Originally published on kevinmd.com Betsy Nicoletti, M.S., CPC When I talk to medical practices about Hierarchical Condition Category (HCCs) and risk-adjusted diagnosis coding, I receive a lot of questions that point to the existence of persistent urban legends! Let’s separate fact from fiction. Don't miss our Billing Guide on Risk-adjusted Diagnosis Coding for an in-depth look at this topic. Urban legend #1: CPT fee-for-service … [Read more...]
Diagnosis coding for screening colonoscopy
Some of you have read my blog post on coding for screening colonscopy. The questions I get about that article are all related to diagnosis coding. The CPT/HCPCS coding and the modifiers don’t raise any questions (or eyebrows) but coders and patients ask about correct diagnosis coding and sequencing of those codes. I recently posed these questions to a friend and colleague, Margaret Skurka, MS, RHIA, CCS, FAHIMA who is an expert on ICD-10 … [Read more...]
HCC’s in brief | The difference between CMS-HCC and HHS-HCC
Demographics and diagnoses Risk adjusted diagnosis coding is a model used to predict future health care costs based on demographics and diagnoses. The model takes into account the age and gender of the population, whether they’re living at home or in an institution, if they are dualy eligible for Medicare and Medicaid, and if they are being treated for end stage renal disease. The disease burden of the population of patients being served … [Read more...]
Changes in HCC diagnosis coding from V22 to V23: what you need to know
CMS pays Medicare Advantage plans differentially based on Hierarchical Condition Category (HCCs). This coding model uses demographics and diagnoses to predict future health care costs for Medicare beneficiaries enrolled in a Medicare Advantage plan. Each year, Medicare announces what the rates will be and indicates any coding changes in the HCC model. Between 2017 in 2018, there were no coding changes to the HCC model. However, changes … [Read more...]
How to improve the accuracy of your diagnosis risk scores | Dr. Edwin Knights
This reference is the companion resource for the webinar I presented in June with Edwin Knights, M.D., Improving the accuracy of your diagnosis risk scores. Members login to watch the webinar on-demand. Not a member? Learn how you can access the webinar. The handout includes: A quick comparison of fee-for-service vs. risk-adjusted diagnosis coding Explanation of risk adjustment (common models and how patients' risk scores are … [Read more...]
Diagnosis Coding | Not just for claims anymore
Physician claims paid based on CPT, are often denied based on diagnosis codes Physicians use CPT or HCPCS codes to tell the payer WHAT was done (colonoscopy, office visit) and modifiers to describe special circumstances (assistant at surgery, bilateral procedure.) We use diagnosis codes to tell the payer: The reason the service was performed. The medical necessity of the service. Additional resources The CodingIntel Guide to … [Read more...]
ICD-10 coding for suspected cancer
Diagnosis coding for possible malignance How would you feel if your primary care physician and your general surgeon told you—and your insurance company—that you had breast cancer when you didn’t have breast cancer? You actually had atypical ductal hyperplasia, not breast cancer. Not only have they told you, the claim has gone to your insurance company and the insurance company thinks you have breast cancer. And, it is listed in your … [Read more...]
Improving the accuracy of your diagnosis risk scores | Webinar
Recorded June 6, 2018 Presented by Betsy Nicoletti with guest speaker Edwin Knights, MD Edwin Knights, M.D. was the physician leader in his practice in implementing risk diagnosis coding and brings experience and strategic knowledge to this important topic. Overview: Many practices have a basic understanding of HCC risk adjusted diagnosis coding, but still struggle with improving the accuracy of the diagnosis codes submitted on claim … [Read more...]
Diabetes coding in Hierarchical Condition Coding (HCC)
Introduction | Diabetes coding in HCC In fee-for-service medicine: Diagnosis coding establishes medical necessity, and may be the reason for a denial, particularly for diagnostic tests or procedures. Services with national or local coverage policies often have specific diagnosis codes that are required for payment. In risk based contracts or Accountable Care Organizations (ACOs): Payers assess the acuity of a panel of patients, and use … [Read more...]
Depression coding in Hierarchical Condition Coding (HCC)
Introduction | Depression coding in HCC In fee-for-service medicine: Diagnosis coding establishes medical necessity, and may be the reason for a denial, particularly for diagnostic tests or procedures. Services with national or local coverage policies often have specific diagnosis codes that are required for payment. In risk based contracts or Accountable Care Organizations (ACOs): Payers assess the acuity of a panel of patients, and … [Read more...]
Dear Resident, Do you Understand Relative Value Units (RVUs)?
Measuring physician productivity with work RVUs: News flash! Physicians are more interested in medicine than coding. No doctor undertook the rigors of medical school in order to be an expert coder. But, when residency ends, some physicians will find themselves looking at employment contracts in which their compensation will be determined in part by productivity. Often, the first two years will be strictly salary-based but will transition in … [Read more...]
Can you screen for an existing condition? | Diagnosis Coding for Lab Services
Can you screen for an existing condition, “In the absence of any signs, symptoms or associated diagnosis” Sometimes, the hardest thing about coding for preventive services isn’t the visit at all. It’s the labs. Patients come in for an annual physical and many times they believe that all of the lab work done that day or in preparation for that day will be covered as part of their preventive service. And we know what that means to patients. … [Read more...]
Compliance issues in ICD-10 coding for risk based contracts and HCCs
Everyone loves to read the general guidelines at the front of the ICD-10 book, right? No? Well, here’s an excerpt. “Code all documented conditions, which coexist at the time of the visit that require or affect patient care or treatment. (Do not code conditions, which no longer exist).” Most of the articles I’ve written have focused on the first sentence in this guideline. This article will focus on the second. “Do not code conditions which no … [Read more...]
HCC diagnosis coding: what medical practices need to know about risk adjusted diagnosis coding
Webinar - Recorded December 14, 2017 Risk coding is all the rage! Are you up-to-date? In fee-for-service medicine, physician services are paid based on the fee associated with that CPT code, HCPCS code and modifiers. The diagnosis coding establishes the medical necessity for this service. With new payment models, diagnosis coding for physician services takes on added importance and affects future payments. In this presentation from … [Read more...]
HCC diagnosis coding: Can you add a code from the past medical history?
Recently a fellow coder wrote to me about risk adjusted diagnosis coding. She was responding to an article that I wrote in which I stated the conditions listed in the past medical history should not be included on the claim form by the coder. I stated that in order to include the condition on the claim form, there should be documentation in the history of the present illness or the assessment and the plan that the condition was addressed at the … [Read more...]
ICD-10-CM Coding Changes for October, 2017
This post has been removed because the content was out-of-date. Additional Resources Diagnosis Coding: It's not just for claims anymore Examination Codes in ICD-10 Diagnosis coding for screening colonoscopy ICD-10 coding for suspected cancer More … [Read more...]
What’s the difference between B20 and Z21? Which is right for positive HIV status?
ICD-10-CM diagnosis coding for positive HIV status Question: For an HIV positive patient without symptoms, is the correct diagnosis code Z21 or B20? What difference does it make to reimbursement? Answer: … [Read more...]
Overview of HCCs | Risk-adjusted diagnosis coding
Lunch and Learn - July 2017 How do we get paid for physician services in medical practices? Watch this 10 minute video and download the handouts below for an overview of HCC diagnosis coding. Also see the billing guide and other diagnosis coding resources here. In the past, payment has been based on what we do, the CPT code, or HCPCS code billed on the claim form. In a fee-for-service world, payors use diagnosis codes to establish the … [Read more...]
Screening pelvic/breast exam and pap smear denials | G0101 and Q0091
Lunch and Learn - June 2017 Updated for 2018 We received this question from one of our members: "We have a medicare patient for whom we provided a pelvic and a breast exam and a pap smear. We submitted it to Medicare and it got denied. Can you tell me why?" Medicare doesn't pay for "routine services", but they do pay for certain screening test. This short video reviews the Medicare requirements and coding for screening pelvic and breast … [Read more...]
Diagnosis Coding for Tick Bites
Question: Why is it so hard to code for a tick bite? And, how is it coded? Answer: The provider searches for the word “tick” and in many systems, up pops W57.xxxA. Someone helpful has changed the ICD-10 definition to include the word tick, although the ICD-10 definition is “Bitten or stung by nonvenomous insect and other nonvenomous arthropods, initial encounter.” A tick is an arthropod. But, the problem with that is, W57.xxxA is an … [Read more...]