Did you know? Heart Disease is the #1 killer of women, claiming almost 435,000 lives a year, or nearly 1 per minute. Your circulatory system of blood vessels (arteries, veins and capillaries) is over 60,000 miles long By the age of 70, the average human heart has beaten more than 2.5 billion times and the heart has pumped about 1 million barrels of blood.

Avoiding Errors in Documentation Over the past 5 years, CMS has audited thousands of MA members’ charts. The results have been both alarming and encouraging. Alarming because the error rate remains high – Risk Adjustment Data Validation (RADV) studies (audits) have increased in scope, and the potential effect on both MA organizations and providers are substantial. CMS has published a final rule on RADV, and overpayments will be extrapolated across a health plan’s network. – OIG / Pacificare of Texas Priority: High

What can physicians do to protect themselves? A small handful of errors in documentation make up the vast majority of coding errors. Better yet, these errors are easily corrected, once physicians understand the underlying ICD-9 coding rules. Due Diligence – Education and Training – Compliane: Policies and Procedures – Become Certified

Physicians must understand that the ICD-9 and clinical medicine have little in common. Physicians must distance themselves from their clinical knowledge, both in general and specifically, about the patient at hand. The ICD-9 doesn’t allow assumption, and relies solely on what’s written in the progress note.  A physician writes a note, and then chooses a code reflecting what’s wrong with the patient, not what they’ve documented in the medical record.  The physician may document signs, symptoms, and historical data, and fail to record a diagnosis. Then, knowing what’s wrong with the patient, they may choose a diagnosis on a superbill—without it having been recorded in the progress note.

Most Common Mistakes Problem: Choosing a code that looks right, without knowing the rules for using that code. Example: Coronary atherosclerosis of unspecified type of vessel, native or graft (414.00). Solution: Understand the rules for use of commonly used codes in your practice. To use code , you must state that the patient has had a CABG, but fail to state whether a native or non-native vessel is affected. If your note simply says “coronary atherosclerosis” or “ASHD”, and does not reference a previous CABG, then the correct code is

Problem: Trying to use ICD-9 titles to support a code selection, or simply writing the ICD-9 code in the medical record. Example: Diabetes with renal manifestations (250.40). Solution: Document both diseases in a brief narrative. For example, if the patient has Stage 3 CKD due to diabetes mellitus, then your note should reflect that. Problem: Writing only a diagnosis code in the chart. Example: Impression: Solution: Since coding is derived from a narrative description of the disease state, writing in the chart cannot be coded. Documentation should clearly reflect the condition of the patient. ESRD secondary to DM clearly describes the condition.

Problem: Documenting and coding CVA in the office setting. A CVA is an acute event. Once the patient is discharged from the hospital or rehabilitation setting, the diagnosis of acute CVA is inaccurate and leads to miscoding. Example: Each time a status post CVA patient is evaluated, the physician documents “CVA” in the record and codes (CVA, ischemic or unspecified). Solution: Document that the patient is status post CVA or has a history of CVA (V12.54). What is often overlooked are the sequelae of CVA, since they have often been present for many years. When assessing the patient, it’s important to document and code these as well. There are ICD-9 codes for all of the common and pertinent sequelae of CVA in the 438.XX series of ICD-9.

Problem: Malignancy coded when the correct coding would be personal history of malignancy of ___________. In the case of malignancies, the ICD-9 again differs from current clinical thinking. The ICD-9 allows coding of the malignancy until definitive treatment is finished (unless there are signs of active disease). Definitive treatment is that aimed at eradicating the cancer, such as surgery, chemotherapy and/or radiation therapy. Patients with biopsy proven malignancies who are not treated continue to be coded with the diagnosis of cancer. Example: Patient who is status post pneumonectomy for lung cancer 5 years ago. The patient is on no therapy, but surveillance is continued for the patient’s lifetime. Solution: Document and code personal history of the cancer. These codes are found in the V10.XX series of the ICD-9.

Problem: Documentation of multiple primary sites of malignancies when the patient has metastatic disease. Example: Patient has primary breast cancer which has metastasized to the brain. Solution: If the patient is being assessed or treated for both, then coding for the breast cancer would be in the 174.X (depending on area of the breast) and 198.3, secondary neoplasm of brain or spinal cord. Problem: “History of” means the disease is in the past. You cannot code an active disease you have documented as a “history of.” Example: History of CHF Solution: Remember to use the term “history of” only for diseases which have resolved. In the case of chronic conditions like CHF and atrial fibrillation, use terms like compensated or controlled to reflect their ongoing status.

Problem: Not restating and coding long standing disease. The ICD-9 and the CMS HCC risk adjustment model have no inherent memory. – A disease only exists at the time it is assessed, documented and coded. All chronic diseases disappear from the risk adjustment model each year, and must be resubmitted. Example: A patient who is 10 years status post colon resection for carcinoma, with colostomy. Solution: When your attention is directed to the illness, or in this case the site (assessing skin integrity or signs and symptoms of a recurrence of the cancer) it is appropriate and important to document and code these conditions. There are codes for artificial openings (tracheostomy, colostomy, ileostomy, etc.) in the V44.X series.

Coding rules don’t allow choosing a code based on lab or radiology reports, unless the physician references them in the body of the progress note. Further, such references must be specific—noting that the result is abnormal or writing a lab value doesn’t support ICD-9 selection.

Document, Document, Document No Documentation = No Justification For Claims Submitted Fact: A Patient’s chronic conditions affect the management of the Patient, even when the Patient is presenting with a straightforward illness that would appear unrelated to the chronic condition. Fact: If the chronic condition isn’t documented To have affected the patient’s care (and how so) It is not to be coded or reported on the claim as an active condition. (“History Of” codes may be used, but are informational unless it’s documented how the patient’s care was impacted by that history.) Fact: Coding and reporting chronic conditions that aren’t documented to have affected the patient’s treatment and management on that particular encounter constitutes billing for conditions that are not supported by the documentation. How to Proceed: Deliver timely comprehensive care Document the care you deliver Code the care you document Capture the codes you document Medicare B News Issue 236 April , Heading: Reminder, Title: Documentation Guidelines for Amended Records - Revised

Cardiology Be specific If the patient has stable angina or a history of myocardial infarction (MI), document this condition as opposed to a less specific diagnosis such as coronary artery disease (CAD) or atherosclerotic heart disease (ASHD).

Documenting MI For coding purposes, an MI is considered acute within the first 8 weeks of the event—after that, you should document an old MI. For an acute MI, the coding is defined by “episodes of care”, so from initial hospitalization through the 8 weeks is the initial episode. If the patient is re-hospitalized for care related to the MI, a subsequent episode of care begins which has a different diagnosis code.

Documenting Arrhythmias Do not forget to document and code ongoing chronic conditions such as atrial fibrillation or arrhythmias, whether symptomatic or asymptomatic due to pharmacological treatment. Arrhythmias that no longer exist due to ablation should not be coded.

Document Heart Failure Codes exist in category 428 for systolic, diastolic and congestive heart failure. More than one code from category 428 may be assigned if the patient has systolic or diastolic failure and congestive heart failure. Codes also exist for acute on chronic heart failure.

Documenting and Coding a Stroke Patients with acute cerebrovascular accident (CVA) usually present in an ER or hospital setting. Patients who recover from CVA without sequelae should be documented as “history of CVA” and assigned code V12.54 as an additional code for history of cerebrovascular disease when no neurologic deficits are present. Unless the patient is still hospitalized for the CVA, you should not be using codes in the 434.XX series.

Late Effects Of a Stroke Assess and document all late effects of CVA. Late effects such as aphasia, aphagia, hemiparesis, etc., should be documented and coded using codes from the 438.XX series. Epilepsy should be fully described(convulsive, non-convulsive, petit mal status, grand mal status) and should describe intractable epilepsy (pharmacology resistant, medically refractive) if present. Dementia should be described fully and include a description of causative factors if they exist.

Atherosclerosis Aortic atherosclerosis and peripheral atherosclerosis are chronic conditions that should be assessed, documented and coded each year. These conditions may have been identified through findings on a radiology procedure, but must be assessed by the treating physician. To code these conditions, the diagnosis must be stated in the progress note. They cannot be coded from the radiology report. According to Coding Clinic, the term “aortic atherosclerosis” is inadequate for coding because it isn’t clear if it is the vessel or the valve. Your wording should make it clear which is involved.

Renal Documentation and Coding CKD coding (585.X) has been changed to conform with the stages of CKD. These changes include stages I-V based on a patient’s glomerular filtration rate (GFR), which is estimated from a urinalysis and/or serum creatinine and basic patient demographics. Remember that some Medicare patients with “normal” creatinine levels may still have significantly impaired renal function. For people at risk, creatinine clearance or GFR should be estimated at least twice per year. Note that stages I and II of CKD must have 3 months of reduced GFR or evidence of kidney damage documented.

Kidney Disease 581 Nephrotic syndrome 583 Nephritis and nephropathy, not specified as acute or chronic Unspecified disorder of kidney and ureter – Acute renal disease – Acute renal insufficiency – Renal disease NOS – Salt-losing nephritis or syndrome » Excludes: chronic renal insufficiency (585.9)585.9 cystic kidney disease (753.1)753.1 nephropathy, so stated ( ) renal disease not specified as acute or chronic, but with stated pathology or cause ( )

Chronic Kidney Disease: Staging ▪ Assign V-code (V45.11) for “dialysis status,” or (V45.12) for “noncompliance to renal dialysis” for all and some ▪ Assign V-code (V42.0) for kidney transplant status ▪ CKD is defined as either kidney damage or GFR < 60ml/min/1.73 m² for ≥ 3 months. * Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies. StageSeverityGFR Value ICD-9 Codes Stage I Some kidney damage with normal or slightly ↑ GFR GFR ≥ 90 ml/min With kidney damage * Stage II Mild Kidney Damage GFR ml/min With kidney damage * Stage III Moderate Kidney Damage GFR ml/min Stage IV Severe Kidney Damage GFR ml/min Stage V ICD-9 Stage V Kidney Failure GFR < 15 ml/min ICD-9 ESRD ESRD Requiring chronic dialysis or transplantation CKD Unsp. CKD NOS, Chronic Renal Failure, or Chronic Renal Insufficiency. Chronic Kidney Disease, Unspecified 585.9

It May Be Necessary to Calculate GFR Some laboratories offer an estimated GFR (eGFR). A manual calculation is necessary if the eGFR is >60 ml/min. Typically many lab reports print out the following: “GFR: greater than 60 ml/min” – This does not give enough detail to stage CKD Stage I and CKD Stage II – Therefore, manual calculations of GFR may still be necessary

DOCUMENTATION TIPS CKD: The stage of CKD should be stated in the medical record based on the documented clinical findings, including the Glomerular Filtration Rate (GFR). CKD and Diabetes: There is no presumed linkage between diabetes and CKD. It must be implied (diabetic) or a causal relationship stated (due to diabetes). CKD and Hypertension: ICD-9 assumes a relationship when a patient has both renal disease and hypertension (cause and effect link). Both conditions, chronic kidney disease (staged) and hypertension, must be documented. 1 World Health Organization, Professional: ICD-9-CM for Physicians-Volumes 1& Alexandria, VA: Ingenix, 2010.

DOCUMENTATION TIPS continued CKD, Hypertension and Heart Disease: There is no presumed linkage between hypertension and heart disease. It must be implied (hypertensive) or a causal relationship stated (due to hypertension). Kidney Failure: It is important to specify the type of kidney failure — acute or chronic — and the cause of the kidney failure, if known. If kidney failure is chronic, document the stage of the CKD. Acute Renal Failure: If patient has temporary dialysis, document it and code V World Health Organization, Professional: ICD-9-CM for Physicians-Volumes 1& Alexandria, VA: Ingenix, 2010.

Diabetes, CKD and Hypertension – Putting it All Together Assigning the 5 th Digit Subclassifications for All DM 250.x Codes: 0 Type II or Unspecified Type, Not Stated as Uncontrolled* 1 Type I [Juvenile Type], Not States as Uncontrolled* *When a Provider documents “poorly controlled” the Index instructs “code to Diabetes, by type, with 5 th digit for not stated as uncontrolled.” 2 Type II or Unspecified Type, Uncontrolled 3 Type I [Juvenile Type], Uncontrolled Reminder: Fifth-digits 0 and 2 are for use with Type II patients, even if the patient requires insulin, depending on the documented control status. Example: The patient has nephropathy due to diabetes with hypertension, and CKD Stage IV