October 12, 2010 Approval Code: IN1070 Ingenix InSite 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 – 10:05 AMWelcome  10:05 AM – 10:10 AMInSite Operations Announcements  10:10 AM – 10:20 AM Report Selection Tool  10:20 AM – 10:30 AMChanges to the CMS-HCC Payment Model and Impact on RAF  10:30 AM – 10:45 AM Focus on: Peripheral Vascular (Arterial) Disease  10:45 AM – 11:00 AMQ & A

InSite Operations Announcements Presented By Susan Rick InSite Business Operations Manager

© Ingenix, Inc. 5 InSite Operations Announcements  Data Refresh Update –InSite Mid-month data refreshed September 20th Data refresh may not impact all InSite users Mid-month data refresh will not replace the normal monthly data refresh –Next monthly data refresh is targeted for October 18th  October 8 th, 2010 – InSite Updates –October Ingenix Insider –Report Selection Tool

InSite Report Selection Tool Presented By Francesca Siciliano InSite Business Analyst

© Ingenix, Inc. 7 InSite Report Selection Tool  Report Selection Tool

Changes to CMS-HCC Payment Model for 2011 and Impact on RAF Presented By Loren Maddy Director, Analytics

© Ingenix, Inc. 9 Overview  Medicare Advantage Reimbursement is a Function of Bid (Ratebook) and RAF –Estimated 2011 Net Impact: -1.6% Ratebook: –No Ratebook changes for 2011 RAF: –Impact of CMS Changes on Otherwise Equal RAF is -1.6% »FFS Normalization: -1.6% »No other CMS changes for 2011 Pmt Yr

© Ingenix, Inc Estimated CMS RAF Change

© Ingenix, Inc. 11 Impact of CMS Changes on RAF: FFS Normalization & MA Coding Pattern Differences

New ICD-9 Codes added to CMS-HCC Payment Model Presented By Pam Holt Manager, SoCal Market Consultation

© Ingenix, Inc. 13 CMS Announces New Codes for Model  On October 1 st each year, new ICD-9 codes are effective  CMS evaluates which codes will be included in the CMS-HCC and Rx Models  CMS posted a new crosswalk including new codes effective Oct 1 st  8 codes were added to the CMS-HCC model  Risk_adjustment.asp Risk_adjustment.asp –Zip File Name: “2011 Model Diagnoses” –File Name: “Risk Model Diagnoses for 2011.xls”

Mary Jo Groome, CCS-P, CPC-H Sr. Provider Training & Development Consultant Peripheral Vascular (Arterial) Disease

© Ingenix, Inc. 15 What is Peripheral Artery Disease (P.A.D.)?  P.A.D. occurs when plaque builds up in the arteries that carry blood to your head, organs, and limbs. Plaque is made up of a fat, cholesterol, calcium, fibrous tissue and other substances in the blood.  When plaque builds up in the arteries, the condition is called atherosclerosis. Over time, plaque can harden and narrow the arteries. This limits the flow of oxygen-rich blood to the organs and other parts of the body.  P.A.D. usually affects the legs, but also can affect the arteries that carry blood from the heart to the head, arms, kidneys and stomach.  Today’s comments will focus on P.A.D. that affects blood flow to the legs.

© Ingenix, Inc. 16 Peripheral Arterial Disease (PAD) Clinical description of PAD  Present in approximately 8 to 12 million individuals in the U.S.  Estimated to be present in 29% of those –Age 70 or over; or –Age 50 to 69 with a history of smoking 10 pack years or those with diabetes. 1  History and physical examination may not be reliable for the detection of lower extremity PAD 8 –Presents with classic claudication 10% to 35% of cases –Many individuals have no symptoms or non-classic symptoms –Poor recognition (under-diagnosis) results in under- treatment (estimated only 25% of those with PAD are treated) 2

© Ingenix, Inc. 17 Peripheral Arterial Disease (PAD) Clinical description of PAD  Often caused by atherosclerosis  Identifies risk for myocardial infarction (also referred to as a heart attack) and stroke 3  Causes poor blood supply to extremities  Symptoms worsen when demand increases (exercise)  As disease progresses, less exercise causes symptoms; if severe – symptoms at rest (with no movement)  May result in pain (disability), skin and tissue damage (ulcers) and infection (gangrene)  Can worsen diabetic complications such as slow healing foot ulcers

© Ingenix, Inc. 18 Peripheral Vascular (Arterial) Disease PAD Facts:  Most major cardiovascular events occur in those without a prior diagnosis of vascular disease.  Over 50% with PAD will not have previous vascular symptoms; 40% have atypical symptoms.  It is estimated that only 25% of afflicted individuals receive care

© Ingenix, Inc. 19  There are two types of PAD –Arteriosclerotic: Involves medium to large vessels and is amenable to bypass. –Diabetic: Involves medium to small vessels and is not typically helped by bypass.  Workup can be done by Ankle Brachial Index (ABI) –Can be used to diagnose PAD and can be performed in any doctor’s office –Reveals a comparison of the systolic blood pressure between the lower and upper extremities and is measured using a Doppler. –An ABI of less than or equal to 0.90 is abnormal and is considered evidence of lower extremity PAD. Prompt investigation and risk-reducing treatments are then warranted Peripheral Vascular (Arterial) Disease

© Ingenix, Inc. 20  Peripheral arterial disease, peripheral vascular disease, and claudication are coded to –It is important to note that this code excludes atherosclerosis of the arteries of the extremities.  Atherosclerosis of native arteries of the extremities, Category 440, is further classified as such: –With intermittent claudication –With rest pain –With ulceration (see ulcer coding rules) –With gangrene (see ulcer coding rules) –Unspecified Documentation & Coding PAD / PVD

© Ingenix, Inc. 21  Diagnostic statements that do not impact severity adjustment as they are coded to: 440.9: Generalized and unspecified atherosclerosis –Arteriosclerotic (vascular) disease –Generalized arteriosclerosis –Arteriosclerotic endarteritis –Arteriosclerosis obliterans –Arteriosclerosis with calcification PAD Documentation & Coding

© Ingenix, Inc. 22 Vascular diseases often occur as a manifestation of diabetes:  Diabetic Peripheral Circulatory Disorders –If the PVD is due to diabetes mellitus, codes 250.7x and would be assigned. –The specificity of the PVD changes to , Peripheral Angiopathy in diabetes mellitus. –Code provides a more comprehensive picture of the patient’s PAD/PVD condition in regard to DM as an underlying cause. –Provide the appropriate linkage for the diabetes with Peripheral Circulatory Manifestations (250.7x) American Hospital Association, AHA Coding Clinic for ICD-9-CM. 3rd Qtr p. 10 World Health Organization, 2009 Ingenix ICD-9-CM Professional for Physicians, Volumes 1&2. 6th ed pp. 8&27 Documentation & Coding PAD / PVD

© Ingenix, Inc. 23 Underlying Disease – Diabetes Mellitus  A patient with Type II controlled Diabetes that has treatment for a manifestation of the disease should have both conditions coded: –PVD due to Diabetes Mellitus Diabetes with peripheral circulatory disorder Peripheral angiopathy in disease classified elsewhere  The underlying disease is coded first, followed by the manifestation code.  The linkage has been documented with “due to” and the 4 th digit is properly assigned on the 250.

© Ingenix, Inc. 24 Peripheral Vascular diseases as a result of atherosclerosis of extremities:  Atherosclerosis of Native arteries of the Extremities (440.2 subcategory). –For coding purposes, the physician must document that the PVD is due to atherosclerosis (ASPVD) before a code from may be assigned. –In fact, Coding Clinic advises to query the physician for further specification if the physician documents vague diagnoses as peripheral vascular disease or intermittent claudication. American Hospital Association, AHA Coding Clinic for ICD-9-CM. 4th Qtr p. 25 3M Health Information Systems (2008, April). Coding for peripheral vascular disease. In, For The Record, Vol. 20 No.8 P. 28. Retrieved March 10, 2009 from: PAD Diagnosis Coding

© Ingenix, Inc. 25 Peripheral Vascular diseases as a result of atherosclerosis of extremities ICD-9-CM Coding:  (Atherosclerosis of Native Arteries of the Extremities) – Atherosclerosis of extremities, unspecified – Atherosclerosis of extremities w/ intermittent claudication – Atherosclerosis of extremities w/ rest pain – Atherosclerosis of extremities w/ gangrene – Atherosclerosis of extremities w/ ulceration  443 category (Other Peripheral Vascular Disease) - Without additional documentation regarding the type or manifestation of PVD/PAD, code would be assigned. –443.9 Peripheral Vascular Disease, unspecified PAD Diagnosis Coding

© Ingenix, Inc. 26 When Assigning Atherosclerosis of Arteries of the Extremities (440 Category)  All patients documented as atherosclerosis with gangrene are coded to –If gangrene is documented without mention of atherosclerosis, only code  All patients documented as atherosclerosis without gangrene, but with ulceration are coded to * –If ulceration is documented without mention of atherosclerosis, only code  Patients documented as atherosclerosis with neither gangrene nor ulceration, but with rest pain are coded to –If rest pain is documented without mention of atherosclerosis, only code  Patients documented as atherosclerosis with intermittent claudication due to atherosclerosis are coded to –If claudication is documented without mention of atherosclerosis, only code Rules of Coding PAD / PVD * Ulcers: Codes from subcategory 707.1x (Ulcer of lower limb) should be assigned in addition to

© Ingenix, Inc. 27 Rules of Coding PAD / PVD: Ischemic Ulcers  Subcategory 707.1x Ulcer of lower limbs, except pressure ulcer ▪ First: Code any underlying or causal condition Example: – Atherosclerosis of Extremities w/ Ulceration x – DM 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

© Ingenix, Inc. 28  Exam: S1S2 no murmur or gallop with regular rhythm. Radial pulses 2+. Feet cool with left pedal faint and absent rt pedal pulse. No edema. Hemosiderin stain of both anterior LE.  Dx:  A/P Stable PVD.  Comments: “Stable PVD.” represents a definitive diagnosis. This is correct coding. Clinical Example

© Ingenix, Inc. 29  HISTORY OF PRESENT ILLNESS: L ankle wound: Had ankle fx 12/07, with small open area on medial aspect of her ankle that heals over and then reopens.  REVIEW OF SYSTEMS VASCULAR: ULCER: Inner left malleolus has non-healing wound. POSITIVE FOR: Ulcer  PHYSICAL EXAM VASCULAR: 1+ pedal pulse on R. Foot warm w/sensation. No reddened or open areas. Clinical Example

© Ingenix, Inc. 30  ASSESSMENT AND PLAN  Diagnosis : Atherosclerosis of native arteries of the extremities with ulceration –Treatment Plan : STATUS: Has open area on inner aspect of left malleolus. very difficult to heal with probable osteomyelitis. Will continue wound healing measures and conservative interventions if wound worsens.  Diagnosis : Ulcer of ankle –Treatment Plan : STATUS: Chronic, PLAN: Had ankle fracture 12'07. has had an open area on the medial aspect of her left ankle that heals over, opens up, heals over, etc. 6'08 has open area 1 cm that has a pinpoint hole in the center. a shiny metal piece is visible which is probably a plate or screw that was used to fix the ankle fracture. xray ordered to r/o osteo. Clinical Example

© Ingenix, Inc. 31  Comments:  ROS documentation states: VASCULAR: ULCER: Inner left malleolus has non- healing wound. POSITIVE FOR: Ulcer  Is this an ulcer or a non-healing surgical wound? –The code for ulcer of the ankle is It maps to HCC 149 with a RAF of –The code for non-healing surgical wound is It does not risk adjust. Clinical Example

© Ingenix, Inc. 32  Atherosclerosis is never mentioned in the documentation. In order to code Atherosclerosis of native arteries of the extremities with ulceration, the documentation must state atherosclerosis, ASPVD or atherosclerotic PVD, etc. – maps to HCC 104 with a RAF of  An argument could be made that the documentation does not support the codes reported.  According to the documentation, the correct codes for this scenario would be , and – does not risk adjust. –443.9 maps to HCC 105 with a RAF of  Specific documentation can make a big difference! Clinical Example

© Ingenix, Inc. 33 References 1 Hirsch, A.T., et al. Peripheral Artery Disease Detection, Awareness, and Treatment in Primary Care. JAMA; Sept ; 286(11): Bhatt DL, Steg PG, Ohman EM, Hirsch AT, Ikeda Y, Mas JL, Goto S, Liau CS, Richard AJ, Rother J, Wilson PW; REACH Registry Investigators. International prevalence, recognition, and treatment of cardiovascular risk factors in outpatients with atherothrombosis. JAMA. 2006;295:180–189 3 Hirsch, A.T., et al. (October 2005). ACC/AHA Practice Guidelines. Journal of the American College of Cardiology, 2006; 47; e1-e192, Retrieved February 12, 2009, from 4 Hiatt, WR. Medical Treatment of Peripheral Arterial Disease and Claudication. N Engl J Med 2001; 344: McDermott, MM, Kerwin, DR, Liu, K, et al. Prevalence and significance of unrecognized lower extremity peripheral arterial disease in general medical practice. J Gen Intern Med 2001; 16:384 6 Norgren, L, Hiatt, WR, Dormandy, JA, et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASCII). J Vasc Surgery 2007; 45: Suppl S:S5 7 "Executive Summary: Standards of medical care in diabetes—2009". Diabetes Care 32: S6– S PAD Peripheral Arterial Disease. March 22,

© Ingenix, Inc. 34 Future InSite Coding Topics: ◘ November -Diabetes, Linda Farrington, CPC, CPC-I ◘ December- Ulcers, Mary Jo Groome, CCS-P, CPC-H

© Ingenix, Inc. 35 User Group Feedback Survey  We want your feedback!  Survey is to be sent immediately after this call

© Ingenix, Inc. 36 Question and Answer