NEPHO Coding Audit Results Quarter 4 2020
The NEPHO Coding Team completed an audit at the end of January 2021. The scope of the audit focused on the Risk Adjustment Coding capture during Quarter 4 2020. NEPHO will be working to help educate providers on Risk Adjustment coding capture to ensure patient health status is accurately presented to the payers. This recent audit showed that many high risk patient conditions are not being captured to their highest specificity. Patients that are being managed with a higher level of risk need resources to support potential relapse, medications, treatment planning to better support their chronic condition management such as: diabetes, COPD, and Vascular Disease. The areas of missed coding opportunities from the Northeast PHO patients and providers include the following:
Missed COPD coding capture during sick visit:
- Example: Patient has a sick visit for flu like symptoms and does have COPD that is being managed by the PCP and Pulmonary. The provider diagnosis capture is:
Muscle pain (M79.1), Fatigue (R53.83), Cough (R05), Shortness of breath (R06.02), Sneezing (R06.7), Loss of appetite (R63.0), Headache (R51), Nasal congestion (R09.81). The provider does not capture the chronic condition COPD (J44.9) – this is a lung condition and the flu like symptoms such as cough, shortness of breath, and fatigue can be linked to the COPD.
CKD Stage 3 coding updates effective 10/1/2020
- Example: Patient has CKD Stage 3 and the current coding is CKD 3 (N18.3). This code was broken down to 3 sub-stages effective 10/1/2020.
- N18.30 (CKD, stage 3 unspecified)
- N18.31 (CKD, stage 3a)
- N18.32 (CKD, stage 3b)
Diabetes with Complications captured to the highest specificity:
- Example: Patient has a 3 month follow-up visit and has the following chronic conditions: Diabetes II (E11.9), CKD 3 stage 3a (N18.31), Morbid Obesity (E66.01) with BMI >40 (Z68.41), hyperthyroidism (E03.9).
- Accurate coding: Diabetes with CKD stage 3a: E11.22, N18.31, Diabetes with complications: E11.69, E66.01, E03.9.
Morbid Obesity and BMI accurate coding capture:
- Example: Patient has Morbid Obesity (E66.01) and BMI is >40 (Z68.41). The provider captures the Morbid Obesity (E66.01) but does not capture the BMI (Z68.41) this will not risk adjust as both the E66.01 and Z68.41 must be documented and coded together to accurately capture the risk adjustment coding. Both the E and Z code needs to be captured.
Capturing chronic conditions during Telehealth visits:
- Example: Patient is having 3 month check in call with provider. Could not have face-to-face visit due to flu like symptoms. Patient is being managed by provider for depression (F33.8), Anxiety (F41.1), Hypertension (I10), and Rheumatoid Arthritis (RA) (M06.9).
- The provider has a check in call with the patient via Video/Audio and captures/documents Depression & Anxiety only. Accurate coding and documentation should have included:
Updating Problem List to help support accurate coding capture:
- Example: Patient has diabetes II (E11.9) and morbid obesity with BMI >40 (E66.01, Z68.41). The patient has been focused on weight loss and diet changes. Their blood sugar level has been normal and their BMI is below <32.
- The provider should update the problem list as Diabetes – Resolved and BMI should be updated to <32 (Z68.32).
Missing High Risk conditions on an annual basis:
- Example: Patient is having their annual visit with their PCP. The patient has been seeing Oncology for prostate cancer and is still on medication after radiation treatment. The PCP captured the prostate cancer (C61) as history of prostate cancer (Z85.46).
- The patient is still on medication for prostate cancer so the cancer should be captured as prostate cancer (C61) not history of prostate cancer (Z85.46).
Missing chronic condition capture during annual visits – Annual Exam Encounter (Z00.00):
- Example: Patient comes in for their Annual Exam and has the following chronic conditions: Asthma (J45.909), Diabetes II (E11.9), CKD 3 stage 3b (N18.32), Hypertension with Heart Failure (I11.0), Congestive Heart Failure (I50.82). The provider only codes the Annual Exam Encounter (Z00.00) and misses all chronic conditions. Accurate coding would include the following:
- Z00.00, J45.909, E11.22, N18.32, I10, I50.32, I13.0 (Hypertensive Heart Disease with HF and CKD 3)
Missing HCCs Rx coding capture when provider is prescribing medication to manage condition:
- Example: Patient has not been seen since October 2020 and PCP is prescribing medication for the following chronic conditions: Anxiety (Zoloft), Hypertension (Acebutolol), Hyperlipidemia (Lipitor). The provider is also managing the patient’s diabetes II – The patient visit was in February 2021 and the provider only codes the diabetes (E11.9). The patient might not come back for a visit in 2021 and the following codes that risk adjust with medication updates are missed Anxiety (F41.1), Hypertension (I10), and Hyperlipidemia (E78.5). To capture this patient accurately for 2021 the following coding should be captured:
- E11.9, F41.1, I10, E78.5 and highest specificity if the hyperlipidemia was linked to the diabetes would be: Diabetes with complications E11.69, E78.5
High Level Results: Area of Coding Capture Opportunity – Quarter 4
- COPD was missed during sick visits.
- CKD Stage 3 was missed in early October – this condition was updated on October 1, 2020 to include 3 sub stages (ICD-10 Updates). November and December showed better capture.
- Diabetes with complications is missing specificity and missing accuracy when capturing complications.
- Missing complete Morbid Obesity coding – must capture E and Z code for Morbid Obesity to Risk Adjust.
- Weight on Telehealth visits and Chronic Conditions are not being captured during Video/Audio Telehealth visits.
- Missing updates to the problem list – this is across the NEPHO organization – maintain an accurate problem list is necessary to keep diagnosis coding accurate – updating resolved conditions, in remission updates and condition progression updates must be maintained.
- Missing high risk conditions annually are being missed such as: Multiple Sclerosis (MS) G35, Cancer – prostate cancer C61 when patient is still on medication.
- Physical Exams (Annual) Coding Z00.00, the provider is not updating chronic conditions during these visits and are only coding Z00.00 (Annual Exam Encounter).
- HCCs that risk adjust when provider is prescribing medication are being missed – example: Hypertension I10, Hyperlipidemia E78.5, and Asthma J45.909.
These examples highlight the areas that are being missed on an annual basis. Complete diagnosis risk capture must be updated annually to ensure the patient’s Risk Adjustment Factor (RAF) score is calculated accurately to have the funds available to support patient care management.
2021 OIG Workplan
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