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Ingenix InSite User Group. October 12, 2010 Approval Code: IN1070. Ingenix InSite User Group: Welcome. Administrative Reminders: This call is hosted in a listen only mode for participants until our Q&A segment.

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october 12 2010 approval code in1070

Ingenix InSite User Group

October 12, 2010

Approval Code: IN1070

ingenix insite user group welcome
Ingenix InSite User Group: Welcome

Administrative Reminders:

  • This call is hosted in a listen only mode for participants until our Q&A segment.
  • Questions you may want to ask prior to the Q&A segment can be typed in our chat panel for the host to address
  • Please keep your phones on mute during Q&A.
  • The webex login password for this call is ‘insite’.
  • When logging into the webex please enter in your first and last name.
  • The user group presentation materials will be sent with the meeting minutes.
  • Ingenix InSite User Group Questions or Product Enhancement requests? Email ingenix.insite@ingenix.com.
  • Ingenix InSite Website Questions? Call or email the Ingenix Helpdesk 1-866-818-7503 or client.support@ingenix.com.
ingenix insite user group agenda
Ingenix InSite User Group: Agenda
  • 10:00 AM – 10:05 AM Welcome
  • 10:05 AM – 10:10 AM InSite Operations Announcements
  • 10:10 AM – 10:20 AM Report Selection Tool
  • 10:20 AM – 10:30 AM Changes to the CMS-HCC Payment Model and Impact on RAF
  • 10:30 AM – 10:45 AM Focus on: Peripheral Vascular (Arterial) Disease
  • 10:45 AM – 11:00 AM Q & A
insite operations announcements

InSite Operations Announcements

Presented By

Susan Rick

InSite Business Operations Manager

insite operations announcements1
InSite Operations Announcements
  • Data Refresh Update
    • InSite Mid-month data refreshed September 20th
      • Data refresh may not impact all InSite users
      • Mid-month data refresh will not replace the normal monthly data refresh
    • Next monthly data refresh is targeted for October 18th
  • October 8th, 2010 – InSite Updates
    • October Ingenix Insider
    • Report Selection Tool
insite report selection tool

InSite Report Selection Tool

Presented By

Francesca Siciliano

InSite Business Analyst

insite report selection tool1
InSite Report Selection Tool
  • Report Selection Tool
changes to cms hcc payment model for 2011 and impact on raf

Changes to CMS-HCC Payment Model for 2011 and Impact on RAF

Presented By

Loren Maddy

Director, Analytics

overview
Overview
  • Medicare Advantage Reimbursement is a Function of Bid (Ratebook) and RAF
    • Estimated 2011 Net Impact: -1.6%
      • Ratebook:
        • No Ratebook changes for 2011
      • RAF:
        • Impact of CMS Changes on Otherwise Equal RAF is -1.6%
          • FFS Normalization: -1.6%
          • No other CMS changes for 2011 Pmt Yr
new icd 9 codes added to cms hcc payment model

New ICD-9 Codes added to CMS-HCC Payment Model

Presented By

Pam Holt

Manager, SoCal Market Consultation

cms announces new codes for model
CMS Announces New Codes for Model
  • On October 1st each year, new ICD-9 codes are effective
  • CMS evaluates which codes will be included in the CMS-HCC and Rx Models
  • CMS posted a new crosswalk including new codes effective Oct 1st
  • 8 codes were added to the CMS-HCC model
  • https://www.cms.gov/MedicareAdvtgSpecRateStats/06_Risk_adjustment.asp
    • Zip File Name: “2011 Model Diagnoses”
    • File Name: “Risk Model Diagnoses for 2011.xls”
mary jo groome ccs p cpc h sr provider training development consultant

Peripheral Vascular (Arterial) Disease

Mary Jo Groome, CCS-P, CPC-H

Sr. Provider Training & Development Consultant

what is peripheral artery disease p a d
What is Peripheral Artery Disease (P.A.D.)?
  • P.A.D. occurs when plaque builds up in the arteries that carry blood to your head, organs, and limbs. Plaque is made up of a fat, cholesterol, calcium, fibrous tissue and other substances in the blood.
  • When plaque builds up in the arteries, the condition is called atherosclerosis. Over time, plaque can harden and narrow the arteries. This limits the flow of oxygen-rich blood to the organs and other parts of the body.
  • P.A.D. usually affects the legs, but also can affect the arteries that carry blood from the heart to the head, arms, kidneys and stomach.
  • Today’s comments will focus on P.A.D. that affects blood flow to the legs.
peripheral arterial disease pad
Peripheral Arterial Disease (PAD)

Clinical description of PAD

  • Present in approximately 8 to 12 million individuals in the U.S.
  • Estimated to be present in 29% of those
    • Age 70 or over; or
    • Age 50 to 69 with a history of smoking 10 pack years or those with diabetes.1
  • History and physical examination may not be reliable for the detection of lower extremity PAD8
    • Presents with classic claudication 10% to 35% of cases
    • Many individuals have no symptoms or non-classic symptoms
    • Poor recognition (under-diagnosis) results in under-treatment (estimated only 25% of those with PAD are treated)2
peripheral arterial disease pad1
Peripheral Arterial Disease (PAD)

Clinical description of PAD

  • Often caused by atherosclerosis
  • Identifies risk for myocardial infarction (also referred to as a heart attack) and stroke3
  • Causes poor blood supply to extremities
  • Symptoms worsen when demand increases (exercise)
  • As disease progresses, less exercise causes symptoms; if severe – symptoms at rest (with no movement)
  • May result in pain (disability), skin and tissue damage (ulcers) and infection (gangrene)
  • Can worsen diabetic complications such as slow healing foot ulcers
peripheral vascular arterial disease
Peripheral Vascular (Arterial) Disease

PAD Facts:

  • Most major cardiovascular events occur in those without a prior diagnosis of vascular disease.
  • Over 50%with PAD will not have previous vascular symptoms;40%have atypical symptoms.
  • It is estimated that only25%of afflicted individuals receive care
peripheral vascular arterial disease1
There are two types of PAD

Arteriosclerotic: Involves medium to large vessels and is amenable to bypass.

Diabetic: Involves medium to small vessels and is not typically helped by bypass.

Workup can be done by Ankle Brachial Index (ABI)

Can be used to diagnose PAD and can be performed in any doctor’s office

Reveals a comparison of the systolic blood pressure between the lower and upper extremities and is measured using a Doppler.

An ABI of less than or equal to 0.90 is abnormal and is considered evidence of lower extremity PAD.

Prompt investigation and risk-reducing treatments are then warranted

Peripheral Vascular (Arterial) Disease
documentation coding pad pvd
Documentation & Coding PAD / PVD
  • Peripheral arterial disease, peripheral vascular disease, and claudicationare coded to443.9
    • It is important to note that this code excludes atherosclerosis of the arteries of the extremities.
  • Atherosclerosisof native arteries of the extremities, Category440,is further classified as such:
        • With intermittent claudication440.21
        • With rest pain440.22
        • With ulceration440.23 (see ulcer coding rules)
        • With gangrene440.24 (see ulcer coding rules)
        • Unspecified 440.20
pad documentation coding
PAD Documentation & Coding
  • Diagnostic statements that do notimpact severity adjustment as theyare coded to:

440.9: Generalized and unspecified atherosclerosis

    • Arteriosclerotic (vascular) disease
    • Generalized arteriosclerosis
    • Arteriosclerotic endarteritis
    • Arteriosclerosis obliterans
    • Arteriosclerosis with calcification
documentation coding pad pvd1
Documentation & Coding PAD / PVD

Vascular diseases often occur as a manifestation of diabetes:

  • Diabetic Peripheral Circulatory Disorders250.70-250.73
    • If the PVD is due to diabetes mellitus, codes 250.7xand 443.81 would be assigned.
      • The specificity of the PVD changes to 443.81, Peripheral Angiopathy in diabetes mellitus.
      • Code 443.81 provides a more comprehensive picture of the patient’s PAD/PVD condition in regard to DM as an underlying cause.
    • Provide the appropriatelinkagefor the diabetes with Peripheral Circulatory Manifestations (250.7x)

American Hospital Association, AHA Coding Clinic for ICD-9-CM. 3rd Qtr. 1991. p. 10

World Health Organization, 2009 Ingenix ICD-9-CM Professional for Physicians, Volumes 1&2. 6th ed. 2008. pp. 8&27

underlying disease diabetes mellitus
Underlying Disease – Diabetes Mellitus
  • A patient with Type II controlled Diabetes that has treatment for a manifestation of the disease should have both conditions coded:
    • PVD due toDiabetes Mellitus
      • 250.70Diabetes with peripheral circulatory disorder
      • 443.81 Peripheral angiopathy in disease classified elsewhere
  • The underlying disease is coded first, followed by the manifestation code.
  • The linkage has been documented with “due to”and the4thdigit is properly assigned on the250.
pad diagnosis coding
PAD Diagnosis Coding

Peripheral Vascular diseases as a result of atherosclerosis of extremities:

  • Atherosclerosis of Native arteries of the Extremities(440.2 subcategory).
    • For coding purposes, the physician must document that the PVD is due to atherosclerosis (ASPVD) before a code from 440.2may be assigned.
    • In fact, Coding Clinic advises to query the physician for further specification if the physician documents vague diagnoses as peripheral vascular disease or intermittent claudication.

American Hospital Association, AHA Coding Clinic for ICD-9-CM. 4th Qtr. 1992. p. 25

3M Health Information Systems (2008, April). Coding for peripheral vascular disease. In, For The Record, Vol. 20 No.8 P. 28.  Retrieved March 10, 2009 from: http://www.fortherecordmag.com/archives/ftr_04142008p28.shtml

pad diagnosis coding1
PAD Diagnosis Coding

Peripheral Vascular diseases as a result of atherosclerosis of extremitiesICD-9-CM Coding:

  • 440.2 (Atherosclerosis of Native Arteries of the Extremities)
    • 440.20Atherosclerosis of extremities, unspecified
    • 440.21Atherosclerosis of extremities w/ intermittent claudication
    • 440.22Atherosclerosis of extremities w/ rest pain
    • 440.23Atherosclerosis of extremities w/ gangrene
    • 440.24Atherosclerosis of extremities w/ ulceration
  • 443 category(Other Peripheral Vascular Disease) -Without additional documentation regarding the type or manifestationof PVD/PAD, code 443.9would be assigned.
    • 443.9Peripheral Vascular Disease, unspecified
rules of coding pad pvd
When Assigning Atherosclerosis of Arteries of the Extremities (440 Category)

All patients documented as atherosclerosis with

gangreneare coded to440.24

If gangrene is documented without mention of atherosclerosis, only code 785.4

All patients documented as atherosclerosis without

gangrene, but withulcerationare coded to440.23 *

If ulceration is documented without mention of atherosclerosis, only code707.9

Patients documented as atherosclerosis with neither

gangrene nor ulceration, but withrestpainare coded to440.22

If rest pain is documented without mention of atherosclerosis, only code 729.5

Patients documented as atherosclerosis with intermittent claudication due to atherosclerosisare coded to440.21

If claudication is documented without mention of atherosclerosis, only code443.9

Rules of Coding PAD / PVD

*Ulcers:Codes from subcategory707.1x (Ulcer of lower limb)should be assigned in addition to 440.23

rules of coding pad pvd ischemic ulcers
Rules of Coding PAD / PVD: Ischemic Ulcers

Subcategory707.1xUlcer of lower limbs, exceptpressure ulcer

▪ First: Code any underlying or causal condition

Example:

- 440.23– Atherosclerosis of Extremities w/ Ulceration

- 250.8x– DM w/ Other Chronic Manifestations

▪ Second:Code associative ulcers to the highest level of specificityExample:

707.10 – Ulcer of lower limb, unspecified

707.11– Ulcer of thigh

707.12– Ulcer of calf

707.13– Ulcer of ankle

707.14 – Ulcer of heel and midfoot

707.15– Ulcer of other part of foot

707.19– Ulcer of other part of lower limb

Chronic ulcer of unspecified site –707.9

Varicose ulcer (lower extremity, any part) –454.0

clinical example
Clinical Example
  • Exam:  S1S2 no murmur or gallop with regular rhythm. Radial pulses 2+. Feet cool with left pedal faint and absent rt pedal pulse. No edema. Hemosiderin stain of both anterior LE.
  • Dx:  443.9
  • A/P Stable PVD.
  • Comments: “Stable PVD.” represents a definitive diagnosis. This is correct coding.
clinical example1
Clinical Example
  • HISTORY OF PRESENT ILLNESS: L ankle wound: Had ankle fx 12/07, with small open area on medial aspect of her ankle that heals over and then reopens.
  • REVIEW OF SYSTEMS VASCULAR: ULCER: Inner left malleolus has non-healing wound.  POSITIVE FOR: Ulcer 
  • PHYSICAL EXAMVASCULAR: 1+ pedal pulse on R. Foot warm w/sensation. No reddened or open areas.
clinical example2
Clinical Example
  • ASSESSMENT AND PLAN
  • Diagnosis :440.23 - Atherosclerosis of native arteries of the extremities with ulceration
    • Treatment Plan : STATUS: Has open area on inner aspect of left malleolus. very difficult to heal with probable osteomyelitis. Will continue wound healing measures and conservative interventions if wound worsens. 
  • Diagnosis :707.13 - Ulcer of ankle
    • Treatment Plan : STATUS: Chronic, PLAN: Had ankle fracture 12'07. has had an open area on the medial aspect of her left ankle that heals over, opens up, heals over, etc. 6'08 has open area 1 cm that has a pinpoint hole in the center. a shiny metal piece is visible which is probably a plate or screw that was used to fix the ankle fracture. xray ordered to r/o osteo.   
clinical example3
Clinical Example
  • Comments:
  • ROS documentation states: VASCULAR: ULCER:Inner left malleolus has non-healing wound.POSITIVE FOR:Ulcer 
  • Is this an ulcer or a non-healing surgical wound?
    • The code for ulcer of the ankle is 707.13. It maps to HCC 149 with a RAF of 0.241.
    • The code for non-healing surgical wound is 998.83. It does not risk adjust.
clinical example4
Clinical Example
  • Atherosclerosis is never mentioned in the documentation. Inorder to code 440.23 - Atherosclerosis of native arteries of the extremities with ulceration, the documentation must state atherosclerosis, ASPVD or atherosclerotic PVD, etc.
    • 440.23 maps to HCC 104 with a RAF of 0.482.
  • An argument could be made that the documentation does not support the codes reported.
  • According to the documentation, the correct codes for this scenario would be 998.83, and 443.9.
    • 998.83 does not risk adjust.
    • 443.9 maps to HCC 105 with a RAF of 0.165.
  • Specific documentation can make a big difference!
references
References

1 Hirsch, A.T., et al. Peripheral Artery Disease Detection , Awareness, and Treatment in Primary Care. JAMA; Sept 19 2001; 286(11):1317-24

2 Bhatt DL, Steg PG, Ohman EM, Hirsch AT, Ikeda Y, Mas JL, Goto S, Liau CS, Richard AJ, Rother J, Wilson PW; REACH Registry Investigators. International prevalence, recognition, and treatment of cardiovascular risk factors in outpatients with atherothrombosis. JAMA. 2006;295:180–189

3 Hirsch, A.T., et al. (October 2005). ACC/AHA Practice Guidelines. Journal of the American College of Cardiology, 2006; 47; e1-e192, Retrieved February 12, 2009, from http://content.onlinejacc.org/cgi/content/full/47/6/e1

4 Hiatt, WR. Medical Treatment of Peripheral Arterial Disease and Claudication. N Engl J Med 2001; 344:1608

5 McDermott, MM, Kerwin, DR, Liu, K, et al. Prevalence and significance of unrecognized lower extremity peripheral arterial disease in general medical practice. J Gen Intern Med 2001; 16:384

6 Norgren, L, Hiatt, WR, Dormandy, JA, et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASCII). J Vasc Surgery 2007; 45: Suppl S:S5

7"Executive Summary: Standards of medical care in diabetes—2009". Diabetes Care32: S6–S12. 2009.

  • PAD Peripheral Arterial Disease. March 22, 2010. <www.padcoalition.org>.
future insite coding topics
Future InSite Coding Topics:

◘ November -Diabetes, Linda Farrington, CPC, CPC-I

◘ December- Ulcers, Mary Jo Groome, CCS-P, CPC-H

user group feedback survey
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