June 14, 2011 Approval Code: IN361 Ingenix InSite Provider User Group

© Ingenix, Inc. 2 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?  Ingenix InSite Website Questions? Call or the Ingenix Helpdesk or

© Ingenix, Inc. 3 Ingenix InSite User Group: Agenda  10:00 AM Welcome  10:03 AM InSite Operations Announcements  10:10 AM CMS County Rate Methodology Change  10:30 AM Documentation and Coding Focus On: Skin Ulcers  10:55 AM Q & A

InSite Operations Announcements – UHG’s Health Services Re-Branding to Optum  Per 4/11/11 Ingenix press release, UnitedHealth Group announced “Optum” master brand for its Health Services Businesses –OptumHealth™ will continue to be –Ingenix™ is now –Prescription Solutions™ is now  This brand unification is focused on making it easier for the broad health services marketplace to understand and access the company’s full range of capabilities that help participants throughout the health care system improve health, increase efficiency and create a better overall experience for consumers.  This change reflects increased coordination and collaboration among three leading health services companies that are committed to addressing meaningful and positive change across the health care system

InSite Operations Announcements Presented By Jerry Gauchat

InSite Operations Announcements – Data Refresh Update  Data Refresh Update –Data refreshed June 6th –Next monthly data refresh is scheduled for July 5th

InSite Operations Announcements – Q Release  Upcoming InSite Updates –New HEDIS/STARS PAF Versions No changes to PAF Management functionality –Summary of Accepted HCCs (SOAH) Modifications Modify query to access report more quickly Upon export - HCC and description will match –Systematic User Entitlement –Changing default sort on Custom List to default to PCP Name –Learning & Resources Tab Adding April, May & June 2011 Ingenix Insiders Removing all 2010 Ingenix Insiders Removing 2010 ICD-9 Brochure Updating RAF Calculator to include updated FFS Normalization value Updating Chart Mechanics for Data Validation document Adding Understanding & Coding Medicare Preventive Services document

InSite Operations Announcements – Q Release (Sep/Oct 2011)  Planned* InSite Updates –Adding Rendering provider logic impacting Population Report PAF CSI / Problem List –Adding new Health Plan Summary report Prevalence by Plan PBP –Adding HCC RAF to Group & Provider Summary Report –Adding plan filters to Management Problem List and Custom List –Adding logic to the report list screen to allow for re-accessing without logging out *Planned – not confirmed

CMS County Rate Methodology Changes Presented By Nick Chiechi

2012 Payment Year Changes  Health Care Reform Bill (Affordable Care Act) Introduced Changes Impacting Medicare Advantage CMS Payments For 2012 and Beyond  Changes Impact CMS Determination of County Rates and Calculation of Rebates –Changes Were Made to Methodology and/or Associated Values Within Existing Methodologies

2012 County Rate Methodology  CMS Introduced a New Methodology For Determining County Rates –New Methodology Will Be Phased in Over Two to Six Years (Varies By County) New Methodology: “Specified Amount” Pre-2012 Methodology: “Applicable Amount” –STARS Quality Bonus Prominently Impacts County Rates STARS Impacts Both New and Pre-2012 Methodologies

Transition Periods For New Methodology  2012 County Rate is Blend of “Applicable Amount” and “Specified Amount” –Plans <=2.5 Stars Capped at Pre-CA Value  Applicable (old) and Specified (new) Amounts Are Independently Calculated  Blended Based on Transition Schedule –Transition Schedule Will Vary By County Based on a One-Time CMS Calculation Using the 2010 Applicable Amount

Transition Schedule

Applicable Amount (Old Methodology) Overview  Greater of: –2012 FFS Rate - OR - –2011 Applicable Amount Adjusted For 2012 National Per Capita MA Growth Percentage  Greater Amount Then Reduced For IME Phase-out  New Twist For 2012 and Beyond –Applicable Amount Will Also Be Adjusted For Each Contract’s STARS Rating

Specified Amount (New Methodology) Overview  A Baseline Amount Is Calculated For Each County –FFS Rate Minus IME Phase-out Amount  For Each County, the Baseline Is Adjusted For the Following: –“Applicable Percentage” Based on Newly Designated Quartile –STARS Quality Bonus Percentage

Specified Amount (New Methodology) Applicable Percentage  Baseline For Each County is Adjusted For A Applicable Percentage  Counties Were Ranked From Highest To Lowest Using Most Recent Rebased FFS Costs –For 2012, 2009 FFS Costs Were Used

STARS Quality Bonus Percentage  Each Contract Achieves a STARS Rating  Each Rating Translates To a Bonus Percentage To Be Applied to Each County’s Calculated County Rate  Bonus Is Applied to Both the Applicable Amount (Old Methodology) and Specified Amount (New Methodology) –Applied Slightly Differently To Specified Amount vs. Applicable Amount

STARS Quality Bonus Percentage * Quality Bonus Percentages Will Be Doubled in “Qualifying” Counties –Qualifying County Determined Using 2012 FFS Rate and Size and Penetration of MA Population

Example  Los Angeles County –Quartile: 4 –Transition Period: 4 Years –Qualifying County?: No  ABC Health Plan –STARS Rating: 3.5 Stars

Applicable Amount Calculation Example 2012 FFS Rate Trended 2011 Applicable Amount Greater of Two Above Amounts Quality Bonus Payment Percentage Quality Adjusted Applicable Amount $ $ % $993.58

Specified Amount Calculation Example 2012 FFS Rate Applicable Percentage Quality Bonus Payment Percentage Quality Adjusted Applicable Percentage Quality Adjusted Specified Amount $ % 3.5% 98.5% $840.54

ApplicableSpecified Quality Adjusted Amount $ $ Blend % 75% 25% Blend Amount $ $ County Ratebook Amount $ Blended County Ratebook Calculation Example +

Pro Forma Blending

CMS RAF Payment Calc Rebates  Overarching Methodology and Application of Rebates is Likely Unchanged For 2012  Rebate % Amounts Are Materially Lower in 2012 and Beyond

Rebate as % of Savings  Rebate % Amounts Are Materially Lower in 2012 and Beyond –Three Year Phase-In of Revised Rebate %’s –Percentages Driven by Plan’s STARS Rating

Changes to Rebate %

Documentation and Coding for Skin Ulcers Presented by: Mary Jo Groome, CCS-P, CPC-H Sr. Training and Development Consultant

Diseases of the Skin and Subcutaneous Tissue Category 707 Chronic Ulcer of Skin 707.0x Pressure ulcer 707.2x Pressure ulcer stages 707.1x Non-pressure ulcer

Pressure Ulcers – 707.0x  Documentation may identify synonymous terms for decubitus ulcers such as bed sores, plaster ulcer, pressure sore or pressure ulcer.  Documentation of pressure ulcer stage is integral to measurement of quality of care by providing a means by which coded records can be used as a part of internal and external health care quality improvement endeavors to promote prevention, healing and reduce the risk of pressure ulcers in the health care environment.

Pressure Ulcers – 707.0x  Two codes are needed to completely describe a pressure ulcer: –Assign the appropriate code for the site of the ulcer from subcategory with an additional code from subcategory to specify the stage of the ulcer. The pressure ulcer stage codes will only be used with ulcers documented as “pressure” ulcers or “decubitus” and not with other types of ulcers (e.g. stasis ulcers)

Coding Ulcers: Decubitus / Pressure By Site  Pressure Ulcer –Use additional code to identify pressure ulcer stage ( ) – – Pressure Ulcer, unspecified site – – Pressure Ulcer, elbow – – Pressure Ulcer, upper back – – Pressure Ulcer, lower back – – Pressure Ulcer, hip – – Pressure Ulcer, buttock – – Pressure Ulcer, ankle – – Pressure Ulcer, heel – – Pressure Ulcer, other site

Coding Ulcers: Decubitus / Pressure By Stage  Pressure Ulcer Stages –Code first site of pressure ulcer ( ) – Pressure ulcer, unspecified stage – Pressure ulcer, stage l – Pressure ulcer, stage II – Pressure ulcer, stage lll – Pressure ulcer, stage lV – Pressure ulcer, unstageable  Note: It is important to code both the location and the stage (depth).

Pressure Ulcer Staging – 707.2x  707.2x Pressure Ulcer Stages (Code first site of pressure ulcer ) TIP: If a pressure ulcer progresses during an encounter from one stage to another, assign only the code for the higher stage; only pressure ulcers are staged. – Pressure ulcer, unspecified stage Healing pressure ulcer NOS Healing pressure ulcer, unspecified stage – Pressure ulcer stage I Healing pressure ulcer, stage I Pressure pre-ulcer skin changes limited to persistent focal erythema – Pressure ulcer stage II Healing pressure ulcer, stage II Pressure ulcer w abrasion, blister, partial thickness skin loss involving epidermis and/or dermis

Pressure Ulcer Staging – 707.2x  707.2x Pressure Ulcer Stages – Pressure ulcer stage III Healing pressure ulcer, stage III Pressure ulcer with full thickness skin loss involving damage or necrosis of subcutaneous tissue – Pressure ulcer stage IV Healing pressure ulcer, stage IV Pressure ulcer with necrosis of soft tissue through to underlying muscle, tendon or bone – Pressure ulcer, unstageable TIP: Assign only if ulcer is covered by eschar, has been treated with skin or other graft, or is documented as a deep tissue injury but not documented as due to trauma.

Know the Difference  Code Pressure ulcer, unspecified stage –Should be assigned when there is no documentation regarding the stage of the pressure ulcer  Code Pressure ulcer, unstageable –Should be used for pressure ulcers whose stage cannot be clinically determined (e.g. the ulcer is covered with eschar or has been treated with a skin or muscle graft). –Pressure ulcers that are documented as deep tissue injury but not documented as due to trauma.

Example Non-surgical pressure ulcer located on left heel measuring about 2.5cm. Unable to classify (stage) because of area of black tissue (necrosis) on 100% of ulcer base. Surrounding tissue has bruising extending about 1.5cm out towards the toes. Tenderness noted when bruised area is touched.

Coding Scenario – Pressure Ulcer  A patient is seen for treatment of Stage II healing pressure ulcer of the left buttock. –Code assignment Pressure ulcer, buttock Pressure ulcer stage II

Coding Scenario – Pressure Ulcer  An elderly patient is being seen in an extended care facility for treatment of a stage III pressure ulcer of the heel. The NP also identifies the patient as a Type I diabetic with related progressive PVD. –Code assignment: Pressure ulcer, heel Pressure ulcer, stage III DM w peripheral circulatory disorders, Type I, unspec Peripheral angiopathy in diseases classified elsewhere

Examples  Unfortunately, some patients may suffer from more than one pressure ulcer, and these ulcers may be at the same or different sites and stages. Here are some examples of documentation and coding: –Pressure ulcer both buttocks, both stage II (buttock) and (stage II) –Pressure ulcer both buttocks, one stage II and one stage III (buttock), (stage II) and (stage III) –Pressure ulcer of left buttock and left elbow both stage II (buttock), (elbow) and (stage II) –Admitted with stage II pressure ulcer of buttocks, which advanced to stage III during encounter (buttock) and (stage III)

Pressure Ulcer Example  Recurrent Decubitus Ulcer with Failed Graft: –A recurrent pressure ulcer that has had a failed graft(s) is reported with Mechanical complication of device implant or graft and a code from the subcategory Look up: Complications graft skin infection or inflammation rejection

Pressure Ulcers  Care should be taken to distinguish between: – pressure ulcers documented as “healed” (no code assigned) – and “healing” (assign the appropriate code for the site and the stage documented).

Diseases of the Skin and Subcutaneous Tissue Category 707 Chronic Ulcer of Skin 707.1x Non-pressure ulcer

707.1 Ulcer of Lower Limb, except pressure ulcer  707.1x Ulcer of lower limbs, except pressure ulcer –Ulcer, chronic Neurogenic Trophic Causal condition…code first: atherosclerosis of the extremities w ulceration ( ulcer code) diabetes mellitus ( / ulcer code)

Coding Ulcers: Chronic, Ischemic, Lower Extremity  Subcategory 707.1x Ulcer of lower limbs, except pressure ulcer ▪ First: Code any underlying or causal condition Example: – Atherosclerosis of Extremities w/ Ulceration x – Diabetes w/ Other Chronic Manifestations ▪ Second: Code associative ulcers to the highest level of specificity Example: – Ulcer of lower limb, unspecified – Ulcer of thigh – Ulcer of calf – Ulcer of ankle – Ulcer of heel and midfoot – Ulcer of other part of foot – Ulcer of other part of lower limb  Chronic ulcer of unspecified site –  Varicose ulcer (lower extremity, any part) – 454.0

707.1x Ulcer of lower limbs, except pressure ulcer  If ulceration is associated with arteriosclerosis of the extremities code: –440.23, Atherosclerosis of the extremities with ulceration –Additional code from (non-pressure ulcer) – Ulcer of lower limb, unspecified – Ulcer of thigh – Ulcer of calf – Ulcer of ankle – Ulcer of heel and midfoot – Ulcer of other part of foot –Toes – Ulcer of other part of lower limb

Nursing Facility Example  Case 3 89 yo female with hx of PVD,Hypertensive Heart Disease Vascular PE: Bilat severe rubor noted. R ankle noted to have ulcer to lateral malleolus. Ulcer improved from last assessment. Continues 1 cm diameter open area with slight area of redness around ulcer. Redness has improved from last week.  Diagnosis Atherosclerosis of native arteries of the extremities with ulceration Chronic: Pt with obvious PVD. Ulcer to R outer malleolous to be treated with Bactroban and covered with window dressing to let wnd breath. Staff states wnd is improving. Continue to monitor progress of wnd and staff to inform NP/PCP of any increased drainage, redness, heat to area.

Documentation & Coding PAD / PVD A condition potentially related to PAD is atherosclerosis. –Atherosclerosis of native arteries of the extremities is classified to code 440.2x. A fifth-digit subclassification is required to differentiate the type of atherosclerosis as follows: Atherosclerosis of the extremities, »With ulceration Use additional code for any associated ulceration ( ) »With gangrene Use additional code for any associated ulceration ( )

707.1x Ulcer of lower limbs, except pressure ulcer  The underlying cause of foot ulcers in a diabetic patient may be diabetic neuropathy (250.6x), diabetic peripheral vascular disease (250.7x) or “other specified diabetic ” (250.8x) depending on documentation.  e.g. Patient has diabetic neuropathy and an associated ulcer of the left great toe. –Codes , and  e.g. Patient’s diabetic PVD has resulted in an ulcer of the right midfoot. –Codes , and  e.g. Patient has a diabetic ulcer of the left ankle – Codes and

Be Specific ▪ Wound Care Do not choose the word “open wound” or “lesion” in your documentation if you really mean “pressure” or other forms of non-healing ulcers. ● Wound – open (by cutting or piercing instrument)(by firearms) (cut) (dissection) (incised) (laceration) (penetration) (perforating) (puncture) (with initial hemorrhage, not internal) ICD-9 notation ● Ulcer, Ulceration – a local defect/excavation of the surface of an organ or tissue produced by sloughing of necrotic inflammatory tissue ● Pressure Ulcer – bed sore, plaster ulcer, decubitus ulcer

Be Specific ▪ Wound Care for the Leg –The chart documentation and choice of words determines the coding: Open Wound Knee, leg (except thigh) ankle UlcerPressure Ulcer (code Stage also) 891.0w/o comp lower, unsp elbow complicated thigh upper back w/ tendon involvement calf lower back ankle hip heel/midfoot buttock other part of foot (toes) ankle other part of lower limb heel other site

Documentation Makes the Difference 1. Patient’s ulcer appears to be healing Patient’s pressure ulcer appears to be healing , Patient’s stage III decubitus ulcer appears to healing , Patient’s decubitus stage II heel ulcer appears to be healing , The patient’s open wound on the left heel appears to be healing Physical exam reveals varicosities on the right lower leg that have ulcerated Varicose veins with ulceration and hemorrhage The patient’s left heel ulcer has healed nicely. No code

Sample Documentation  History states: “PVD with ulcers”  Exam states: “SKIN: Current Status: Bilateral ace wraps to legs in place.” “CARDIOVASCULAR: BASELINE: Regularly irregular rhythm. S1, S2. No M/C/R. 2+ BLE nonpitting edema. No JVD. Ace wraps BLE. Current Status: RRR S1 S2. No murmur.”  Diagnosis : Unspecified peripheral vascular disease Treatment Plan : PVD is most likely secondary to long history of HTN and CAD. Continue with supportive care of chronic wounds and edema management. Consult wound nurse with AMT prn. Recurrence of wounds expected. Continue with podiatry care.  Diagnosis : Ulcer of lower limb, unspecified Medications : Zinc Sulfate; Treatment Plan : refer to  Comments: This represents correct coding for the PVD and ulcers based on the documentation. We cannot code the causal condition when it is documented as “most likely secondary to”. –If the documentation had stated “PVD is secondary to long history of HTN and CAD”, we would code (HTN), (CAD) and (peripheral angiopathy in diseases classified elsewhere). –If the documentation had stated ulcer due to arteriosclerosis or arteriosclerotic ulcer, we would code (atherosclerosis of the native arteries of the extremities with ulceration) and

Sample Documentation  His R foot has a 2.5 cm x 1.2 ulceration weeping sero- sanguinous drainage after podiatry debrided 2 days ago.  Comments: Because we do not know the type of the ulcer, we can only code by site – Ulcer of other part of foot.

Sample Documentation  History states: “Skin: Decubitus ulcer, 2007”  Exam states: “Skin:…. Decubitus ulcer to sacrum/buttocks, followed by treatment nurse.”  Treatment plan states: “…, resident with coccyx/sacral ulcer, open area from hospitalization in July, exact measurements in wound care nurses records.”  Diagnosis: does not mention ulcer  Comments: –Code – Pressure ulcer, sacrum – and code – Pressure ulcer, buttock – should be added to reported diagnoses. –We are unable to code the specific stage of the ulcer due to lack of documentation, so we would code also – Pressure ulcer, unspecified stage.

Coding Ulcers: A Summary  Pressure ulcer documentation needs to address the site (707.0x) of the pressure ulcer and the stage (707.2x). Both risk adjust but are bundled into each other (HCC 148).  If documentation indicates a “healed” ulcer, no code is assigned. A “healing” ulcer is coded to the correct category.  Non-pressure ulcers of the lower limb code to subclassification 707.1x.  If the ulcer is due to a causal condition such as diabetes or atherosclerosis, the causal condition is coded first.

Coding Ulcers: A Summary  Based on Causal Condition:  Arteriosclerosis of extremities with ulceration – –Use additional code for any associated ulceration ( – 707.9)  Diabetic ulcer – 250.8x, –Specify site and code specifically to site: 250.8x, ( – 707.9) –If provider documents diabetic ulcer as a neurologic manifestation or a peripheral circulatory manifestation, code to 250.6x or 250.7x respectively  Varicose ulcer (lower extremity, any part) – 454.0

For More Information…

Revised Future Documentation & Coding Topics  July – no meeting  August – Venous Thrombosis  September – Major Depression  October – Peripheral Artery Disease  November – Cirrhosis  December - COPD

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