put on Coumadin for treatment of acute DVT. Last INR test looked good.
- Will schedule follow-up visits to check PT/INR.
- Code: Z86.718 - Personal history of other venous thrombosis and embolism
Dementia is an overall term for diseases and conditions characterized by a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities.
Important Coding Information
When documenting dementia, include the following:
- Underlying condition.
- Type of dementia (senile, vascular, etc.).
- Presence of behavioral disturbances (delirium, delusions, depression, aggressive or violent behavior).
Etiology
- When coding Dementia, if the etiology of the condition is known, it is important to code both the underlying condition as well as Dementia. Examples of etiology codes are, but not limited to:
F10.27, F10.97 | Alcoholic dementia
G10 | Huntington’s disease
G20 | Parkinson’s disease
G30.0-G30.9 | Alzheimer’s disease
G31.01 | Pick’s disease
G31.09 | Frontotemporal dementia
G31.83 | Lewy body disease (Parkinsonism)
G31.89 | Other specified degenerative diseases of nervous system
G35 | Multiple Sclerosis
- When the etiology is unknown, the following codes should be used:
Patients with complications resulting from long-standing diabetes mellitus (DM) are regarded by the Center for Medicare & Medicaid Services (CMS) as being at higher risk for mortality than patients with uncomplicated diabetes. Chronic complications of diabetes include diabetic neuropathy, retinopathy, nephropathy and peripheral vascular disease (PVD). At the same time, CMS coding guidelines prohibit the assumption of a cause and effect relationship between DM and a potential diabetic complication. To capture accurate severity-of-illness within your documentation, you must link DM with any condition felt to be a complication of diabetes.
Examples of CMS Compliant Documentation
1. Don't separate DM diagnosis and diabetic complications.
- Do document this language: o DM with peripheral neuropathy or diabetic peripheral neuropathy
- DM with PVD or diabetic PVD
- DM with retinopathy or diabetic retinopathy
- DM with chronic kidney disease (CKD) or diabetic CKD
2. When multiple complications are present, include them in the same sentence, e.g., DM with diabetic neuropathy, nephropathy and retinopathy.
3. Always document uncontrolled DM and hypoglycemia when present
Diabetes Uncontrolled is often used as an umbrella term for Diabetes with Hyperglycemia or Diabetes with Hypoglycemia. In order to make sure the proper code is selected, medical record documentation must clearly indicate the presence of hyperglycemia or hypoglycemia. Documentation of Uncontrolled DM alone does not allow coders to assign a specific code. If Uncontrolled DM is documented without either of those phrases, E11.9 - Type 2 diabetes mellitus without complications will be the associated code.
It is best practice to clearly identify any diabetic complications and causal relationships with linking verbiage “such as”, “due to”, or “secondary to.”
Acceptable Documentation:
- 70-year-old female here for DM follow-up
- Poorly controlled diabetes with hyperglycemia, working on controlled diet
- Code: E11.65 - Type 2 diabetes mellitus with hyperglycemia
Unacceptable Documentation
- 70-year-old female here for DM follow-up
- Uncontrolled diabetes, working on controlled diet
- The code that would be selected for the above documentation would be E11.9 - Type 2 diabetes mellitus without complications, is the associated code
The ICD-9 code for depression (311) was eliminated with the implementation of ICD-10. The default ICD-10 code assigned when a provider documents major depression, depression or depressive order is F32.9. F32.9 has a description of: major depressive disorder, single episode, unspecified. This will not be the correct description to use for every patient with depression/MDD. For example:
- Status (second part of description): a patient has been on antidepressants for many years so they have 'recurrent' rather than a 'single episode' of depression.
- Severity (third part of the description): severity of depression will vary among patients and should be documented as mild, moderate, severe or in remission.
In order to generate a code that accurately reflects the illness for a particular patient, the provider needs to specify the status and severity in their documentation.
Emphysema is generally associated with chronic obstructive pulmonary disease (COPD) and chronic bronchitis.
When coding for emphysema:
- With COPD or chronic bronchitis, use J44.9 - chronic obstructive pulmonary disease, unspecified.
Without COPD or chronic bronchitis use:
- J43.0 - unilateral pulmonary emphysema J43.0.
- J43.1 - panlobular emphysema.
- J43.2 - centrilobular emphysema.
- J43.8 - other emphysema.
- J43.9 - emphysema, unspecified
Proper coding and documentation can impact a patient's overall quality of care and is a medical record requirement with the Centers for Medicare & Medicaid Services (CMS). Consider these four best practices for coding/documenting:
- Problem list: Should be kept up-to-date and show the status of each condition, e.g., active, chronic or resolved, and whether the condition is "current" or no longer has the condition "history of." Do not use only default, unspecified codes – they do not accurately show severity.
- Include all problems in the assessment: Don't limit the diagnosis codes to only those that brought the patient into the office. All problems assessed during the visit should be noted in the assessment and coded accordingly.
- All diagnoses should be documented: Any diagnoses that were part of the provider's medical decision-making process should be documented. Example: patient being treated with medication that might affect the treatment of the current presenting issue should be documented and coded.
- Annually document all chronic conditions: All chronic conditions should be assessed during a face-to-face encounter, at least once annually, and documented in the medical record. This includes status codes such as amputations, transplant status, ostomies, etc., as well as pertinent past conditions and other underlying medical problems.
Importance of Documentation
- Assures all the patient's medical conditions are addressed during the visit.
- Supports accurate claim payment, reducing denials.
- Accurate coding of conditions is needed for appropriate Risk Adjusted payment.
- If a condition is not documented, it cannot be coded.
Health status codes are important because they can influence health status and affect treatment plans. Unlike most condition codes that require supporting documentation, certain status codes can be captured anywhere in the chart and do not require supporting documentation. These status codes include the following:
- Amputations Z89-
- Artificial Openings Z93-
- HIV B20 • Renal Dialysis Z99.2
- Organ transplant Z94-
Hemiplegia is defined as paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one‐sided weakness, but without complete paralysis.
There are multiple causes of hemiplegia, but TIAs and CVAs are the most common. Most often, stroke sufferers experience the less severe form of hemiplegia, called hemiparesis. However, if residuals do not diminish over time, the long-term effect can be hemiplegia.
Important Coding Information
A sequela is aftereffect of a disease, condition, or injury. To properly code a sequela, documentation must specify the underlying cause, the type of late effect, and whether the dominant or non‐dominant side is affected. If no residual deficits exist, code Z86.73 for personal history of cerebral infarction without residual deficits should be used.
Code Selection
Category I69.- codes are codes related to the sequelae of cerebrovascular accident.
I69.35- Hemiplegia and hemiparesis following cerebral infarction
- I69.351 – affecting right dominant side
- I69.352 – affecting left dominant side
- I69.353 – affecting right non-dominant side
- I69.354 – affecting left non-dominant side
- I69.359 – affecting unspecified side
When billing for home health services, use this handy chart to accurately reflect the appropriate service provided. As an example, service provided by a physical therapy assistant would use the code G0157 and service provided by a physical therapist would use the code G0151.
HCPCS | Services performed in 15-minute increments
G0151 | Physical Therapy
G0152 | Occupational Therapy
G0153 | Speech Language Pathology
G0155 | Clinical Social Worker
G0156 | Home Health Aide
G0157 | PT assistant
G0158 | OT assistant
G0159 | PT establish or deliver safe and effective PT maintenance program
G0160 | OT establish or deliver safe and effective OT maintenance program
G0161 | SLP establish or deliver safe and effective SLP maintenance program
G0299 | Direct skilled services of a licensed nurse (RN)
G0300 | Direct skilled services of a licensed nurse (LPN)
G0493 | RN for the observation and assessment of the patient’s condition
G0494 | LPN for the observation and assessment of the patient’s condition
G0495 | RN training and/or education of a patient or family member
0496 | LPN training and/or education of a patient or family member
HIV is a virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases. If left untreated, HIV can lead to the disease AIDS (acquired immunodeficiency syndrome).
Lifelong chronic conditions, such as HIV, often require ongoing medical attention and the diagnoses are typically unresolved once diagnosed. It is appropriate to report these conditions, even when stable or documented in the past medical history at the time of the encounter.
Important Coding Information
Code Z21, Asymptomatic human immunodeficiency virus [HIV] infection status, is to be used when there are not symptoms or HIV related conditions documented
Code B20, Human immunodeficiency virus [HIV] disease, is to be applied when there are other associated HIV conditions such as AIDS.
Code B97.35, Human immunodeficiency virus, type 2 [HIV 2] as the cause of diseases classified elsewhere is to be used when the patient has HIV 2, which is a less common type of HIV
It is common for patients with long-standing HTN to develop heart disease or heart failure. When assigning diagnosis codes for HTN, there is a presumed causal relationship between HTN and heart disease that can be coded without documentation that explicitly links them together.
There are two types of HTN with heart disease:
1. HTN heart disease without heart failure: If the patient has HTN with heart disease, but without heart failure, only one diagnosis code is needed: I11.9.
2. HTN heart disease with heart failure: A patient with HTN heart disease and heart failure require two codes: assign diagnosis code I110 with an additional code to identify the type of heart failure I50.x.
Acceptable documentation:
A 65-year-old male admitted with congestive heart failure. The patient presented with shortness of breath, pedal edema, and tachycardia. B/P 180/94, H/R 104, R/R 22. BNP 420. Chest X-ray shows pleural effusion. HR with preserved ejection fraction of 55% (HFpEF). The patient started on Lasix 40mg IV or PO with Amlodipine 5mg PO, daily, and discharged on the fourth day of admission.
Final diagnosis:
- Hypertension with acute diastolic.
- Heart failure.
Codes:
- I11.0 Hypertensive heart disease with heart failure.
- I50.31 Acute diastolic (congestive) heart failure.
The Centers for Medicare & Medicaid Services (CMS) recognizes that when introducing, managing or adjusting insulin for the chronic management of diabetes, additional time and care must be attributed to the patient. Also, managing existing patients who use insulin requires significant training for clinicians, patients and their families to ensure proper management and safety of the condition. Documentation of this code helps illustrate the increased complexity of patients who require this treatment.
Documentation Examples
Starting Long-Term Insulin:
- 70 year old male newly diagnosed with diabetes
- Assessment: Uncontrolled fasting blood glucose (FBC) of 480 with Hgba1c of 11.1 suggesting need for insulin therapy.
- Plan: Education provided. Start Glucophage XR 500 mg daily. Start 2 units of regular insulin with each meal.
- Code to identify long-term use of insulin: Z79.4 Long-term (Current)(Prophylactic) Insulin:
Managing Existing Long-Term Insulin:
- 68 year old woman with diabetes using insulin daily
- Assessment: Poorly controlled HgbA1c of 9.4
- Plan: Extensive counseling provided, answered patient questions and increased dose of Lantus by 2 units.
- Code to identify long-term use of insulin: Z79.4 Long-term (Current)(Prophylactic) Insulin
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) of the American Psychiatric Association (APA) advises that major depression is a mental disorder, marked by a depressed mood and loss of interest or pleasure in all activities that lasts for at least two weeks and represents a change from previous functioning.
Important Coding Documentation
- Document major depressive disorder to the highest level of specificity, including recurrence, severity and current status:
- Episode: Single episode or recurrent
- Severity: Mild, moderate, severe, with or without psychotic symptoms
- Status: In partial remission or in full remission
- Document the treatment plan
- Psychotherapy
- Antidepressant medication
F32 Major depressive disorder, single episode
- F32.0 - Major depressive disorder, single episode, mild
- F32.1 - Major depressive disorder, single episode, moderate
- F32.2 - Major depressive disorder, single episode, severe without psychotic features
- F32.3 - Major depressive disorder, single episode, severe with psychotic features
- F32.4 - Major depressive disorder, single episode, in partial remission
- F32.5 - Major depressive disorder, single episode, in full remission
- F32.9 - Major depressive disorder, single episode, unspecified
F33 Major depressive disorder, recurrent
- F33.0 - Major depressive disorder, recurrent, mild
- F33.1 - Major depressive disorder, recurrent, moderate
- F33.2 - Major depressive disorder, recurrent severe without psychotic features
- F33.3 - Major depressive disorder, recurrent, severe with psychotic symptoms
- F33.40 - Major depressive disorder, recurrent, in remission, unspecified
- F33.41 - Major depressive disorder, recurrent, in partial remission
- F33.42 - Major depressive disorder, recurrent, in full remission
- F33.8 - Other recurrent depressive disorders
- F33.9 - Major depressive disorder, recurrent, unspecified
Like any other documentation, it is important that the diagnostic statement matches the assigned code. Below is a common mistake when documenting Major Depressive Disorder.
Unacceptable documentation
- Diagnostic statement: Depression Disorder
- Assigned code: F33.0 – Major depressive disorder, recurrent, mild
- Correct code: F32.9 – Major depressive disorder, single episode, unspecified
Acceptable documentation
- Diagnostic statement: Recurrent major depressive disorder, mild
- Assigned code: F33.0 – Major depressive disorder, recurrent, mild
References: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
BMI is defined by the ratio of an individual’s height to his or her weight. Normal BMI ranges from 20-25. An individual is considered morbidly obese if he or she is 100 pounds over his/her ideal body weight, has a BMI of 40 or more, or 35 or more and experiencing obesity-related health conditions, such as high blood pressure or diabetes.
Important Coding Information
- To code morbid obesity appropriately, providers must document morbid obesity in the assessment and/or plan to address the morbid obesity. (weight loss, diet, exercise, referral to dietitian or bariatric surgeon)
- If morbid obesity is documented in the physical exam section without additional documentation supporting the clinical significance of this condition, it should not be captured. Providers must document the condition in the A/P and address the treatment plan such as weight reduction, diet or counseling.
- If morbid obesity is documented and a BMI ≥ 40+ is documented, then it is appropriate to capture E66.01 (Morbid Obesity) and Z68.4X (BMI of 40 or greater).
- If BMI of 40 or greater is documented and there is no mention of a related diagnosis, such as overweight, obesity, morbid obesity etc., then it is NOT appropriate to code a BMI status code.
According to the ICD-10-CM Coding Guidelines, the BMI may be recorded by non-physician clinicians, such as nurses or dieticians; but it cannot be reported unless also documented by the physician and associated with a related condition, such as overweight or obesity. Therefore, unless the physician makes a comment on the significance of the BMI, it cannot be coded.
Correct Coding
- Vitals: BMI 41
- A/P: Morbid Obesity – working on a controlled diet with exercise
- Coded: Morbid Obesity (E66.01)
Incorrect Coding
Vitals: BMI 41 A/P: Diabetes Mellitus – encouraged controlled diet and exercise (No other conditions are listed under the A/P for this visit)
Coded: Body mass index (BMI) 40.0-44.9, adult
(Cannot capture BMI without documenting a secondary diagnosis to support the BMI)
Important Coding Documentation
- Identify and document the number of weeks since the MI occurred
- Indicate subsequent MI appropriately
- Document when a NSTEMI evolves into a STEMI and when a STEMI converts into a NSTEMI as a result of thrombolytic therapy
- If the patient is still receiving care for the MI, then you should use the term ‘aftercare’ and if the patient no longer receives care for the MI, use the term ‘old’ or ‘healed’ MI
- Document the exact site (for example, left main coronary, anterolateral wall or true posterior wall)
ICD-10
- I21.x
- I22.x
- I25.2
DESCRIPTION
- STEMI and NSTEMI
(Acute) - Subsequent MI
- Old MI
CODING GUIDANCE
- MI specified as acute or with a stated duration of 4weeks (28 days) or less from onset
- Acute MI occurring within 4 weeks (28 days) of a previous acute MI. Can only be assigned when previous MI was type 1 or unspecified
- Healed or past MI diagnosed (greater than 28 days)
Parkinson's Disease is a progressive disease of the nervous system, associated with degeneration of the basal ganglia of the brain and a deficiency of the neurotransmitter dopamine. Below are helpful coding tips.
- When associated with Dementia, G20 is used as the primary code and then Parkinsonism Dementia coded as secondary – F02.80 and F02.81.
- Secondary Parkinson's G21 – G21.9 – can be caused by medications. The cause and or medication is documented.
Consider MEAT when documenting this condition.
M: Monitoring
E: Evaluating
A: Assessing/Addressing
T: Treating
Example of Parkinson's Disease documented with MEAT
- Patient came in for follow-up visit for the following conditions:
- Hypertension – refill on Lisinopril.
- Hyperlipidemia – Controlling with statin.
- Parkinson's Disease – Currently taking Carbidopa to treat symptoms.
- Dementia.
- Diagnosis Codes:
- I10 essential (primary) hypertension.
- E78.5 hyperlipidemia, unspecified.
- G20 Parkinson's disease.
- F02.80 dementia in other diseases classified elsewhere without behavioral disturbance
Pneumonia is an inflammatory infection in the lungs that can be caused by bacteria, viruses, and fungi. Symptoms of Pneumonia vary, but can include productive or dry cough, chest pain, fever, and trouble breathing. In order to properly diagnose Pneumonia, a physical exam, along with lab tests are required. Treatment will vary based on the origin of the infection.
Important Coding Documentation
- Since Pneumonia requires an extensive physical exam and testing to diagnose, this condition is typically only captured in the inpatient setting. Any follow-up visits for this condition should be coded as history of.
- Pneumonia specificity is based on the origin of the infection. It is important to document whether it is caused by a bacteria, a virus or a fungi.
Correct Coding of Pneumonia (Inpatient)
A: Pneumonia due to Streptococcus pneumoniae (J13) - Patient arrived with chest pain and found to be very out of breath and feverish. Strep Pneumonia antigen was positive and respiratory cultures grew heavy strep pneumonia.
P: Treated with IV Ceftriaxone and Azithromycin. Changed antibiotics to Cefpodoxime on discharge to finish the 8-day course.
Incorrect Coding of Pneumonia (Outpatient)
A: Pneumonia due to Streptococcus pneumoniae (J13) - Patient is here for follow-up visit of Pneumonia. Admitted and diagnosed with Streptococcal pneumonia.
P: Finishing course of antibiotics
The evolution of the medical record.
The role of the medical record in healthcare has evolved over the years from being a collection of notes providers write to assist them in keeping track of a patient's conditions and plan of care, to a repository for data used in all aspects of healthcare analytics to gather information about the severity of illness of patients as well as the quality of care they receive. A provider's image in the eyes of prospective patients, the public in general, as well as in the eyes of health plans, including Medicare, is built largely from data abstracted from the medical records of their current patients. That fact emphasizes the importance of maintaining an accurate, complete, concise and relevant medical record.
Documenting the medical record.
Today, it is the provider's responsibility to not only ensure that their patients receive the highest quality of care, but to also ensure that the documentation in the medical record reflects that quality and includes a clear picture of the patients' severity of illness to justify providing said care. Often times in the hustle to get their work done, providers will document non-specific diagnoses or pick the code that populates the search results first in the electronic medical records (EMR) regardless of specificity. This results in under-reporting the patient's severity of illness which has multiple negative ramifications on the patient, provider and health plan. Examples of under-reporting severity of illness include:
- Documenting and coding diabetes, without complications, when a patient has diabetes-related complications
- Documenting and coding a single episode of depression, with unspecified severity, when a patient has recurrent moderate depression
- Documenting and coding unspecified macular degeneration when a patient has exudative (wet) macular degeneration
It is imperative that providers capture the true severity of illness of their patients in the medical record by documenting diagnoses to the highest specificity and assigning the appropriate diagnosis codes (when working with an EMR).
MEAT
In order for a provider's documentation of any diagnosis to be acceptable to Medicare for the purposes of abstracting an ICD-10 code and reporting that diagnosis as active, the documentation has to include at least one of the following, in addition to the diagnosis itself:
Monitoring - a diagnosis for changes by ordering laboratory or imaging studies, e.g., ordering an abdominal ultrasound to monitor an abdominal aortic aneurysm, ordering a platelet count to monitor thrombocytopenia.
Evaluation - of a diagnosis with a targeted component of the physical examination, e.g., monofilament exam for diabetic neuropathy, checking pedal pulses and capillary refill for evidence of PVD or circulating va.scular volume.
Assessment - of the stability or progression of a diagnosis in either direction, e.g., documenting that a diagnosis is stable, improving, worsening, progressing as expected, unchanged, etc.
Treatment - of a diagnosis by either prescribing new medications, changing or continuing current medications. Documentation of treatment may also include treatment by a specialist to whom the patient was referred.
Remembering the acronym MEAT should help providers determine whether their documentation is substantive enough to support abstracting a diagnosis code and reporting it as active.
Documentation when others are managing the care, i.e., Specialists.
Some primary care providers are under the impression that they should not include any diagnoses documentation in the medical record if they are not directly managing the diagnosis. Others believe that they will be subject to some sort of a penalty if they include any ICD-10 codes for diagnoses managed by specialists on their claim for an office visit. Both of those notions are untrue.
Primary care providers are expected to keep track of, and document in their records, every diagnosis their patients have. They are expected to inquire about the status of these conditions and be aware of plans for testing, follow-up and treatment put in place by specialists to whom they refer their patients. They are also expected to maintain within their record any correspondence they receive from the specialists.
At least once every calendar year, and during a face-to-face visit, the minimum documentation related to conditions being managed by specialists should include the diagnosis itself, any recent changes or findings and plans for follow-up and/or treatment by the specialist
Rheumatoid arthritis (RA) is a chronic autoimmune disorder that results in swollen, painful joints.
- A specialist often diagnoses and treats this condition, but it is important to capture all chronic conditions on an annual basis.
- Best practice is to spell out and fully describe the type of RA; try not to use the unspecified code • M05.- codes contain detail that indicate the anatomical site, along with any organ involvement • Documenting the type, location, and/or associated complications of the RA is important in making sure the highest specified code is selected
Acceptable Documentation
65-year-old female in for annual wellness exam. Patient has history of Rheumatoid Arthritis in her right elbow. Currently taking Methotrexate and is seeing Rheumatologist next month.
Code: M05.721 - Rheumatoid arthritis with rheumatoid factor of right elbow without organ or systems involvement
Pulmonary embolism (PE) is a sudden blockage in a lung artery. The blockage is usually caused by a blood clot traveling from a leg vein to the lung. If the traveling clot originally formed in a deep vein, it's called deep vein thrombosis (DVT).
Important Coding Information
Specify whether PE/DVT is: acute, chronic, or history of (Hx) – use Hx because there is no specific timeframe distinguishing acute from chronic.
Acute Condition
- Can only be coded during the initial encounter.
- After the initial encounter, it must be documented and coded as Hx.
Chronic Condition
- Must be documented as chronic.
- Treatment, monitoring method and diagnosis must be documented.
Anticoagulation Therapy
- Code Z7901 – Long-term (current) use of anticoagulants.
Acceptable Documentation for Acute Condition
- 70-year-old female presents with severe pain in right leg. Ultrasound of right lower extremity shows deep vein thrombosis.
- Acute DVT of right leg: Heparin flush. Coumadin at 5 mg/day.
- Will check INR test in 4 (four) days.
- Code: I82401 - Acute embolism and thrombosis of unspecified deep veins of right lower extremity
- Code: Z7901 – Long-term (current) use of anticoagulants
Acceptable Documentation for History of Condition
- 70-year-old female here for follow-up anticoagulation medication. Placed on Coumadin for treatment of acute DVT. Last INR test looked good.
- Will schedule follow-up visits to check PT/INR.
- Code: Z86.718 - Personal Hx other venous thrombosis and embolism.
Sepsis usually starts with localized infection that enters the blood stream and then affects your patients' tissues and organs. The cause of systemic infection is usually pneumonia, UTI, influenza, E. coli, and other bacterial infections. These infections may show symptoms such as tachycardia, leukocytosis, tachypnea, and fever. Although, these symptoms are typical symptoms of any infection when they are identified, it is up to the physician’s clinical judgment to decide whether the patient has sepsis or Systemic Inflammatory Response Syndrome (SIRS).
It cannot be assumed the patient has sepsis or SIRS based on the criteria being met. It is important for physicians to document their findings and clinical judgment when they diagnose sepsis, severe sepsis, and septic shock. Due to the severity of the condition, it is typically not diagnosed in the outpatient setting.
Important Coding Documentation
- Sepsis is coded based on the causative organism (i.e. Listerial sepsis, Streptococcal sepsis, Sepsis due to Staphylococcus aureus, Sepsis due to Escherichia coli etc.)
- If the underlying infection or organism is not specified for an accurate diagnosis, code A41.9, Sepsis, unspecified organism, should be assigned.
Correct Coding of Sepsis (Inpatient)
A: Streptococcal sepsis, unspecified (A40.9) - Patient arrived with elevated heart rate, fever and confusion. Lab results showed positive for Streptococcal sepsis.
P: Treatment may include IV antibiotics administered, aggressive IV fluids to prevent organ failure, supplemental oxygen, careful monitoring of vital signs and organ function and often intensive care.
Incorrect Coding of Sepsis (Outpatient)
A: Streptococcal sepsis, unspecified (A40.9) - Patient is here for follow-up visit of Sepsis. Was admitted and diagnosed with Streptococcal sepsis.
P: Continue antibiotics
Sick Sinus Syndrome (SSS) is a relatively uncommon heart rhythm disorder. SSS is a group of signs or symptoms that indicate the sinus node, the heart's natural pacemaker, is not correctly functioning, causing a heart rate that is too slow or too fast.
Important Coding Information
The presence or absence of any current signs or symptoms related to SSS, as well as the physical examination findings (e.g. abnormally slow or fast heart rate, low blood pressure and diagnostic testing results), are essential to document to assign the appropriate code. Some of the standard diagnostic tests used to diagnose SSS include, but not limited to:
- ECG ordered and reviewed.
- Holter monitor.
- Rx prescribed.
- Cardiologist referral.
Acceptable Documentation for SSS
Pacemaker interrogation is a routine computer evaluation of pacemaker function to verify the device is programmed accurately and to assess the battery and lead function. Once a pacemaker is in place, SSS will not be coded.
- 70-year-old female with a history of SSS is in the clinic today for a routine follow-up and device check. Device interrogation was performed and demonstrated normal pacemaker function with no alarms.
- ICD-10 Code: Z95.0 – Presence of cardiac pacemaker
Sick sinus syndrome (SSS) is the name for a group of heart arrhythmias in which the sinus node, the heart’s natural pacemaker, doesn’t work properly. Sick sinus syndrome is also known as sinus node disease or sinus node dysfunction.
Important Coding Information
- According to updated coding guidelines, it is appropriate to code the specific cardiac arrythmia condition and the presence of the cardiac device.
- For example, assign codes I49.5, Sick sinus syndrome, and Z95.0, Presence of cardiac pacemaker. The SSS is still present and is a reportable chronic condition.
- Although the pacemaker is controlling the heart rate, it does not cure SSS and the condition is still being managed/monitored.
Status Codes
Certain health status codes are very important to assess, document and code at least once annually using the highest level of specificity. These codes are relevant to the members current health status and allow for a full picture of the members medical record:
- Transplants
- Ventilators
- HIV Status
- Tracheostomy Status
- Artificial openings/Ostomies Dialysis
- Prosthetics/Amputations
- BMI Status Codes
Important Coding Information
- If an artificial opening was closed, that date should be documented and the opening should not be coded as active.
- BMI status codes are important to document, but should only be captured if documented by the physician in the Assessment and Plan. This cannot be captured from the vitals section of the chart
Risk Adjustment Data Validation (RADV) or Improper Payment Measure (IPM)
In accordance with risk adjustment requirements, CMS performs Risk Adjustment Data Validation (RADV) or Improper Payment Measure (IPM) audits to validate the members’ diagnosis data that was submitted by Trinity Health Plan New York drawn from provider claims submissions. These audits are typically performed annually. If Trinity Health Plan New York is selected by CMS for an RADV or IPM audit or to validate submitted diagnosis information, you are required, as a participating provider to comply and timely submit requested medical records to substantiate the diagnosis data submitted.
Encounter Data Processing System (EDPS)
Trinity Health Plan New York is required to submit accurate diagnosis information on all of its members to CMS through the Encounter Data Processing System (EDPS). For EDPS submissions, CMS will filter claims data according to their risk adjustment guidelines. This filtering logic may prevent some claims that have traditionally been paid by Trinity Health Plan New York from being accepted by CMS for risk adjustment purposes. Because of this, there may be instances where Trinity Health Plan New York will need to reach out to a provider to obtain missing or incomplete data that would be needed for Risk Adjustment submissions. Below are the CMS websites that provide technical information on EDPS guidance.
Informing Members of Advance Directives
The federal Patient Self-Determination Act (PSDA) gives individuals the legal right to make choices about their medical care in advance of incapacitating illness or injury through advance directives.
Under this federal act, physicians and other professional providers, including hospitals, skilled nursing facilities, hospices, home health agencies and others must provide written information to members on state laws about advance treatment directives, about members’ rights to accept or refuse treatment and about your own policies regarding advance directives.
To comply with this requirement, we also inform members of laws on advance directives through our Member Agreement and other communications. We encourage these discussions with your patients.
As long as the member can speak for him/herself, you must honor his/her wishes. If the member becomes so sick that he/she cannot speak for him/ herself, then this directive will guide you in treating the member and will save the member’s family, friends and other providers from any guesswork as to what course of treatment, if any, the member would have wanted.
There may be several types of advance directives to choose from, depending on state law. Most states recognize:
- Durable Power of Attorney for Health Care (DPAHC): DPAHC form allows the member to appoint an agent (family, friend or other person) whom he/she trusts to make treatment decisions for him/her should there come a time the member is unable to make them for him/herself.
- Living Wills: The living will is a document through which a member may inform his/her physician that, if the member has a terminal condition (no chance of recovery) and death will occur in a relatively short period of time, the member only wants a desired level of care provided. This document goes into effect only when a member is permanently unconscious or terminally ill and can no longer speak for him/herself.
- Rights of the Terminally Ill Act: Members have the right to control decisions relating to their medical care when they are terminally ill. This includes the decision not to undergo procedures that extend life in case of a terminal illness. To do this, the member must make a written notice advising his/her physician to withhold or withdraw procedures that continue life in the event of a terminal condition. The member is encouraged to give this form to his/her physician and closest relative and it should be kept on file should the event ever occur.
You must document in a prominent part of the member’s medical record whether or not the member has executed an advance directive.
Referrals and Prior Authorization Requests
You are responsible for the care of your members whether you provide the care directly or indirectly. All medical care sought out of network (excluding emergent or urgent care) at your direction but not prior authorized, will be subject to Trinity Health Plan New York’s Remediation Policy. Prior authorization requests received after the date of service will not be processed.
All referrals and prior authorization requests for members seeking out of network services should be made by a network provider and will be validated during the medical necessity review during the Prior Authorization process.
See the Utilization Management Section in this manual for more details.
Member Rights and Responsibilities
We tell our members that they have the following rights and responsibilities, all of which are intended to help uphold the quality of care and services they receive from you.
Members’ Rights
- To be treated with dignity, respect and fairness at all times by Trinity Health Plan New York and network providers.
- Privacy of your medical records and personal health information.
- To see network providers and get covered services within a reasonable period of time and within a reasonable distance from your home.
- To know your treatment choices and to participate in decisions about your health care.
- To use advance directives (such as a living will or a power of attorney).
- To make complaints if you experience problems or have concerns related to your coverage or your care.
- To obtain information about your health care coverage and costs.
- To obtain information about Trinity Health Plan New York and network providers.
Members’ Responsibilities
- Be familiar with your coverage and the rules to follow to obtain care as a member.
- Give your physician and other professional providers the information they need to care for you, and to follow the treatment plans and instructions that you and your providers have agreed upon.
- Act in a way that supports the care given to other patients and does not prevent the provider or Trinity Health Plan New York office from running smoothly.
- Pay your plan premiums and any copayments/ coinsurance you may owe for covered services received.
- Contact us with any questions, concerns, problems or suggestions.