File Name: hcc coding guidelines 2017 .zip
Z55 — Problems related to education and literacy. Z56 — Problems related to employment and unemployment.
As new payment methods shift risk from the payer to the provider, this approach may be changing. The diagnoses must be documented by the physicians who provide care. Additionally, risk factors are assigned for gender, age, living situation and Medicaid eligibility.
WordPress Shortcode. Alan Smith Follow. Published in: Healthcare. Full Name Comment goes here. Are you sure you want to Yes No. Nandhini Podamekala. Sindhuja Bajineni. Show More. No Downloads. Views Total views. Actions Shares. No notes for slide. HCC Training Manual 2.
Developing and maintaining information systems that meet the clinical data collection needs of the organization. Hierarchical Condition Category Category of medical conditions that map to a corresponding group of ICD-9 diagnosis codes. Eligible diagnosis codes must be reported to CMS at least once during each calendar year for Risk Adjusted payment. In addition, each member is assigned a demographic risk factor by CMS based upon their demographics e.
Coding Exclusions Documentation acceptable for risk adjustment should be from a face-to-face visit. Code each unique Dx though it pops up same HCC General Medical Record Documentation Considerations 1. Please make sure to carefully review each record. Please ensure that each of the following rules is met when reviewing the medical record for HCC validation.
However, if the patient name and DOS are not on each page of the record, the record will be acceptable for coding as long as it is clear that each page of the record is for the same patient and same DOS. The coder should carefully review the entire record for context and should use best judgment.
Conditions coded must be stated in the medical record using text i. Reported conditions must be supported with medical record documentation. Each physician record must be from an acceptable provider type see table of acceptable providers on previous pages. Each physician or outpatient hospital encounter must be from a face-to-face visit.
Each record must comply with CMS signature and credential requirements. Followup visit 2. Return visit 3. Office visit 4. Opeative procedures done in Medical centers or Physician offices. Discharge summary given with Admission and Discharge date. All operative reports, consultation ,inpatient progres notes, colonoscopy reports found within the same day inpatient visit should be clubbed together with discharge summary and coded in a single visit.
Discharge date found in any of the Inpatient document is acceptable for DOS 4. Same day Admit and Discharge 2. Emergency Department 3. Operative procedures done in Hospital setting 4. Encounter information itself given as "Type — OP" Format of Records Conditions can be coded from any part of the record provided the condition is documented appropriately with MEAT. The main goals are to verify that each encounter is a face-to-face visit, with an acceptable provider, and that the conditions coded have MEAT to support them within the documentation.
This would include inpatient consults, inpatient progress notes coded as physician records , and ER visits on the day of admission which are reviewed under the outpatient coding guidelines. Use coding judgment to determine acceptable sources of support within each document. The provider is noting issues or conditions as part of the visit, therefore assessing the systems of the body.
There is no need to code all DOSs of a specific period of therapy if all of them have the same dx. Note that although not required, the date of the signature should be noted. The coder should able to read the entire record to determine the context. Miscellaneous Coding Guidelines Combinations in Coding: A combination code is a single code used to classify — Two diagnoses — A diagnosis with an associated secondary process — A diagnosis with an associated complication Identified by referring to sub-term entries in the Alphabetic Index and by reading the inclusion and exclusion notes in the Tabular List Assign only the combination code when that code fully identifies the diagnostic condition involved.
Secondary codes may be necessary Is the record for the Date of Service legible? Is the record from a face-to-face visit? Is the record from an acceptable provider type? Is the record for the Date of Service signed with provider signature and credentials? Has the Date of Service been entered correctly on the tool?
Are the page numbers noted correctly on the tool for the DOS? Code all valid diagnoses in the medical record. E — Sepsis — Malignant Hypertension — S. S — Complication codes Indicates clinical response to treatment, but does not differentiate between benign and malignant type Elevated blood Pressure does not code to hypertension-use Elevated BP increases pressure in the blood vessels, causing thickening over time.
As the heart pumps against this pressure, it must work harder. This increased work causes the heart muscle to thicken, eventually leading to congestive heart failure if not treated. The thicker heart muscle needs more oxygen, and insufficient oxygen can lead to ischemia angina Thickening of the blood vessels may worsen atherosclerosis.
This is most damaging to the smallest blood vessels, such as in the heart and kidney, leading to damage of these end organs XX and Heart Disease code. If controlled or uncontrolled is not mentioned in the record, then code as controlled DM. XX Presence of another underlying condition is major differentiating factor. This usually but not always manifests in adulthood, may be managed with diet and exercise, but may require oral meds or insulin. It may have a genetic component too.
The initial or subsequent episode of care for selection of 5th digit by reviewing the document carefully. Common symptom intermittent claudication. Bronchitis is considered chronic if there is cough and excess mucus production most days for three months in a year, two years in a row.
For risk adjustment coding, there must be documentation of the condition elsewhere on that DOS. If the record does not document the condition other than listing only the ICD9 code , do not code the condition. For example, the term leiomyosarcoma is indexed to malignant neoplasms in the ICD-9 code book. On the other hand, lipoblastoma is indexed to benign neoplasms in the ICD-9 coding manual. Current Cancer vs. Documentation must show clear presence of current disease to code current malignancy.
Higher-cost HCCs have higher relative weights. Note 2: The absence or presence of a HCPCS code and the payment allowance limits in this table does not indicate Medicare coverage of the drug. This is not an all-inclusive list of telehealth, virtual care, and care management codes that contribute to HCC capture, but highlights those that are most commonly used by primary and specialty care clinics. A federal government website managed and paid for by the U. Centers for Me. Each HCC is assigned a relative weight proportional to the relative costs associated with its constituent diagnoses. Add to cart.
ICDCM Official Guidelines for Coding and Reporting. FY Page 2 of outpatient medical record is insufficient to assign a more specific code.
One aspect of the fee schedule is the values of the various Current Procedural Terminology CPT codes that health professionals use to report the services they provide. Current Procedural Terminology Code , previously a parent code, was revised. The Current Procedural Terminology CPT code set is a medical code set that is used to report medical, surgical, and diagnostic procedures and services to entities such as physicians, health insurance companies and accreditation organizations.
Blog About Us Contact. In addition to helping predict health care resource utilization, RAF scores are used to risk adjust quality and cost metrics.
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