Welcome to UASI’s Lunch and Learn: CDI Management Series ...

Welcome to UASI’s Lunch and Learn: CDI Management Series. We will begin shortly.

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UASI CDI/UR Service Line Stats

▪ 4 out of 5 UASI clients request ongoing or return services following an initial CDI engagement

• UASI works for top hospitals utilizing our experienced team of consultants to deliver value tailored to our client’s specific needs

• CONSULTANTS average 8 years in CDI and/or UR, and 22 years in clinical nursing

• MANAGERS average 11 years in CDI and/or UR and 24 years in clinical nursing

UASI CDI/UR Services

UASI Lunch and Learn: CDI Management Series

Outpatient CDI HCC Clinical ConceptsTara Bell, MSN, RN, CCDS, CCM

Senior Manager, UASI CDI/UR [email protected]

mailto:[email protected]

Desired Outcomes


At the end of this presentation, attendee will be able to:

• Understand the importance of provider documentation in the physician practice

• List key documentation concepts in the physician practice

• Recognize the common clinical components for each concept

Polling Question


How would you describe your organization’s current Outpatient CDI abilities?

1. We have a CDI program in all outpatient settings (ASCs, physician offices, etc.) that is tied to our inpatient CDI program

2.We have a CDI program in all outpatient settings (ASCs, physician offices, etc) that runs separately from our inpatient CDI program

3.We have a CDI program in some outpatient areas

4.We’ve evaluated an outpatient CDI program but fully steps to implemented at this time

Morbid ObesityHCC Category 22


Obesity-Definition


The Centers for Disease Control and Prevention defines a BMI of 30.0 or higher as obese

The National Institute of Health defines obesity as morbid if,

• The patient demonstrates a BMI over 40, OR

• The patient demonstrates a BMI of 35 or more and has at least two weight-related comorbid conditions.

A BMI can be taken from Nursing notes, Anesthesia notes, Progress notes, Nutrition notes, etc.

Obesity: Definition & Concepts


Obesity Related Comorbidities

Diabetes

Hypertension

Stroke

Heart DiseaseArthritis

Sleep Apnea

Gallbladder DiseaseTip: When querying for

Morbid Obesity with a BMI 35.0-39.9 make sure at

least two weight related comorbid conditions have a documented relationship to the Morbid Obesity. This

clinically validates the presence of Morbid

Obesity and offers stronger support for reporting.


Obesity & Provider Documentation

Providers may often hesitate to document terms such as overweight, obesity, or morbid obesity as patients are sensitive to these diagnoses and have greater access to their medical records via patient portals. The terms are characterized by some as ‘fat shaming’. Therefore, some providers will only include the BMI on the problem list.

However, this practice can lead to noncompliant reporting OR missed HCC capture as per ICD-10 Official Coding Guidelines: In order to capture the BMI code you MUST have an associated reportable diagnosis such as Obesity or Morbid Obesity.

When only the BMI z-code is documented query the physician for an associated reportable diagnosis such as Obesity or Morbid Obesity.

Obesity-Types and Codes

Code Description HCC

E66.01 Morbid (severe) obesity due to excess calories

Yes

E66.09 Other obesity due to excess calories No

E66.1 Drug-induced obesity No

E66.2 Morbid (severe) obesity with alveolar hypoventilation

Yes

E66.8 Other obesity No

E66.9 Obesity, unspecified No

Z68.4X BMI 40 & greater*MUST have an associated reportable diagnosis to report

Yes

Z68.3X BMI 30.0-39.9 No


BMI

• BMI 41

Reportable Diagnosis

• Morbid Obesity

Obesity: Type & Codes


HCC Category 22: Morbid

Obesity

No ‘drops’ associated

with HCC 22

Case Example

Yes: Query to link any associated obesity related comorbidities such as DM, HTN and HLP to obesity; along with documentation of Morbid Obesity.

Update to capture Morbid Obesity (E6601)

Query?

Office Note 1/25/20 BMI 36.95; Office Note 12/7/20 BMI 39.59 67 y/o female with DM , HTN and HLP


Case Example


Update to capture Morbid Obesity (E6601)

Yes: Query to link any associated obesity related comorbidities such as HTN and arthritis to obesity; along with documentation of Morbid Obesity

Query?

Office note 1/6/20: BMI 38.47; Office Note 9/20/20 BMI 37.53. Patient has comorbid conditions of HTN and arthritis

Query for Morbid Obesity (E6601)

Case Example


Office note 3/22/20 BMI 43.85, Per office note 7/15 BMI 43.9. Pt. is also known to have HLP and HTN

Office note 3/25/20 BMI is 44.26. Pt. noted to have OA and HTN

DepressionHCC Category 58


Major Depression Definition Concepts


• Full- No significant signs or symptoms for >2 months following an MDD episode

• Partial- Symptoms of the MDD episode persist but full criteria no longer met, or a period of <2 months without significant symptoms following an episode

Remission Status

• Single-First occurrence of an MDD episode followed by remission

• Recurrent-Any subsequent episode of MDDEpisode

• Mild-A few symptoms, intensity distressing but manageable, minor functional impairment

• Moderate-Symptoms intermediate between mild and severe

• Severe-Large number of symptoms, especially suicidal symptoms or deeply withdrawn, intense and unmanageable symptoms, marked functional impairment

• Psychotic Features-Delusions and/or hallucinations

Severity

Major Depression-Definition & Concepts

Depression


In ICD-10 ‘Depression’ falls into the Major Depressive Disorder (MDD) category.

Major Depressive Disorder encompasses a large number of diagnoses, each with associated codes.

As with any condition, it is crucial to asses for M.E.A.T criteria. Review for medication such as serotonin reuptake inhibitors (SSRI), serotonin and norepinephrine reuptake inhibitors (SNRI), tricyclic antidepressants (TAC), tetracyclic antidepressants, dopamine reuptake blockers, 5-HT1A receptor antagonists, 5-HT2 and 5-HT3 receptor antagonists, monoamine oxidase inhibitors (MAOI), and noradrenergic antagonists. Also look for any behavioral health care documentation and/or treatment.

Depression: Coding Concepts


Major Depression-Documentation to Consider

Diagnosis Total Score

Minimal depression 0-4

Mild depression 5-9

Moderate depression 10-14

Moderately severe depression 15-19

Severe depression 20-27

PHQ-Score Action

≤ 4 The patient may not need treatment for depression

5-14 Physician uses clinical judgement regarding treatment based on functional impairment and duration of symptoms

>14 Merits treatment using antidepressant, psychotherapy, or a combination of both

The Patient Health Questionnaire (PHQ-9)

Depression: Types and CodesCode Description HCC

F32.0 Major depressive disorder, mild, single episode

Yes

F32.1 Major depressive disorder, moderate, single episode

Yes

F32.2 Major depressive disorder, severe without psychosis, single episode

Yes

F32.3 Major depressive disorder, single episode, severe with psychotic features

Yes

F32.4 Major depressive disorder, partial remission, single episode

Yes

F32.5 Major depressive disorder, full remission, single episode

Yes

F33.0 Major depressive disorder, recurrent, mild Yes

F33.1 Major depressive disorder, recurrent, moderate

Yes



F33.2 Major depressive disorder, recurrent, severe without psychotic features

Yes

F33.3 Major depressive disorder, recurrent, severe with psychotic symptoms

Yes

F33.40 Major depressive disorder, recurrent, in remission, unspecified

Yes

F33.41 Major depressive disorder, recurrent, in partial remission Yes

F33.42 Major depressive disorder, recurrent, in full remission Yes

F33.8 Other recurrent depressive disorders Yes

F33.9 Major depressive disorder, recurrent, unspecified Yes

F32.9 Major depressive disorder, single episode, unspecified No

The documented diagnosis of “Depression” maps to F32.9 Major depressive disorder, single episode, unspecified

Depression: Types & Codes


HCC 57: Schizophrenia

HCC 58: Reactive and Unspecified

Psychosis

HCC 59: Major Depressive, Bipolar, and Paranoid

Disorders

HCC 60: Personality Disorders

Tip: If starting in a lower HCC category

look for clinical indicators to move up

the tier and subsequently ‘drop’ the lower weighted

HCC categories.

Query for episode and severity:

F320 Major Depressive Disorder, single episode, mild

or

F339 Major depressive disorder,

recurrent

Case Example


05/14/20 office visit: Positive for depressed mood. States she sees Psych but does not feel like her symptoms are controlled.

Treatment: Medications include Remeron and Cymbalta

Plan: Initiated Abilify

Case Example



F339 Major depressive

disorder, recurrent

Patient noted to have PMH of Recurrent major depressive disorder in 5/16/20 office note

11/18/20 office note: Depressed mood noted in exam. Patient given instructions to stay engaged in activities and with family.

Plan: Continue Wellbutrin

Office Visit 4/20/20: She feels hopeless. She is spending all of her time in bed.

Office Visit 6/1/20: Patient states her symptoms include being tearful, decreased energy, and feeling lack of interest in things

Plan: Medication changes to increase Cymbalta & discontinue Lexapro

Case Example



F320 Major Depressive Disorder, single episode, mild

or

F339 Major depressive disorder,

recurrent

DiabetesHCC Categories 17-19


Diabetes- Definition


Diabetes Mellitus-Definition

Diabetes Mellitus (DM) is often referred to as impaired insulin secretion and or variable degrees of peripheral insulin resistance, leading to hyperglycemia. The various types of DM not only have their own clinical definition but also have an associated ICD-10 Code. These include:

• Type 1 Diabetes (E10.9)

• Type 2 Diabetes (E11.9)

• Latent Autoimmune Diabetes in Adults (LADA or Type 1.5 diabetes) (E13.9)

• Secondary Diabetes (E08.9)

• Drug-induced Diabetes (E09.9)

• Gestational Diabetes (P700)

Generally combination codes will capture the type of diabetes and any associated complications

• If no type of diabetes is identified, the default is Type 2 Diabetes

• Query the provider if there is conflicting or ambiguous documentation


Diabetes Mellitus-Documentation Concepts

Review the documentation for any associated conditions or manifestations

The Official Guidelines for Coding and Reporting, Section I.A.15 states, “The classification presumes a causal relationship between the two conditions linked [the terms ‘with’ and ‘in’ in the Alphabetic Index or Tabular List. These conditions should be coded as related even in the absence of provider documentation explicitly linking them”

Review the Alphabetic Index and Tabular List closely for a complete list. ICD-10 assumes a relationship with the following common Diabetic complications

✓ Cataract✓ Charcot’s joint✓ Gangrene✓ Gastroparesis

✓ Neuropathy ✓ Osteomyelitis ✓ Peripheral Angiopathy✓ Retinopathy✓ Foot Ulcer

✓ Glaucoma✓ Nephropathy✓ Neuralgia✓ Skin Ulcer

When the above diagnoses are documented, AND M.E.A.T. criteria is present, query the provider to include the associated DiabeticComplication Combination code for added HCC capture


Diabetes Mellitus-Documentation Concepts

All diabetic complications listed in the ICD-10 Alphabetic Index and Tabular List as ‘not elsewhere classified’ (NEC) are not assumed relationships

These include: arthropathy NEC (E11.618), circulatory complication NEC (E11.59), kidney complication NEC (E11.29), and neurologic complication NEC (E11.49)

The ‘not elsewhere classified’ conditions would require a query to establish a cause and effect relationship between it and Diabetes if clinical indicators are present

Best practice is to teach or encourage providers to link any associated manifestation/complication to the diabetes

Review and document for long term insulin use


Diabetes Mellitus-Documentation Concepts (Cont.)

Control Status

Poorly Controlled, Inadequately Controlled,

or Out of Control Diabetes are reported as

Diabetes with Hyperglycemia (E1165)

ICD-10 has no default code for Uncontrolled

Diabetes and this documentation will need

queried as to whether the ‘uncontrolled’ is referring

to hyperglycemia or hypoglycemia.

Review fasting blood glucose & HbA1C

levels for hypo/hyperglycemia

and query when appropriate

Review for any potential

complications or manifestations

related to Diabetes and query when

appropriate

A higher Diabetes

HCC category

Diabetes: Types and CodesCode Description HCC

E119 Type 2 diabetes mellitus without complication Yes

E1122 Type 2 diabetes mellitus with diabetic chronic kidney disease

Yes*

E1136 Type 2 diabetes mellitus with diabetic cataract Yes*

E11649 Type 2 diabetes mellitus with hypoglycemia without coma

Yes*

E1139 Type 2 diabetes mellitus with other diabetic ophthalmic complication

Yes*

E1121 Type 2 diabetes mellitus with diabetic nephropathy

Yes*


Diabetes Mellitus Type 2 Codes


E11622 Type 2 diabetes mellitus with other skin ulcer Yes*

E1140 Type 2 diabetes mellitus with diabetic neuropathy Yes*

E1151 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene

Yes*

E11319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema

Yes*

E11621 Type 2 diabetes mellitus with foot ulcer Yes*

E1165 Type 2 diabetes mellitus with hyperglycemia Yes*

* Indicates a higher HCC category

Per office visit 8/14/20: "Peripheral Neuropathy-noted A1c to be 6.9 on last testing. Discussed neuropathy and treatment options "

Continue on current medications, check A1C at next follow up on 11/18

Update Type 2 diabetes mellitus without complications (E119)

TO

Type 2 diabetes mellitus with diabetic neuropathy (E1140)

Diabetes Examples


Case Example

Query for Diabetes Mellitus with hyperglycemia (E1165)

2/18/2020 A1c 9.4; 6/9/2020 A1c 8.5

Visit 09/17/20 : Documentation states a review of diabetic goals and maintaining HgbA1c below 8. Current HgbA1c is A1C: 10.1. Added additional medication to Metformin


HCC: 17

Diabetes

with

Acute Complication

HCC 18: Diabetes with Chronic Complication

HCC 19: Diabetes without Complication




the tier and subsequently ‘drop’ the lower weighted

HCC categories.

Chronic Kidney Disease (CKD)

HCC Categories 135-138


CKD- Definition


CKD-Definition & Documentation Concepts

2012 clinical practice guidelines for CKD

published by the National Kidney Foundation are the

only authoritative diagnostic standards for

CKD

“Abnormalities of kidney structure or function, present for >3 months, with implications for health.” Diagnostic criteria are either of the following present for > 3 months:

• Decreased GFR <60ml/min, or

• Markers of kidney damage

Consider a query for CKD when GFR is <60 for >3 months:

• CKD Stage 3 (GFR 30-59)

• CKD Stage 4 (GFR 12-29)

• CKD Stage 5 (GFR<15)

• ESRD (GFR <15 typically requiring chronic dialysis)

Chronic Kidney Disease has an assumed relationship with both Diabetes & Hypertension in ICD-10

• Query to also include the Diabetes/CKD combination code when appropriate.

• This allows capture of HCC category 138/137 (CKD) & HCC category 18 (Diabetes with Chronic Complications)

Review for Dialysis Status

CKD Example


Query to capture CKD stage 3 (N183)

6/16/20 eGFR 42; 12/15/20 eGFR 40

Per 12/15/20 visit: Noted CKD unspecified documented, as well as HTN

8/13/2020 eGFR 27

8/22/2020 Office Note pt. has essential HTN and DM 2

3/24/2020 eGFR 29; For last 9 months prior to March 2020 eGFR ranged from 28-31

Case Example


Query for Chronic Kidney Disease Stage

4 (N184)

Possible capture of DM 2 with Diabetic Chronic Kidney

Disease (E1122)

Query for Chronic Kidney

Disease

Stage 3 (N183)

Case Example


Office visit 10/14/20 CKD 2 was documented

Labs: 3/25/20 BUN 24, Creatinine 1.20, eGFR 46

Labs: 8/6/20 BUN 22, Creatinine 1.18, eGFR 43


N181 Chronic kidney disease, stage 1 No

N182 Chronic kidney disease, stage 2 (mild) No

N183 Chronic kidney disease, stage 3 (moderate) Yes

N184 Chronic kidney disease, stage 4 (severe) Yes*

N185 Chronic kidney disease, stage 5 Yes*

N186 End stage renal disease Yes*

Z99.2 Dependence on renal dialysis Yes*


CKD: Codes

* Indicates a higher HCC category


HCC 134:

Dialysis Status

HCC 135: Acute Renal Failure

HCC 136: Chronic Kidney Disease, Stage 5

HCC 137: Chronic Kidney Disease, Severe (Stage 4)

HCC 138: Chronic Kidney Disease, Moderate (Stage 3)



the tier and subsequently drop the

lower weighted HCC categories.

COPDHCC Categories 110-112


COPD: Definitions


Bronchitis: inflammation of the bronchial tubes leading to cough, often with mucus production

• Acute Bronchitis: commonly related to a viral infection and typically resolved in a few weeks

• Chronic Bronchitis: is a form of COPD

Emphysema: results from destruction of alveoli and bronchioles

• The larger spaces within the lungs lead to lung over-inflation. CO2 then becomes trapped, not allowing O2 to enter easily

• A component of chronic bronchitis if often seen. Radiology reports may describe the lung tissue as ‘hyperinflated’

COPD: umbrella term used to describe progressive lung disease

• Recognized as persistent respiratory symptoms and airflow obstruction due to airway and/or alveolar abnormality. This is usually caused by exposure to noxious particles or gases, most commonly tobacco smoke


COPD: Documentation Concepts

When obstruction is present air cannot pass out of the lungs which interferes with the process of gas exchange within the alveoli. As the disease progresses, the patient may start to demonstrate hypoxemia and hypercapnia.

Review for Home Oxygen use and query for Chronic Respiratory Failure as appropriate.

Common comorbidities related to advanced COPD include respiratory neoplasm, malnutrition, depression, and nicotine dependence. Review documentation carefully for clinical indicators and query appropriately for added HCC capture.

Although rare in the outpatient setting, when patients present with acute changes, encourage providers to describe the presentation as compared to baseline function.

• This clinically validates the presence of an acute exacerbation and offers stronger support for reporting in the outpatient setting.


J20.9 Acute bronchitis, unspecified No

J41.0 Simple chronic bronchitis ( Smokers Cough) Yes

J42 Unspecified chronic bronchitis Yes

J43.9 Emphysema, unspecified Yes

J44.9 Chronic obstructive pulmonary disease, unspecified Yes

J96.10 Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia

Yes*

J96.11 Chronic respiratory failure with hypoxia Yes*

J96.12 Chronic respiratory failure with hypercapnia Yes*


COPD: Documentation Concepts

* Indicates an additional HCC

category to capture

HCC 110:

Cystic Fibrosis

HCC 111: Chronic Obstructive

Pulmonary Disease

HCC 112: Fibrosis of Lung and Other Chronic Lung

Disorders




the tier and subsequently drop the

lower weighted HCC categories.

Case Example

Query for COPD (J449)

Medication list verified patient on Albuterol Sulfate as needed

Per 8/22/20 Office Note pt. is noted to have mild wheezing present…hx of tobacco abuse…hx of COPD-on prn albuterol


Case Examples


Pt #1: Office visit 09/25/20- Pt. with history of COPD. Current medications include Duo Nebs and Singulair

Pt #2: Office Visit 10/15/20-Pt. is noted to have a medical history of COPD and smoking. Medications include albuterol HFA inhaler

Query to determine if COPD is still active

TOADAlways query scenarios



Always Conditions: TOAD

•TransplantsT

•OstomiesO

•Amputations & AIDS/HIVA

•Dialysis statusD

Join us for the next UASI CDI Management Series Lunch and Learn Topic:Strategies for Effective Management of Remote Staff

April 28, 2021

email: [email protected] for invite


Download the FREE UASI Passport to HCC’s: https://uasisolutions.com/

mailto:[email protected]


Tara BellMSN, RN, CCDS,CCM

Senior Manager, CDI/UR Services, [email protected]

Questions ?

UASI CDI/UR Services


UASI CDI/UR Services Stats

▪ 4 out of 5 UASI clients request ongoing or return services following an initial CDI engagement

• UASI works for top hospitals utilizing our experienced team of consultants to deliver value tailored to our client’s specific needs

• CONSULTANTS average 8 years in CDI and/or UR and 22 years in clinical nursing

• MANAGERS average 11 years in CDI and/or UR and 24 years in clinical nursing

UASI at a Glance


Headquarters:

Founded:

Clients:

Team:

Charts handled annually:

Solutions:

Experience

• Management: 22 years of HIM experience;

11 in CDI

• Coding staff: 8+ years

Quality

• 97% accuracy in coding

• 100% target for accuracy, certification and

meeting industry standards

Reliability

• 35+ years in business

• 40 clients in US News & World Report best

regional and honor roll hospitals

Culture

• People-centric, team-driven culture

• High employee satisfaction

• 20% new hires referred from current employee

• Industry-leading average employee tenure

Cincinnati, Ohio

1984

200+ hospitals/health systems nationwide

450+ employees, including AHIMA/AAPC-certified

coders, HIM and clinical documentation specialists

3.75 million coded; 200,000 audited

Coding Services, Coding Reviews, Clinical

Documentation Improvement, Revenue Integrity,

HIM Solutions, Strategic Consulting

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Welcome to UASI’s Lunch and Learn: CDI Management Series ...

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