1 / 28

Diabetes Coding and Documentation

Diabetes Coding and Documentation. Provider Education. Overview. Diabetes is a chronic illness that requires continuing medical care and ongoing patient self management education and support to prevent acute complications and to reduce the risk of long-term complications.

karsen
Télécharger la présentation

Diabetes Coding and Documentation

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Diabetes Coding and Documentation Provider Education

  2. Overview • Diabetes is a chronic illness that requires continuing medical care and ongoing patient self management education and support to prevent acute complications and to reduce the risk of long-term complications. • A thorough understanding of proper/specific documentation leads to more competitive benefits to attract members into a Medicare Advantage (MA) plan • Coding to the highest specificity in one plan leads to a more accurate representation of acuity in a market, resulting in appropriate funding to care for the members

  3. Projected Real Growth – Medicare Direct Spending on Diabetes and it’s Complications, Medicare Overall and GDP, 2009-2034

  4. Diabetes Status in Texas, 2012 Prevalence of Diabetes among Adults in Texas by Age Group *Texas behavioral Risk Factor Surveillance System, DSHS

  5. Diabetes Statistics • Medicare Population2009 – 23.7 million people with diabetes 2034 – 44.1 million people with diabetes • Direct Medical Cost of Medicare Population 2009 – 113 billion dollars (2007 US) 2034 – 336 billion dollars * Health Affairs, Milwood 2009

  6. Diabetes is the 6th leading cause of death in Texas and it is the 4th leading cause of death in Bexar County • 1.7 Million Texans Diagnosed (9.3% of the Total Population) • 440,468 Texans Undiagnosed • 137,009 People Diagnosed in Bexar County (11.8% of the Total Population)

  7. In San Antonio… • Among Hispanics age 65 and over, 39,926 have diabetes and another 50,407 are undiagnosed. • The rate of diabetes in Hispanics age 65 and over is 34.8% • The incidence of diabetes among older Hispanics in target areas may be as high as 59%.

  8. MCCI Member Summary Average Membership (since 1/1/2011) 20,829 Total Diabetic Conditions 5,988 Total Diabetic Members 4,661 Avg. DM diagnosis per member 1.28

  9. MCCI Member Summary Average Membership (since 1/1/2012) 13,622 Total Diabetic Conditions 9,668 Total Diabetic Members 3,065 Average DM diagnoses per Member 3.15

  10. Diabetes… An Epidemic in South Texas • In October 2007, the National Association of County & City Health Officials (NACCHO) reported San Antonio having the 2nd highest death rate from diabetes after New Orleans. • In Bexar County, 14 %(202,250) of the 1.5 million individuals are living with diabetes, with an additional 67,416 individuals undiagnosed. • The cost of diabetes in Bexar County alone is $481 million/year or $348 per resident per year.

  11. MCCI Resolution • Identify and Diagnose Earlier • Secondary prevention to delay or prevent complications from diabetes. • Focus on improving physician adherence to diabetes standards of care and patient adherence through disease self-management. • Community Interventions and Education: • Chronic Disease Self-Management Program • Insulin Teaching and Training • Improvements come from a prepared, proactive practice team AND an informed, activated patient – It takes BOTH

  12. Modifiable Health Risk Behaviors • Lack of physical activity • Poor Nutrition • Tobacco Use • Excessive Alcohol Consumption • The World Health Organization has estimated that if the major risk factors for chronic disease were eliminated, at least 80% of all Heart Disease, Stroke and Type 2 Diabetes would be prevented, and morethan 40% of cancer would be prevented.

  13. Risk Adjusted Payments • Funding is based upon acuity of diagnosis • Accurately documented medical records ensure that CMS pays the correct amount, not too much, not too little, and ensure that the programs pay the right people. • With accurate documentation, patients receive the highest quality of care, which promotes patient safety. • Accurate documentation helps healthcare providers avoid liability and stay out of fraud/abuse trouble. • Accurate medical records prevents patients from unnecessary medical services and avoids harm, such as giving a patient incorrect medication.

  14. Diabetes Coding • Documentation of complications or manifestation must be stated (due to or secondary to) or implied (Diabetic) • If the patient uses insulin routinely, append V58.67 • Sequence the 250 codes before the codes for the associated conditions *Always code etiology first and then manifestation

  15. Linking Words • Linking words create a relationship between diseases and manifestations • Assures coders of a cause and effect between disease and manifestation, as we cannot assume (except in hypertensive renal disease) • Appropriate terms: • Due to • Secondary to • Use of associative suffix ‘ic’ or ‘ive’ (diabetic ulcer or hypertensive heart disease) • The terms “probable” and “more than likely” do not provide linkage

  16. 4th Digit in Diabetes Coding

  17. Buddy Codes in Diabetes • Required when 4th digit is 1-8 • Peripheral Neuropathy due to Diabetes • 250.60 Diabetes with neurological manifestations • 357.2 Polyneuropathy in Diabetes • Diabetic Peripheral Vascular Disease • 250.70 Diabetes with peripheral circulatory disorders • 443.81 PVD in Diabetes • Diabetic Calf Ulcer • 250.80 Diabetes with other specified complications • 707.12 Ulcer

  18. Diabetes Categories w/ RAF • 15 – Diabetes with renal or peripheral circulatory manifestations 0.464 • 16 – Diabetes with neurological or other specified manifestations 0.372 • 17 – Diabetes with acute complications 0.309 • 18 – Diabetes with ophthalmic or unspecified manifestations 0.236 • 19 – Diabetes without complication 0.148

  19. Why Documentation Matters • “Pt. complains of visual disturbance. PMH positive for Retinopathy and DM2” • 250.00 and 362.10 (Diabetes, Retinopathy w/o mention of diabetes • Risk Score: .162 (.162 + 0) • “Proliferated retinopathy due to Diabetes” • 250.50 and 362.02 • Risk Score: .511 (.259 + .252)

  20. When Documenting, Think MEAT • You must follow the rules of ICD-9 coding when coding chronic conditions. You must also have "MEAT" to code these chronic conditions... • M=Monitor, E=Evaluated, A=Addressed/Assess, T=Treated • If no "MEAT" is found for conditions stated, you cannot code. • Providers must also follow CMS signature guidelines. • REMEMBER: If it is not documented, it didn’t happen!!!

  21. Disease Interactions * RF / CHF / DM is hierarchical to RF / CHF and DM / CHF

  22. Coding Corner • 51 year old man with type II DM, well controlled on januvia with elevated urine microalbumin/creatinine 3 months apart CrCL of 65 cc/min *** Only the highest diabetes HCC weight will count, but the associated manifestations are additive

  23. Case #1 • Dr. P: Mrs. Jones, you’re here for a follow up on your diabetes? How are you doing? Are you taking your meds? • Mrs. Jones: I’m doing OK. I got a lot of chocolate for Valentine’s Day. • Dr. P: How are your feet doing? Are those sores healing? How is your angina? • Mrs. Jones: I don’t have much feeling left down past my ankles, so my feet don’t really hurt. But, the odor is terrible and the bandages stay wet all the time – it’s a real mess! • Dr. P: Your ulcers are a complication of your uncontrolled diabetes, and the culture showed an infection. It has reduced your circulation, so you don’t heal like you should. Your angina is okay for now….. I see we’ve rec’d a consult note from Dr. Vaicys, and he says you have aortic stenosis – we’ll have to watch that, it could be a problem once you get up and around more.

  24. Case #1 Cont. • Dx. and Plan: • Diabetes, Type II, not responding to treatment, worsening, will consult home health to adjust medications • Foot Ulcers due to Peripheral Vascular Disease, will refer to wound care for ulcers • Neuropathy in Diabetes, stable, will continue Lyrica • Skin infection, Anaerobic, not responding to treatment, will refer to surgeon for debridement • Angina, stable, continue medications • Aortic Stenosis, (consult Dr. Vaicys 1/2012) stable, followed by cardiologist

  25. Coding Case #1 Low Specificity High Specificity 250.02 - AODM, Type II, Uncontrolled 0.162 356.9 Neuropathy, NOS 707.15 Foot Ulcers, NOS 0.449 443.9 Peripheral Vascular Disease 0.316 424.1 Aortic Stenosis 413.9 Angina, NOS 0.244 Demographic Factor: 80 yrs old Female/Aged in: 0.544 TOTAL RISK SCORE= 1.715 250.72 AODM, Type II, w/ Peri Circ, Uncontrolled 0.508 443.9 Peripheral Vascular Disease 0.316 337.1 Peripheral Neuropathy in Diabetes 0.327 707.15 Diabetic Foot Ulcers 0.449 041.84 Anaerobic infection 424.1 Aortic Stenosis 413.9 Angina, NOS 0.244 Demographic Factor: 80 yrs old Female / Aged in: 0.544 TOTAL RISK SCORE= 2.391

  26. Case # 2 • Dr. P: Hello, what brings you into the office today? • Mr. Diaz: I’m not doing very well. I only feel like eating mashed potatoes and ice cream, probably because I am so tired all the time. My feet hurt all the time and I don’t get much exercise. You told me to come back after I’ve been on the iron pills for month, but they make me nauseous. • Dr. P: Your diabetes is probably out of control with a diet like that, and it only makes your neuropathy worse? Dr. Wright’s notes say that the cancer has to your liver, which also affects your appetite and your energy level. We gave you the iron pills to help with anemia that is caused by your colon cancer. We need to try something else if you’re not able to tolerate them. • Mr. Diaz: I’m having a hard time breathing sometimes too. I can’t even walk to the mailbox without taking a puff on my inhaler, and that doesn’t even help much. • Dr. P: Your last chest x-ray showed your COPD, but otherwise nothing new. This is probably a spell of asthma that’s aggravating you lung disease. Your diabetic neuropathy may keep you from being active, in addition to everything else.

  27. Case # 2 cont. • Dx. and Plan • Diabetes, Type II, with complications, worsening, diet and compliance with meds discussed • Colon cancer with METS, not responding to treatment, followed by oncologist • Anemia in cancer, not responding to treatment, consider IM iron treatment • Polyneuropathy in Diabetes, worsening, add Lyrica • Asthma with COPD, worsening, will add inhaler

  28. Coding Case # 2 Low Specificity High Specificity 285.9 Anemia, unspec. 153.9 Colon Cancer 0.208 250.00 Diabetes, unspec. 0.162 355.9 Neuropathy, NOS 493.90 Asthma, unspec Demographic Factor: 61 yrs old/female/disabled: 0.411 TOTAL RISK SCORE= 0.781 285.2 Anemia in Cancer 153.9 Colon Cancer 0.208 Colon Cancer w/ metastasis – Liver 2.276 250.60 Diabetes w/ neurologic comp 0.408 357.2 Diabetic Neuropathy 0.327 493.21 Asthma with COPD 0.399 Demographic Factor: 61 yrs old/female/disabled 0.411 TOTAL RISK SCORE= 4.029

More Related