RISK ADJUSTMENT 2018 AND RAF SCORES 101
RISK ADJUSTMENT 2018ANDRAF SCORES 101Robert Resnik MD MBA
Terminology HCC- Hierarchical Condition Categories –Chronic conditions used to create a riskadjustment methodology (PART A,B,C) RX HCC – Some HCC codes adjust risk dueto prescription burden of disease (Part D) RAF – Risk Adjustment Factor
Demographic RAF for Medicare Enrollees
Disease HierarchiesSome HCCs will “override” others so that if a patienthas more than one HCC within a category . Diabetes HCCs Diabetes with Acute Complications-HCC17 Diabetes with Chronic Complications-HCC18 Diabetes without Complications-HCC19HCCIf the Disease Group is Listed in this Column 17Diabetes with Acute Complications18Diabetes with Chronic ComplicationsThen drop theDisease Grouplisted in thiscolumn18, 191910
Table 1. HCCs included in the CMS-HCC risk-adjustment model6HCC number and brief description of disease/conditionHCC1 HIV/AIDSHCC2 Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/ShockHCC6 Opportunistic InfectionsHCC8 Metastatic Cancer and Acute LeukemiaHCC9 Lung and Other Severe CancersHCC10 Lymphoma and Other CancersHCC11 Colorectal, Bladder, and Other CancersHCC12 Breast, Prostate, and Other Cancers and TumorsHCC17 Diabetes with Acute ComplicationsHCC18 Diabetes with Chronic ComplicationsHCC19 Diabetes without ComplicationHCC21 Protein-Calorie MalnutritionHCC22 Morbid ObesityHCC23 Other Significant Endocrine and Metabolic DisordersHCC27 End-Stage Liver DiseaseHCC28 Cirrhosis of LiverHCC29 Chronic HepatitisHCC33 Intestinal Obstruction/PerforationHCC34 Chronic PancreatitisHCC35 Inflammatory Bowel DiseaseHCC39 Bone/Joint/Muscle Infections/NecrosisHCC40 Rheumatoid Arthritis and Inflammatory Connective Tissue DiseaseHCC46 Severe Hematological DisordersHCC47 Disorders of ImmunityHCC48 Coagulation Defects and Other Specified Hematological DisordersHCC54 Drug/Alcohol PsychosisHCC55 Drug/Alcohol DependenceHCC57 SchizophreniaHCC58 Major Depressive, Bipolar, and Paranoid DisordersHCC70 QuadriplegiaHCC71 ParaplegiaHCC72 Spinal Cord Disorders/InjuriesHCC73 Amyotrophic Lateral Sclerosis and Other Motor Neuron DiseaseHCC74 Cerebral PalsyHCC75 Myasthenia Gravis/Myoneural Disorders, Inflammatory and Toxic NeuropathyHCC76 Muscular DystrophyHCC77 Multiple SclerosisHCC78 Parkinson's and Huntington's DiseasesHCC79 Seizure Disorders and ConvulsionsHCC80 Coma, Brain Compression/Anoxic Damage
ICD-10HCCYEARHCCe11.9201819DiagnosisType 2 diabetes mellitus without complicationsOverrid 8Type 2 diabetes mellitus with hyperosmolarity withoutnonketotic hyperglycemic-hyperosmolar coma (NKHHC)Type 2 Diabetes due to severe nonproliferative retinopathy withmacular edema201818Type 2 diabetes mellitus with unspecified diabetic retinopathy withmacular edemaY0.31818Diabetes mellitus due to underlying condition with diabeticneuropathic arthropathyY0.31818Drug or chemical induced diabetes mellitus with other diabeticophthalmic complicationY0.31818Drug or chemical induced diabetes mellitus with neurologicalcomplications with diabetic 39e09.4220182018201817e09.41201818Drug or chemical induced diabetes mellitus with neurologicalcomplications with diabetic mononeuropathye11.592018 Demographic RiskFactor201818Type 2 diabetes mellitus with other circulatory complications0.3792018 HCC Risk Factor0.3182018 Total Risk Factor0.697
01818DiagnosisType 2 diabetes mellitus with diabetic peripheral angiopathy withgangreneType 2 diabetes mellitus with diabetic peripheral angiopathy withgangreneType 2 diabetes mellitus with diabetic peripheral angiopathy withgangreneType 2 diabetes mellitus with diabetic peripheral angiopathy withoutgangreneType 2 diabetes mellitus with diabetic peripheral angiopathy withoutgangrenee11.59201818e11.402018e11.41Overrid RiskeScoreN1.461Y0.298N0.318Y0.298Y0.318Type 2 diabetes mellitus with other circulatory complicationsY0.31818Type 2 diabetes mellitus with diabetic neuropathy, unspecifiedY0.318201818Type 2 diabetes mellitus with diabetic mononeuropathyY0.318e11.42201818Type 2 diabetes mellitus with diabetic polyneuropathyY0.318E11.9201819Type 2 diabetes without complicationsY0.104e11.51g57.90Mononeuropathy of left lower limbN/A NO RAFg60.9I96I70.0N/A NO RAFY1.461Y0.298g61.92018 Demographic RiskFactor20182018106108Hereditary and Idiopathic nueropathyGangrene, not elsewhere classifiedAtherosclerosis of Aorta201875Inflammatory polyneuropathy, unspecifiedN0.4570.3792018 HCC Risk Factor2.2362018 Total Risk Factor2.615
Type 2 diabetes mellitus with diabetic arthropathyType 2 diabetes mellitus with diabetic 621Overri Riskde ScoreNoN/A RAFN0.318Type 2 diabetes mellitus with other diabetic arthropathyY0.31818Type 2 diabetes mellitus with diabetic dermatitisY0.3182018161Type 2 diabetes mellitus with foot ulcerN0.535201818Type 2 diabetes mellitus with foot ulcerY0.3182018161Type 2 diabetes mellitus with other skin ulcerY0.535201818Type 2 diabetes mellitus with other skin ulcerY0.318E11.628201818Type 2 diabetes mellitus with other skin complicationsY0.318E11.630201818Type 2 diabetes mellitus with periodontal diseaseY0.318e11.638201818Type 2 diabetes mellitus with other oral complicationsYType 2 diabetes mellitus with oral complicationsN/A0.318NoRAFType 2 diabetes without complicationsY0.104E11.622e11.63E11.92018 DemographicRisk Factor2018190.3792018 HCC Risk Factor0.8532018 Total Risk Factor1.232
PATIENT RAF ScoreAVERAGE MEDICARE PATIENT’s RAF IS 1.0National Average 1.0 9000 non-MACMS reimburses 1% HIGHER for every 0.01 RAF increaseApproximately 900 for ever 0.1 RAF increaseDIAGNOSIS CODING DRIVES THE RAF SCORERAF SCORE DRIVES THE REIMBURSEMENTPROPER DOCUMENTATION RETAINS THE REIMBURSEMENT
Adjustments to Risk Score Continued Blending of Encounter Data and FFS diagnosis riskscores and RAPS (Risk Adjustment Processing Center) and FFSDiagnoses25/75 percent split in PY201750/50 percent split in PY201875/25 percent split in PY2019100 percent Encounter Data implementation in PY2020 Normalization Factor Applied to keep average risk score at 1.0For 2018 just slightly over 1.01MA Coding Pattern Adjustment Applied to adjust for difference in coding patterns between MA andFFS for 2018 around 5.66% (Risk score x .944)
HCC DOCUMENTATIONVALID HCC DOCUMENTATIONREQUIRES (3) POINTS Diagnosis - Face to Face Visit Status or Condition – Stablecondition, worsening, labs or testsordered, medications adjusted Plan of Action – COPD, Stable,continue current medications
Why are documentation andspecificity important ? B19.20 Hepatitis C, unspecified (No HCC) B17.10 Hepatitis C, acute (No HCC) B18.2 Hepatitis C, chronic (HCC-29 RAF .165)
Documentation for Every Diagnosismust have the M.E.A.T.Monitor—signs, symptoms, diseaseprogression, disease regression Evaluate—test results, medicationeffectiveness, response to treatment Assess/Address—ordering tests,discussion, review records, counseling Treat—medications, therapies, othermodalities
Without theM.E.A.T.CMS may findyou guilty ofdeceitThis can landyou in their hotseat
Progress Notes MUST EVALUATE EACH DIAGNOSIS ON PROGRESS NOTE MUST BE FACE TO FACE CAN NOT REFER TO PROBLEM LIST AS DOCUMENTATIONUse:1. DM with Neuropathy – Stable, meds adjusted,2. CHF- compensated, continue meds,3. COPD – PFT ordered, refer to pulmonary4. HTN- uncontrolled, add medication5. Hyperlipidemia – stable on meds. Check labs and increaseexerciseDIAGNOSIS listed on the progress note without an evaluationor assessment is considered a “problem list” and does notprovide correct documentation
PROBABLE , SUSPECTED, POSSIBLEDO NOT CODE non-definitive conditions Probable Possible Questionable Rule outCode the condition to the highest degree of specificity Signs/Symptoms Abnormal test results Other reason for the visit
IF IT IS NOTDOCUMENTEDIN THE MEDICALRECORD.THEN IT DIDNOT HAPPEN
MUST Create a clear relationship tothe diagnosis ACCEPTABLE LINKING VERBIAGE “due to” “because of” “related to” NOT ACCEPTABLE The word “with” does not establish acause and effect relationship except in thecase of “diabetes”
MUST INCLUDE PERMANANTCONDITIONS EACH YEAR Transplant statusQuadriplegiaDialysis statusCurrent ostomiesAmputationsAsymptomatic HIV infection
PrescriptionRX RAFScoresMedicarePart DForMedicareAdvantagenot MSSP
ICD-10 that have “O” RAF for HCC butdo RAF for RX HCC for MEDs on PART D Hypothyroid/Hyperthyroid/Goiter Panic Disorder/Phobia/ADD HypercholesterolGeneral AnxietyDementia/ Alzheimer's Carotid StenosisCerebrovascular Disease/TIA GlaucomaIschemic Cardiomyopathy MigraineAsthmaGERD/Barrett’sOsteoporosisCoronary disease due to plaque (I25.83)
RXHCC RISK SCORESChronic Myeloid LeukemiaMultiple Myeloma and Other NeoplasticDisordersChronic Hepatitis CMultiple SclerosisSecondary Cancers of Bone, Lung, Brain, andOther Specified Sites; Liver CancerAlzheimers DiseaseDiabetes with ComplicationCOPDKidney Transplant StatusDiabetic Retinopathy7.383Lung, Kidney, and Other Cancers 0.2943.946Atrial Arrhythmias0.2883.2022.35Diabetes without 0.3340.330.307Major Depression0.127Hypertension0.123Thyroid Disorders0.101Breast and other cancer and tumors0.096Osteoporosis0.052
Disease Interactions RAFSome diseases “interact” with each other, causing an increasein care management and a corresponding additional risk factor.Congestive HeartFailureDiabetes with ChronicComplicationsHCC 85RAF .323HCC 18RAF .318RAF SCORE.323 .318 .641DISEASE INTERACTION RAFCHF AND DIABETES RAF of .154TOTAL RAF SCORE.641 .154 .79531
Disease InteractionCHF and DM 0.154CHF and COPD 0.19CHF and specified Heart Arrhythmias .105CHF and Renal Disease/Failure 0.27COPD and Cardiorespiratory Failure 0.336Cancer and Disorder of Immunity 0.893(SCID , Wiskott-Aldrich , PNP deficiencyetc)
Diabetes ICD -10 codes E08.xxx - Diabetes due to an underlying condition E09.xxx - Drug or Chemical Induced DM E10.xxxx - DM type 1 E11.xxxx - DM type 2 E13.xxx - Secondary DM Z79.4 - Use of Insulin does RAF as HCC 19 .104
Quality Documentation in Diabetes Type of diabetes: Type I (E10.xxx) or Type II (E11.xxx) Is there a manifestation/complication? Manydiabetics have some manifestation or complication Name the manifestation (next slide) in the system andstate manifestation is DUE TO DIABETES Should comment on Controlled or uncontrolled
ManifestationsEvery patient with diabetes should be evaluated for the manymanifestations, co-morbidities of the disease, and complications withthe progress notes and tests showing that this evaluation was doneDIAGNOSISICD-10HCC WEIGHTWithout complicationsE11.9.104DM W/Kidney Comp.E11.2X.318DM W/OphthalmicComp.E11.3X.318DM W/Neurologic Comp.E11.4X.318DM W/Circulatory Comp.E11.5X.318DM w/Oral Comp.E11.6X.318DM W/CKDE11.220.318
Complications of diabetes are the most frequentlyomitted conditions in physician medical records.If medical recordsays only diabetesmellitus (DM)Must use DMuncomplicatedICD 10 codeDIABETESWHEEL OFMISFORTUNEE11.9(RAF 0.104)HCC 19
Diabetes Codes that will not RAF DM with ophthalmologic complications E08.3xxx or E11.3xxx except if unspecified .311 or .319NO RAF if you use ( 3 digits)Must have 4 digitsE11.321 NO RAF Type 2 diabetes mellitus with mild nonproliferativediabetic retinopathy with macular edemaE11.3211 RAF Type 2 diabetes mellitus with mild nonproliferativediabetic retinopathy with macular edema, right eyeDM with other complications (hypoglycemia, neuropathy, skin,oral) using 2 digits. Must use 3 digits E08.61x E08.62x E08.63x E08.64xE11.61x E11.62x E11.63x E11.64x
Differentiate Proliferative vs Non-proliferative vsunspecified retinopathy and with or w/o macular edema E11.311 DM 2with unspecified diabetic retinopathy with macular edema HCC 18 RAF .318 E11.351 DM 2 diabetes mellitus with proliferative diabetic retinopathy with macular edemaNO RAF Must specify which eye E11.3511 DM 2 diabetes mellitus with proliferative diabetic retinopathy with macular edemaright eyeHCC 18 RAF .318 HCC122 RAF .217 E11.359 DM 2 diabetes mellitus with proliferative diabetic retinopathy without macularedema NO RAF E11.3591 DM 2 diabetes mellitus with proliferative diabetic retinopathy without macularedema right eyeHCC 18 RAF .318 HCC122 RAF .217E11.319 DM 2with unspecified diabetic retinopathy without macular edema HCC 18 RAF .318E11.321 DM 2 with mild nonproliferative diabetic retinopathy with macular edema NO RAFE11.3212 DM 2 with mild nonproliferative diabetic retinopathy with macular edema left eyeHCC 18 RAF .318
Coding ScenarioType II Diabetic is seen for a severe full thicknessleft heel pressure ulcer into muscle .The patient’s history clarifies that ulcer issecondary to Diabetic Peripheral Neuropathy.HbA1C is 9.6%. Physical shows very weak pedalpulses and purple cold toes with poor capillaryrefill.
WHAT WOULD YOU DOCUMENTIN THE ASSESSMENT? DM W/PVD Diabetic Neuropathy Diabetic induced pressure ulcer Pressure UlcerStage 4
ICD-10HCCYEARHCCe11.512018108201818DiagnosisType 2 diabetes mellitus with diabetic peripheralangiopathy without gangreneType 2 diabetes mellitus with diabetic peripheralangiopathy without gangrene2018161201818Overri Riskde ScoreN0.298N0.318Type 2 diabetes mellitus with foot ulcerY0.535Type 2 diabetes mellitus with foot ulcerY0.318L89.609Pressure ulcer of heel, stage unspecifiedN/A0L89.601Pressure ulcer of heel site, stage 1N/A0L89.602Pressure ulcer of heel site, stage 2N/A0e11.621L89.6032018158Pressure ulcer of heel, stage ressure ulcer of heel, stage 4Non-pressure chronic ulcer of skin of heel with necrosisof bone (L97.404) unspecified severity (L97.409)Y0.535Type 2 diabetes mellitus with diabetic mononeuropathyY0.318Diabetes mellitus due to underlying condition withdiabetic neuropathic arthropathyY0.318E11.41e08.6102018 DemographicRisk Factor2018 HCC Risk Factor2018 Total RiskFactor0.3792.7793.158
NEED TO BE SPECIFIC62 year old obese (BMI 40) with Type II diabetes with diabetic retinopathy and agerelated macular degeneration with CHFSystolic CongestiveHeart Failure I50.2Diabetes with ChronicComplications E11.351Type 2 DM with proliferative diabeticretinopathy with macular edemaRAF ZERORAF ZERORAF SCOREZERONO DISEASE INTERACTION RAFCHF AND DIABETES or RAF of .154TOTAL RAF SCORE ZeroCorrect Codes RAF.641 .154 .795 or 800042
MORE SPECIFICDiabetes with ChronicComplications E11.351Type 2 diabetes mellitus withproliferative diabetic retinopathywith macular edemaH35.321Exudativeage-related maculardegeneration, righteye,Systolic Congestive Heart FailureI50.2Diabetes with ChronicComplications E11.3511Type 2 diabetes mellitus withproliferative diabetic retinopathy withmacular edema right eyeRAF .318 HCC 18RAF 0.217 - HCC122Chronic Congestive Heart Failure SystolicI50.22RAF .154 InteractionCHF/DMBMI 40-45 Z68.41RAF .271 HCC 22RAF ZERORAF .499HCC 124Proliferative RetinopathyRAF .323 HCC 85ObesityE66.9H35.3211Exudativeage-related maculardegeneration, righteye, with activeneovascularizationTotal RAF 1.752 Approx 15000
Chronic Kidney DiseaseStageSeveritySTAGE 1GFR ValueICD-10HCC WtGFR 90 mL/minwith kidney damage(microalbuminuria 1 proteinuria)N18.10STAGE 2MildGFR 60-89 mL/minwith kidney damage(microalbuminuria 1 proteinuria)N18.20STAGE 3ModerateGFR 30-59 mL/minN18.30STAGE 4SevereGFR 15-29 mL/minN18.40.237STAGE 5Kidney FailureGFR 15 mL/minN18.50.237ESRDCode with renaldialysis statusZ99.2Requiring chronicdialysis or transplantN18.60.422CKD Unspec.N18.90CKD Unspecified
MICROALBUMINURIA or PROTEINURIAProteinuria orMicroalbuminuriadocumented in chartsecondary to diabetesDiabetes withoutcomplicationsE11.9 RAF .104Chronic Kidney DiseaseStage 1 or 2 due to DM IIE11.22 Diabetes withdiabetes chronic kidenydiseaseRAF .318HCC 18
CARDIOLOGY Be specific:Avoid less specific terms Coronary artery disease (CAD) Atherosclerotic heart disease (ASHD) If patient has more specific diagnosis use:Angina - treated or untreated with pharmacological treatmentor interventional cardiology.ANGINA remains active if pharmacologic RX prescribedANGINA resolved with PTCA or CABG and no furthermedication can not be coded as active
CODING OF MI – ACUTE Vs. OLDAcute MI – I22.9 for only 4 weeks after diagnosis is madeIf you have face-to-face office visit within first 4 weeksthen correct code is I22.9 If a patient is seen after 4 weeks of an acute MI, andhas no continued anginal symptoms, the correct codeis I25.2 (recent MI, old MI, or history of MI) If angina symptoms persist code ANGINA I20.9RULE- “ACUTE” becomes “OLD”after 4 weeks
ANGINARULE- code for cardiac angina if treating.If asymptomatic due to pharmacological treatment,may still continue to code.DIAGNOSISICD-10HCC WEIGHTAngina PectorisI20.9.140Chronic IschemicHeart DiseaseI25.90
CHF and other ChronicCardiovascular Conditions Chronic cardiovascular conditions: Document and code ongoing chronic conditions such as“atrial fibrillation” or arrhythmias Symptomatic Asymptomatic because of the need for pharmacologicaltreatment and/or interventional cardiology. Congestive heart failure is always chronic after diagnosis. After it is diagnosed, CHF is a chronic condition Should be documented, coded, and treated as such.
CHF-You only get credit for one offollowingDIAGNOSISICD-10HCCWEIGHTSI50.90.323I50 I50.2I50.3 I50.4I50.8NO RAFAcute on chronic systolic heart failureI50.230.323Diastolic Heart Failure unspecifiedI50.300.323Left Heart FailureI50.10.323Pulmonary HypertensionI27.00.323Congestive Heart FailureCongestive Heart Failure
ARRHYTHMIASOnce an Arrhythmia,Always an Arrhythmiaunless permanently correctedwithout ongoingpharmacological ormechanistic intervention
ARRHYTHMIASDIAGNOSISICD-10HCC WEIGHTAtrial FibrillationI48.910.268Atrial FlutterI48.920.268Sick Sinus SyndromeI49.50.268Atrioventricular Block,CompleteI44.20.268Paroxysmal Supravent Tach(PSVT)I47.10.268Paroxysmal VentricularTachycardiaI47.20.268Ventricular FibrillationI49.010.302Additional 0.105 RAF given for CHF and Arrhythmia interactionNo CHF/Arrhythmia interaction give for PVC’s, palpitations,tachycardia, bradycardia dysarrhythmia
VASCULARDIAGNOSISICD-10HCC WEIGHTAbdominal Aortic Aneurysm -AAAConsider screening males over 65 years of ageand patients with risk factors i.e. HTN, smoker,hyperlipidemiaAtherosclerotic disease of coronary arterywithout anginaI71.40.298I25.10NO RAFAortic EctasiaI77.8190.298Aortic AtherosclerosisAs found on CXR, CTAtherosclerosis Renal ArteryI70.00.298170.1NO RAFAtherosclerosis, ExtremitiesI70.2090.298I70.2 or 170.20NO RAFI73.90.298Peripheral Vascular DiseaseClinical Dx in patient with decreased palpablepedal pulses, thin, hairless, lower legs, cool purpletoes
RISK ADJUSTMENTConditions that DON’T risk adjConditions that DO risk adjHypertension benignHypertensive heart diseaseMalignant with heart failureICD-10 I11.0Coronary atherosclerosis,unspecified type of vesselAngina pectoris unspecifiedICD 10 I20.9AtherosclerosisAtherosclerosis, extremitiesI70.20 NO RAF I70.29 RAFChest PainUnstable AnginaI20.0 RAF value doubleAngina Unspecified I20.9DysrhythmiaAtrial fibrillationI48.9
PULMONARYDIAGNOSISICD-10HCC WEIGHTObstructive Chronic BronchitisChronic cough or mucus production for at least 3months out of the year in 2 successive years diagnosedclinically and PFT with obstructive pattern (low FEV,high TLC)J44.90.328EmphysemaDamage to alveoli frequently diagnosed by smokinghistory, wheezing, CXR findings and obstructive ordecreased perfusion capacity PFTJ43.90.328Chronic Obstructive AsthmaChronic asthma characterized by SOB, cough,wheezing, and response to bronchodilators diagnosedclinically or PFT revealed obstructive pattern(FEV1/FVC 80%) reversible with bronchodilatorsJ44.90.328COPD NEC, NOS/CHR Airway ObstructionChronic obstructive lung disease often diagnosed withsmoking history, wheezing, CXR or PFT showingobstructive pattern (FEV1/FVC 80%)J44.90.328Simple Chronic BronchitisJ420.328
MAJOR DEPRESSION Episodic mood disorders (F32.X) are mental diseasesthat include mood disturbances such as majordepression. Must carefully document the characteristics of themood disturbance (e.g. mania, depression, single orrecurrent episode) and use specific mental disorderterminology in the final diagnosis. NO descriptor terms such as “major” or “recurrent”,the code F32.9 is used which has NO HCC weight.
MAJOR DEPRESSIONDIAGNOSISICD-10HCCWEIGHTMajor Depressive .90.395SchizophreniaF20.90.608Single EpisodeOne episode of major depression (must havedepressed mood and/or loss of interest plus 4out of the following: change in appetite, sleepdisturbance, behavior change, decrease inenergy, guilt, inability to concentrate, suicidalideation)Major Depressive Disorder,Recurrent EpisodeRecurrent episodes of major depressionMajor Depressive DisorderIn remission
ICD-10HCCYEAR .5201858DiagnosisMajor depressive disorder, single episode,mildMajor depressive disorder, single episode,moderateMajor depressive disorder, single episode,severe with psychotic featuresMajor depressive disorder, single episode, inpartial remissionMajor depressive disorder, single episode, infull remissionRiskOverride Score0.395Y0.395Y0.395Y0.395Y0.395f32.8Other depressive episodesN/ANO RAFf32.9Major Depressive Disorder unspecifiedN/ANO RAF
PSYCHIATRYDIAGNOSISICD-10HCC WEIGHTAlcohol Dependence/AlcoholismOnce an alcoholic, always an alcoholic, even if sober foryears. Code annually.F10.200.383Drug DependenceConsider opioid or benzodiazepine dependence in patientswho have maladaptive pattern of substance use andwithout the medication would have signs or symptoms ofphysical or psychological withdrawal and would seek refills.i.e. patients with chronic pain syndromes on morphine ER,oxycontin, fentanyl patches.F11.x0.383Opioid DependenceF11.200.383Benzodiazepine dependenceF13.200.383
Alcohol DEPENDENCE Drinking more or for longer periods of time than intendedMore than once wanting to cut down or stop but being unable to do soSpending lots of time drinking, or getting over the effects of drinkingWanting a drink so badly that you can’t think of anything elseDrinking or the effects of drinking interferes with the ability to care forfamily or causes problems on the job or at schoolGiving up other interests or activities in order to drinkContinued drinking even when it causes problems with friends or familyContinued drinking even though it causes health or emotional problemsor a blackoutHaving to drink more than you once did to achieve the same effectsMore than once gotten into potentially harmful situations during orafter drinkingExperienced withdrawal symptoms when the effects of alcohol wear offMild – 2 to 3 of criteria Moderate 4-5 Severe 6 or more criteria
Opioid DependenceLong term opioid treatment Z79.891Opioid dependenceF11.20NO RAFRAF 0.383A maladaptive pattern of substance use, leading to clinicalimpairment or distress as manifested by 3 of the following: Tolerance Withdrawal symptoms Increased usage over a longer period than intended Desire or unsuccessful effort to cut down on use Excess time spent in activities to obtain the substance Continued use despite doctor advice or patientknowledge of physical or psychological problem relatedto the substance use
NO RAF SCORES F10.10 Alcohol Dependence Unspecified Opioid abuse, uncomplicated (F11.10) Unspecified opioid use, uncomplicated (F11.90)
MALNUTRITION ICD-10 Codes E44.x - Malnutrition is often underreported Conditions often seen in the senior patient that limit nutrientingestion and absorption: Cancer Pancreatitis Alcohol abuse and/or dependence Liver Disease, Alcoholic hepatitis, cirrhosis Obesity CHF, COPD ESRD Celiac Disease Cystic fibrosis Depression / Dementia
MALNUTRITIONDIAGNOSISICD-10HCC WEIGHTUnspecified malnutritionE460.545E44.10.545E44.00.545Wt loss of 5% in 3 months or 10%in 6 months, orBMI 17.9 and low albuminMild malnutritionBMI 16-17.9 Albumin 3.5Moderate malnutritionBMI 16.0 Albumin 3.5
MORBID OBESITYDIAGNOSISICD-10HCC WEIGHTMorbid Obesity BMI 40BMI 40-44.9BMI 45-49.9BMI 50-59.90BMI 60-69.9BMI 70 or 0.2730.2730.2730.273Morbid Obesity w/CoMorbidConditions BMI 35(Be sure to link to co morbidCondition)Arthritis, Sleep Apnea, HTN,Hyperlipidemia, DiabetesUse Zcode forBMI 3539.9Z68.35-.39RXHCC
Coding of Strokes Strokes are an acute event, and shouldonly be coded when the patient ishaving the stroke in front of you. Code as history of stroke but to getRAF you must code any applicable lateeffects of the stroke
NEUROLOGYDIAGNOSISLate EF-Hemiplegia Side NOSNonspecific persistent hemiparesis from CVAdiagnosed clinically (paralysis of one side of thebody)Late EF Other paralytic syndromeNon specific persistent weakness as a result of aCVA diagnosed clinicallyLate EF Monoplegia Lower limbPersistent weakness involving one lower limb asa result of CVA diagnosed clinicallyLate EF Monoplegia Upper limbICD-10HCC .395
NEUROLOGYDIAGNOSISICD-10HCC .83F02.81G35NO RAFNO RAFNORAF.441Be sure to document and code annuallyParkinsonsConsider Parkinsons in patients withresting tremor of head, hands, arms, andpossible muscle rigidity, slowness ofmovement, or postural instabilityAlzheimer's DementiaLewy Body DementiaDementia with behavioralMultiple Sclerosis
ONCOLOGY Under ICD-10 guidelines, malignancies are only coded until thepatient has completed definitive treatment: Definitive treatment means surgery, chemotherapy and/orradiation therapy aimed at eradicating the malignancy Patients who do not receive definitive treatment for the theirmalignancy continue to be coded for the malignancydiagnosis Patients on Adjuvant therapy like for Breast and Prostate CApatients(Examples Taxanes, Trastuzumab, Aromatase Inhibitors,Docetaxol) are coded as if they have active disease
ONCOLOGY DOCUMENTATION PITFALLSSURVEILLANCEPatients who have completed therapy can only be coded with a“personal history of cancer” diagnosis codeThis includes patients undergoing surveillance for re-occurrence of themalignancyMETASTATIC DISEASE Has a separate section in the ICD-10, and a separate CMS-HCC paymentgroup. This is an instance where lack of specificity in documentationleads to a lower payment rate. It is important to indicate when metastatic disease is present, as asecondary malignant neoplasm.
C00-C14 Malignantneoplasms oflip, oralcavity andpharynxC43-C44 Melanomaand othermalignantneoplasms ofskinMalignantneoplasms ofmale genitalorgans C15-C26Malignantneoplasms ofdigestiveorgans C40-C41Malignantneoplasms ofbone andarticularcartilage C50-C50C51-C58Malignantneoplasms offemalegenitalorgansC69-C72Malignantneoplasms ofeye, brainand otherparts ofcentralnervoussystemMalignantneoplasms ofbreast C64-C68Malignantneoplasms ofurinary tractC45-C49Malignantneoplasms ofmesothelialand softtissueC30-C39Malignantneoplasms ofrespiratoryandintrathoracicorgans C60-C63 C73-C75Malignantneoplasms ofthyroid andotherendocrineglands
0182018201820182018201899Malignant neoplasm of upper lobe, left bronchus or lungMalignant neoplasm of lower third of esophagusNodular sclerosis Hodgkin lymphoma, lymph nodes of head, face,10and neck10Malignant neoplasm of left ovary10 Lymphoid leukemia, unspecified not having achieved remission10 Chronic lymphocytic leukemia of B-cell type not having achieved remission10Malignant neoplasm of brain stem11Malignant neoplasm of sigmoid colon11Malignant neoplasm of laryngeal cartilage11Malignant neoplasm of left renal pelvis12Malignant melanoma of right upper limb, including shoulder12 Malignant neoplasm of upper-inner quadrant of left female breast12Malignant neoplasm of thyroid 0.3010.3010.3010.1460.1460.146
Metastatic 111111121212888888Malignant neoplasm of upper lobe, left bronchus or lungMalignant neoplasm of lower third of esophagusNodular sclerosis Hodgkin lymphoma, lymph nodes of head, face,and neckMalignant neoplasm of left ovaryLymphoid leukemia, unspecified not having achieved remissionChronic lymphocytic leukemia of B-cell type not having achieved remissionMalignant neoplasm of brain stemMalignant neoplasm of sigmoid colonMalignant neoplasm of laryngeal cartilageMalignant neoplasm of left renal pelvisMalignant melanoma of right upper limb, including shoulderMalignant neoplasm of upper-inner quadrant of left female breastMalignant neoplasm of thyroid glandSecondary malignant neoplasm of boneSecondary malignant neoplasm of brainSecondary malignant neoplasm of unspecified lungDisseminated malignant neoplasm, unspecifiedSecondary malignant neoplasm of liver and intrahepatic bile ductSecondary malignant neoplasm of unspecified 52.6252.625YYYYY
Breast Cancer Breast Cancer HCC 12 ICD 10 --- C50.510 RAF 0.146 Breast Cancer that has spread to lymph nodes ICD 10 --- C50.510 Overridden by I
2018 18 Type 2 diabetes mellitus with foot ulcer Y 0.318 E11.622 2018 161 Type 2 diabetes mellitus with other skin ulcer Y 0.535 2018 18 Type 2 diabetes mellitus with other skin ulcer Y 0.318 E11.628 2018 18 Type 2 diabetes mellitus with other skin complications Y 0.318 E11.630 2018 18 Type 2 di
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Why is Risk Adjustment Done? To accurately reimburse providers and health plans to care for their patients - specifically higher risk patients. This is done using Risk adjustment scores AKA Risk Adjustment Factor (RAF) scores. Risk adjustment scores are highe r for a patients wit
RAF and MEK inhibitors are now approved and used in the clinic. There is now much interest in targeting at the level of ERK1/2 for a variety of reasons. First, since the pathway is linear from RAF-to-MEK-to-ERK then ERK1/2 are validated as targets per se. Second, innate resistance to RAF or MEK inhibitors involves relief of negative
Medicare Risk Adjustment RAF 101 Presenter: Renee White, LPN, CCS, CPC, CPCI, CPMA, CRC 1. Disclaimer The information presented herein is for information purposes only. HIMS BMG/BUMG Documentation and Coding Education Te
RAF payment methodology also used by ACA plans (HHS‐HCCs) and certain Medicaid plans . Pneumonia J189 ‐‐ 0.0 Acute respiratory failure J9600 84 0.329 Pulmonary hypertension I272 85 0.368 Total RAF 1.679 Annual payment 15,111 RAF Calculation Example . 02_2017 Outpt
RTK The RAF/MEK/ERK pathway and R TK Shc itsinhibitors Grb2 Sos Ras RAF Mos MEKK1 PD098059 U0126 PD184352 (CI‐1040) MEK ‐ 4) PD0325901 Selumetinib Trametinib BRAF‐selective or Pan‐RAF Inhibitors ERK ( and more to come from Merck, Roche, Novartis,
Delphi Study of the RAF Benefits and Performance Indices Technical Paper #5 Prepared by World Perspectives Inc. 3 November 2008 Not edited . . As a component of the Global Environment Facility's (GEF) Mid-Term Review of its Resource Allocation Framework (RAF), World Perspectives, Inc. was retained to conduct .
BROADWAY Falcon 20 Ews FRA / FAA BROMIDE Falcon 20 Ews FRA / FAA BRUSH Boeing KC-135 Stratotanker RAF Mildenhall 100th ARW, USAF BUCK F-15E RAF Lakenheath 494 FS, 48th FW, USAF BULKHEAD Tornado GR4 RAF Marham 9 Sqn BD BUSH Lockheed MC-130H
