Risk Adjustment

Risk Adjustment is the method developed and used by the Department of Health and Human Services (HHS) to predict health costs of members enrolling in Affordable Care Act (ACA) or Medicare Advantage (MA) plans. Risk Adjustment prevents health plans from only attracting and enrolling healthy members, known as adverse selection. Effective Risk Adjustment programs ensures members are receiving quality care and enable health plans to offer more comprehensive and affordable benefits to members.

Arkansas Health and Wellness is required by law to report complete and accurate diagnostic information on enrollees. This information is gathered from claims data and information obtained from medical record reviews and audits.

We encourage all providers to take every face-to-face encounter as an opportunity to provide comprehensive care and document chronic and co-existing conditions, active status conditions, and pertinent past conditions using the applicable ICD-10 code and supporting the condition with proper documentation in the medical record.

Arkansas Health and Wellness is required to validate member diagnosis annually through a Risk Adjustment Data Validation (RADV) audit. Health plans also engage in chart review projects to ensure member diagnoses are being reported accurately.

Arkansas Health and Wellness engages providers through various incentive programs that reward providers for risk adjustment gap closure.

Cardiac Arrhythmias^[1]

An arrhythmia is an abnormal heart rhythm. Arrhythmias occur when the electrical impulses that coordinate your heartbeats don’t work properly, causing your heart to beat too fast, too slow or irregularly.

RISK FACTORS:

• Hypertension
• Heart attack
• Abnormal heart valve
• Coronary artery disease
• Emphysema /lung disease
• Stress
• Congenital defects
• Viral infections
• Metabolic imbalance
• Thyroid disorder
• Stimulants
• Smoking

SYMPTOMS:

• Palpitations
• Chest pain
• Weakness / fatigue
• Confusion
• Blood pressure change
• Shortness of breath
• Lightheadedness
• No symptoms

Paroxysmal Tachycardia

Tachycardia is a fast heart rate; in adults a rate greater than 100 beats per minute is considered tachycardia. Paroxysmal tachycardia is characterized by periods of rapid heartbeats that start and stop abruptly.

There are 2 types of paroxysmal tachycardia:

• Supraventricular Tachycardia occurs when the rapid heart rate originates in the heart’s upper chambers (the atria)
• Ventricular Tachycardia involves a rapid heart rate originating in the lower chambers of the heart (the ventricles). Ventricular tachycardia lasting longer that a few seconds can lead to ventricular fibrillation, the most serious and life-threatening cardiac rhythm disturbance.

Atrial Fibrillation and Flutter

Atrial fibrillation and flutter are arrhythmias involving the atria. They may come and go or be sustained. Risk of stroke or heart failure is increased if either atrial fibrillation or atrial flutter is not controlled or persists for more than a couple of days.

• Atrial fibrillation is a rapid, irregular heart rate caused by chaotic electrical impulses in the atria. These cause rapid, uncoordinated, weak contractions of the atria and blood is not moved from the atria into the ventricles effectively. Atrial fibrillation is the most common type of arrhythmia.
• Atrial flutter is characterized by a rapid, but regular heartbeat that causes the atria to beat too fast, producing atrial muscle contractions that are faster than and out of sync with the ventricles.

Sick Sinus Syndrome (SSS)

SSS, also known as "Sinoatrial node dysfunction" or "Tachycardia-Bradycardia syndrome," is the name given to a group of arrhythmias in which the sinus node, the heart’s natural pacemaker, doesn’t send impulses properly. As a result, the heart might beat too fast, too slow, or it might speed up and slow down intermittently.

Treatment options depend largely upon the severity of a patient’s symptoms. Many with SSS initially experience few, if any, symptoms. At this stage treatment usually consists of regular checkups and monitoring. Once a patient’s symptoms become more problematic, further treatment is pursued.

Many with SSS eventually need a permanent artificial pacemaker to monitor and regulate the heart’s rhythm and send electrical signals to stimulate the heart when it’s beating too slowly.

A pacemaker controls but does not cure SSS, therefore, it is a reportable chronic condition.[2]

Patients who have a rapid heart rate as part of their SSS may need additional treatments after pacemaker placement to control fast rhythms.

Treatment Options

• Anti-arrhythmic drugs
• Heart-rate control drugs
• Anticoagulant therapy
• Electrical cardio conversion
• Anti-bradycardia pacing
• Coronary artery bypass
• Pulmonary vein isolation
• Catheter ablation
• Maze procedure
• Valve surgery

There are many cardiac devices designed to help control irregular heartbeats, such as pacemakers, implantable cardioverter-defibrillators (ICDs) and loop recorders. These are often surgically implanted in the chest or abdominal wall, just below the collarbone.

CARDIAC DEVICES

Coding and Documentation^[3]

When documenting cardiac arrhythmias, include the following:

• Location — atrial, ventricular, supraventricular, etc.
• Rhythm name — flutter, fibrillation, etc.
• Acuity — paroxysmal, persistent, longstanding, chronic, etc.
• Cause — hyperkalemia, hypertension, etc.

ANTICOAGULANT THERAPY

• Documentation must state the relationship between an­ticoagulation therapy and cardiac arrhythmias. It cannot be assumed since anticoagulants are used to manage other conditions.
• Even when the conditions are linked, document the type, status, and severity of the arrhythmia. Anticoagulant therapy is also used to prevent blood clots in patients with a history of cardiac arrhythmias. - Z79.01: Long term (current) use of anticoagulants

HISTORY OF

• Document “history of,” along with a specification that the condition is no longer current in the final assessment.
• If the condition is currently active and under management do not specify as “history of,” even if stable.
• There is not a specific code for personal history of cardiac arrhythmia. Use Z86.79: Personal history of other diseases of the circulatory system.

PRESENCE OF CARDIAC DEVICE

• Z95.0      Presence of a cardiac pacemaker
• Z95.810  Presence of automatic (implantable) cardiac defibrillator
• Z95.811  Presence of heart assist device
• Z95.818  Presence of other cardiac implants and grafts

Reference

[1] Cardiac Arrhythmias

[2] AHA Coding Clinic, 2019 Q1, Volume 6 pg. 3

AMB21-AR-H-112 Updated October 22, 2021

Chronic Kidney Disease^[1]

The clinical criteria for chronic kidney disease (CKD) is either kidney damage or a decreased glomerular filtration rate (GFR) of less than 60 for at least three months. When the reduction of functional renal mass reaches a certain point, irreversible sclerosis leads to a progressive decline in the GFR.

ICD-10-CM^[2] classifies CKD by the severity level of decreased kidney function. 

The GFR value may can be used as supporting evidence for renal failure, renal insufficiency, or other renal diseases documented by the provider. It cannot be interpreted to stage CKD or other renal condition. 

Signs and Symptoms

Patients with CKD stages 1-3 are generally asymptomatic. Typically, it is not until stages 4 or 5 that endocrine/ metabolic derangements or disturbances in water or electrolyte balance become clinically manifested.

When the disease progresses, symptoms presented are:

• Edema of feet and ankles
• Need to urinate more often, especially at night
• Nausea
• Blood or protein in urine
• Chest pain
• Twitching and cramps in the muscles
• Shortness of breath
• Erectile dysfunction, amenorrhea, or decreased libido
• Fatigue
• Platelet dysfunction with tendency to bleed
• Loss of appetite
• High blood pressure (hypertension)

Coding and Documentation^[3]

Acute vs. Chronic

Acute kidney failure is not an acute exacerbation of chronic kidney failure. They are two separate and distinct conditions. The causes, symptoms, treatments, and outcomes of acute and chronic are different.

• Acute renal failure has an abrupt onset and is potentially reversible.
• Chronic kidney failure progresses slowly over time and can lead to permanent kidney failure.

If both acute and chronic kidney failure are clearly documented, code both N179 (AKI) and N18.^[4]

End Stage Renal Disease

End-stage renal disease (ESRD) is when the kidneys permanently fail to work. ESRD requires renal dialysis or kidney transplant.

• Code N18.6 is assigned when ESRD is documented by provider
• Code Z99.2: Dependence on renal dialysis when documentation supports the presence of an arteriovenous shunt/fistula for dialysis
• Code Z91.15: Patient's noncompliance with renal dialysis when explicitly documented

“With”

Patients with CKD may also suffer from other serious conditions, most commonly diabetes mellitus and hypertension. The sequencing of the CKD code in relationship to codes for other contributing conditions is based on the conventions in the Tabular List.

Diabetes with Kidney Complications 

Relationship between diabetes and CKD or ESRD (N18.1 - N18.6) is assumed when both conditions are found anywhere in the note as long as there is no conflicting documentation

• Use an additional code to identify stage of chronic kidney disease (N18.1-N18.6).
• The ICD-10 “With” guideline only applies to CKD.
• Unspecified (N18.9): When CKD unspecified has been assessed during the encounter.

Hypertensive Chronic Kidney Disease

Hypertension and CKD have an assumed relationship unless documentation specifies CKD is caused by a condition other than hypertension.

• Assign code from category I12
• Use an additional code to identify stage of chronic kidney disease with I12.0 (N18.1-N18.4, N18.9) or I12.9 (N18.5-N18.6)

Hyperparathyroidism

Hyperparathyroidism is a pathologic manifestation of CKD.  

• Documentation must link the complication and the conditions to assign code N25.81: Hyperparathyroidism of renal origin.
• Do not assume causal relationship between these two conditions.

Reference

[1]Chronic Kidney Disease

[2] ICD-10-CM

[3] Coding and Documentation (PDF)

[4] AHA Coding Clinic, Volume 27, Q3, 2010, Pg. 5

AMB21-AR-H-111 Updated October 22, 2021

Coagulation Defects and Other Specified Hematological Disorders^[1]

Coagulation (also known as clotting) is the process by which blood changes from a liquid to a gel, forming a blood clot. Clotting results in hemostasis, the cessation of blood loss from a damaged vessel. It is achieved through a series of interactions between platelets, blood vessel walls, and adhesive blood proteins known as clotting factors.

Coagulation disorders involve disruption of the clotting process and may result in:

• Hemorrhage: Too little clotting that causes an increased risk of bleeding. Examples include:
  • Von Willebrand disease
  • Primary thrombophilia
  • Activated protein C resistance
  • Hemophilia
  • Hereditary factor XI deficiency
  • Evans syndrome
  • Thrombocytopenia
  • Allergic purpura
    

• Thrombosis: Too much clotting that causes blood clots to obstruct blood flow. Examples include:
  • Factor V Leiden mutation
  • Antithrombin III (ATIII) deficiency
  • Primary thrombocytosis
  • Antiphospholipid antibody syndrome
  • Prothrombin (PT) gene mutation
  • Protein C or protein S deficiency
  • Lupus anticoagulant syndrome
    

Signs, Symptoms, and Treatment of Hemorrhagic Disorders

Signs & Symptoms

• Blood in the urine or stool
• Sudden pain, swelling, and warmth in the joints or muscles
• Nosebleeds that seem to have no cause
• Repeated vomiting
• A painful headache that will not go away
• Extreme fatigue
• Bruising easily and excessively, or petechiae
• An injury that will not stop bleeding
• Prolonged bleeding from cuts, surgery, or dental work
• Vision problems, such as double vision
• An enlarged spleen

Treatment

• RICE — Rest, ice, compression, and elevation
• Infusion
• Transfusion
• Desmopressin (Willebrand factor synthetic hormone)
• Discontinuation of aspirin and other NSAIDs

Hemophilia^[2]

Hemophilia is a hereditary blood disease characterized by greatly prolonged coagulation time. The blood fails to clot, and abnormal bleeding occurs.

Hemophilia is a sex-linked hereditary trait transmitted by normal heterozygous females who carry the recessive gene occurring almost exclusively in males.

• Factor VIII deficiency (classic hemophilia, hemophilia A) associated with recurrent, spontaneous, and traumatic hemarthrosis
• Factor IX deficiency (hemophilia B, Christmas disease, plasma thromboplastin component)
• Von Willebrand disease
  • Type 1 - Partial quantitative deficiency of von Willebrand factor; Type 1C von Willebrand disease
  • Type 2 subtypes include qualitative defects of von Willebrand factor
    • type 2A - with decreased platelet adhesion and selective deficiency of high-molecular-weight multimers
    • type 2B - with high-molecular-weight von Willebrand factor loss; with hyper-adhesive forms; with increased affinity for platelet glycoprotein lb
    • type 2M - with defective platelet adhesion with a normal size distribution of von Willebrand factor multimers
    • type 2N - with defective von Willebrand factor to factor VIII binding; with markedly decreased affinity for factor VIII
  • Type 3 - (Near) complete absence of von Willebrand factor; Total quantitative deficiency of von Willebrand factor
  • Acquired von Willebrand syndrome
  • Other – platelet-type; pseudo-von Willebrand disease

Acquired hemophilia, developing after birth, is a rare condition caused by the development of antibodies (immune system proteins) directed against the body’s own VIII or IX blood clotting factors.

• Non-genetic disorder affecting both males and females
• Can be related to other conditions (i.e., pregnancy, cancer, certain medications)

Frequency and severity of hemorrhagic activity induced by hemophilia are related to the amount of coagulation factor in the blood.

Treatment depends on the severity of the disease and may include the administration of blood clotting factors such as Factor VIII, Factor IX, Factor VIIa and, Anti-inhibitors to control the bleeding.

Thrombocytopenia

Thrombocytopenia occurs when the platelet count falls lower than 150,000 platelets per μl of blood. Circulating platelets are reduced by one or more of the following:

• Trapping of platelets in spleen caused various other disorders
• Decreased platelet production can be caused by leukemia, chemotherapy, heavy alcohol consumption certain anemias, and viral infections (Hep B, HIV)
• Increased breakdown of platelets

Treatment

• Identify and treat underlying cause
• Splendectomy
• Corticosteroids/immunosuppressants
• Blood or platelet transfusions

Primary Thrombocytosis

Primary Thrombocytosis, also known as Primary Thrombocythemia (ET), is an uncommon disorder in which the body produces too many platelets.

Signs, Symptoms, and Complications

• Fatigue
• Lightheadedness
• Vision changes
• Increased risk of blood clots, myelogenous leukemia (AML), and myelfibrosis

Treatment

• Low dose aspirin
• Anagrelide
• Hydroxyurea
• Interferon alfa or pegylated interferon alpha 2a

Coagulopathy^[3]

Coagulopathy is impaired clot formation or any derangement of hemostasis resulting in either excessive bleeding or clotting. Document coagulopathy when appropriate to reflect the seriousness of the condition. Specify the underlying etiology of coagulopathy to support the diagnosis.

• When patient is maintained on anti-platelets and/or an anti-coagulant, document coagulopathy due to anti-coagulation or anti-platelets use, if linked to bleeding.
• If coagulopathy is documented due to abnormal ROTEM (rotational thromboelastometry), additional clinical relevance will help validate the diagnosis:
  • Need
  • Type
  • Screen in anticipation of blood products transfusion (ffp)

Coding & Documentation

Quality patient care relies on complete documentation.

• Accurately capture the patient’s health status.
• Note condition details, including status, complications, and comorbidities.
• Report the diagnosis to the highest specificity found in the documentation.

All providers must fully understand and follow all existing laws, regulations, and rules for hemophilia clotting factors and must properly submit valid claims for them. Relevant CMS manual instructions and policies may be found in the Internet-Only Manuals (IOMs) published on the CMS website.

ICD-10-CM Diagnosis Codes^[4]

Lists are not all-inclusive. Refer to the official ICD-10-CM diagnosis coding & documentation guidelines for the current year.

[1]. American Society of Hematology. Hematology.org. https://www.hematology.org/. 

[2]. Local Coverage Determination (LCD): Hemophilia Clotting Factors. CMS.gov. https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdId=33684&ver=46.

[3]. Coagulopathy and Perioperative Hemorrhage and Hematoma (PSI-9). ICD10monitor.com. https://icd10monitor.com/coagulopathy-and-perioperative-hemorrhage-and-hematoma-psi-9/.

[4]. 2022 ICD-10-CM Codes D50–D89. ICD10data.com. https://www.icd10data.com/ICD10CM/Codes/D50-D89.

Updated on March 1, 2022

Chronic obstructive pulmonary disease (COPD) is a progressive chronic respiratory disease that causes blocked airways and breathing-related problems. COPD can be caused by long-term exposure to harmful particles or gases that irritate the lungs such as tobacco smoke and exposure to air pollution.^[1]

Types of COPD

Chronic bronchitis — hypersecretion of mucus with chronic productive cough lasting more than 3 months in 2 consecutive years^[2]

• Simple — non obstructive; smokers cough (J41.0)
• Mucopurulent — production of sputum containing mucus and pus (J41.1)
• Mixed — chronic simple and mucopurulent bronchitis (J41.8)
• Chronic bronchitis, NOS (J42)

Emphysema — enlarged or over inflated air space in the lung due to damaged alveoli (air sacs) or alveolar wall resulting in breathing difficulty and increased risk of respiratory infections.

• Unilateral pulmonary emphysema – MacLeod’s syndrome (J43.0)
• Panlobular — affecting lower lobes (J43.1)
• Centrilobular — affecting upper lobes (J43.2)
• Other and Unspecified (J43.8, J43.9)

Chronic obstructive pulmonary disease — chronic bronchitis and emphysema causing irreversible airflow obstruction

• With (acute) respiratory infection (J44.0)
• With (acute) exacerbation (J44.1)
• COPD, unspecified (J44.9)

Stages of COPD^[3]

COPD Treatment and Management

There is no cure for COPD, but early intervention can slow the disease progression and reduce the risk of complications. Treatment for COPD can include:

• Antibiotics — fights bacterial infection
• Bronchodilators — opens airways
• Bullectomy — removal of air space from collapsed air sacs
• Corticosteroids — reduces inflammation
• Lung transplant — replace diseased lung with a healthy one
• Lung volume reduction — removes diseased lung tissue
• Oxygen therapy — reduces shortness of breath
• Pulmonary rehabilitation — includes disease management,  exercise, and counseling
• Smoking cessation — slows progression
• Vaccines — lower risk of flu or pneumonia

Asthma

Asthma is a chronic lung disease causing inflammation and constriction of the airways that affects the ability to breathe. Asthma triggers may be different for each person and can change over time. Different triggers cause different types of asthma.^[4]   

• Allergic — Dust mites, mold, pollen, pets, household pests, etc.
• Non-allergic — Cold air, medications, household chemicals, air pollution, tobacco smoke, infection, etc.
• Exertional — Induced by exercise or physical activity.
• Occupational — Caused by breathing chemicals or industrial dust particles at work.

Asthma is classified by frequency and severity of symptoms as well as complications of the disease: (J45.-) 

• Mild, moderate, severe
• Intermittent, persistent
• Uncomplicated, with acute exacerbation, with status asthmaticus  

Diagnostic Testing^[5]

Document diagnostic test results and any clinical findings that support the diagnosis, along with disease status and treatment plan.

• Bronchoprovocation — tests pulmonary response or reaction to the drug methacholine.
• Bronchoscopy — procedure using a small camera on the end of a long flexible tube, or scope, to look at air passages
• Chest x-ray — imaging test to look at the structures and organs of the chest
• Computed tomography (CT) scan — computerized digital scan that creates two-dimensional, cross-sectional images
• Endobronchial Ultrasound (EBUS) — bronchoscopy performed using scope with an ultrasound probe attached
• Fractional exhaled nitric oxide (FeNO) test — measures levels of nitric oxide exhaled from a breath
• Lung biopsy — procedure to collect a tissue sample used in disease diagnosis  
• Peak Expiratory Flow (PEF) — measures speed of air blown out of the lungs using maximum effort
• Pulse oximeter (Pulse Ox) — measures the saturation of oxygen carried in your red blood cells
• Spirometry — measures volume capacity and the force of air expelled from the lungs

A diagnosis is not supported by the simple reference of a diagnostic study. The provider must interpret the results and include the clinical significance in the medical record

Coding and Documentation

ICD-10 code assignment depends on documentation details that should include:

• Specific diagnosis
• Severity, frequency, or complication
• Condition status and controlling agents
• Causal relationships
• Coexisting and/or underlying conditions

Refer to the tabular list for guidance on diagnosis inclusions, exclusions and additional coding notes.

Use Additional Codes to identify:

• Exposure to environmental tobacco smoke (Z57.31, Z77.22)
• Tobacco use (Z72.0), tobacco dependence (F17.-), or history of tobacco dependence (Z87.891)
• Dependence on supplemental oxygen (Z99.81); use of long-term supplemental oxygen regardless of the duration each day^[6]
• Dependence on respirator [ventilator] (Z99.11); use of respirator or ventilator for life support^[7]
• Long-term (current) use of inhaled or systemic steroids (Z79.5-)
• Other diseases of the pleura (J90-J94)
• Intraoperative and post procedural complications and disorders of respiratory system (J95)
• Other diseases of the respiratory system (J96-J99)

Reference:

[1] Basics about COPD

[2] Chronic Bronchitis

[3] What are the Four Stages of COPD?

[4] ICD-10 J45 Asthma

[5] Lung Procedures, Tests and Treatments

[6] AHA Coding Clinic, 2002, Q4,

[7] Ventilator/Ventilator Support

AMB21-AR-H-143 Updated on November 15, 2021

Condition status Z codes are informative and distinct from “history of” codes. “History of” codes indicate a past condition has been resolved and is not present. Condition status codes indicate that a patient is either a carrier of a disease or has the sequela or residual of a past disease or condition. The status can affect the course of treatment and its outcome but they are commonly overlooked. ^[1]

Amputation Status — Category Z89

Codes in Category Z89 describe traumatic or post-procedural absence of a limb, when there are neither complications of the amputation nor treatment directed toward the site. Documentation should include anatomical location and laterality.

Artificial Opening Status — Category Z93

Codes in category Z93 describe functional artificial opening status. Artificial openings can be permanent or temporary depending on circumstances of creation. These codes are appropriate when no treatment is directed at the site. Documentation should include date of initial procedure and/or reversal, if applicable.

Organ Transplant Status — Category Z94

Category Z94 codes identify post-transplant status when there are no complications of the transplanted organ. A code from this category is appropriate as an additional code when treatment of a condition does not affect the function of the transplanted organ.

Supplemental Oxygen or Respirator Dependence – Category Z99

Category Z99 codes identify supplemental oxygen or ventilator dependence status when there is no complication or malfunction of the equipment on which the patient is dependent.^[2] Dependence status can be for a short or long period of time in the hospital, another medical setting, or at home. Dependence on supplemental oxygen status is appropriate for any patient using long-term supplemental oxygen, regardless of the duration of use each day. Use dependence on respirator [ventilator] status codes when respiratory device or equipment is for life sustaining support.

Renal Dialysis Status

ICD-10-CM includes codes for dependence on renal dialysis and noncompliance with renal dialysis. These codes are appropriate when the presence of AV shunt for renal dialysis is indicated.

Lifelong Chronic Conditions^[3]

Lifelong chronic conditions often require ongoing medical attention and the associated diagnoses are typically unresolved once diagnosed. It is appropriate to report these conditions, even when stable, if documented in any part of the medical record at the time of the encounter.

It is important to include all condition details in documentation. Report all applicable Z status codes and chronic condition diagnosis codes.

• When presence affects medical decision making or a pertinent factor of overall health.
• During a wellness or physical exam, at least once per calendar year for as long as they exist.

Reference:
[1] ICD-10-CM Chapter 21: Factors influencing health status and contact with health services

[2] ICD-10-CM Codes Lookup

[3] Lifelong Chronic Conditions (PDF)

[4] ICD-10 Diagnosis

Heart Failure is a chronic, progressive condition in which the heart is unable to pump enough blood to meet the body's needs for blood and oxygen. Heart failure is usually caused by another condition that either damaged the heart or caused it to work too hard.

Risk Factors

• Hypertension
• Diabetes
• Endocarditis
• Coronary artery disease
• Congenital heart disease
• Cardiomyopathy
• Obesity
• Sleep apnea
• Severe lung disease

Signs and Symptoms

• Edema in the feet, ankles, and legs
• Fatigue, weakness, or lightheadedness
• Irregular or fast heartbeat
• Dyspnea, orthopnea, or persistent coughing
• Confusion, impaired thinking, or decreased ability to concentrate

Types of Heart Failure

Heart failure can affect either the heart’s left or right side, or both sides, and it can be acute, chronic, or acute-on-chronic.

• Left-sided heart failure or left ventricular (LV) heart failure – Failure of the left ventricle, the main pumping chamber of the heart, to pump blood out to the body effectively. Accumulation of excess fluid behind the left ventricle causes dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and/or acute pulmonary edema.
  There are two different types of left-sided heart failure which call for different treatment approaches:
  • Systolic heart failure — Heart failure with reduced ejection fraction (HFrEF) – the left ventricle loses its ability to contract normally. The heart can’t pump with enough force to push enough blood into circulation.
  • Diastolic heart failure — Heart failure with preserved ejection fraction (HFpEF) – the left ventricle loses its ability to relax normally because the muscle has become stiff. The heart can’t fill properly with blood during the resting period between each beat.
    
    
• Right-sided heart failure, or right ventricular (RV) heart failure — Failure of the right ventricle to move blood returning from systemic circulation into the lungs. Blood backs up in the body’s veins, causing systemic venous congestion (distended neck veins), pitting edema of the lower extremities or other dependent portions of the body, enlarged tender liver, and/or ascites.
• Chronic heart failure develops slowly and the onset of symptoms may be gradual. Treatment is aimed at managing the underlying cause, minimizing symptoms, and preventing the heart failure from becoming worse.
• Acute heart failure develops suddenly, and symptoms are initially severe which may be experienced until the underlying condition is identified and treated. This can happen with:
  • Severe anemia
  • Hyperthyroidism
  • Pulmonary embolism
  • Arrhythmia
  • Severe infections or allergic reaction
• Acute on chronic heart failure occurs when there is an acute decompensation of chronic heart failure.

Coding and Documentation

When documenting heart failure, include the following:

• Type — systolic, diastolic, etc.
• Acuity — acute, chronic, etc.
• Disease status — stable, improved, etc.
• Treatment plan — medicines, lifestyle changes, etc.

Code all documented conditions present at the time of the encounter that require or affect patient care, treatment or management. This includes stable chronic conditions and comorbidities. Include the ICD-10 coded to the highest specificity on the claim.

“Exacerbated” or “Decompensated”

Coding guidelines advise that “exacerbation” and “decompensation” indicate an acute flare-up of a chronic condition. When systolic or diastolic heart failure is described in these terms, the appropriate code indicating acute on chronic heart failure should be assigned.

Congestive heart failure

The term congestive heart failure refers to the back up of fluid into the lungs and tissues. Assign code I50.9, heart failure NOS for a diagnosis of unspecified congestive heart failure.

“With”

When documentation links either systolic or diastolic dysfunction with heart failure, report as systolic/diastolic heart failure. Link CHF to other associated conditions unless specifically documented as “unrelated”.

• Hypertension
• Chronic kidney disease (CKD)

ALL21-AR-H-084 Updated on October 20, 2021

Occasionally, a reported diagnosis may be omitted from a claim due to errors or limitations of electronic claims submission. Improve the capture of risk adjustment conditions by entering the diagnosis codes on the claim correctly.

Diagnosis “pointers” connect the diagnosis made by the provider to each CPT® code billed on the claim. Only four (4) diagnosis pointers can be listed per CPT® code.

• Identify the 4 most important or serious diagnoses that the procedure is intended to treat.
• Enter the diagnosis pointers in order of severity.

Maximize reporting opportunities:

Avoid missing eligible risk adjustment conditions by thorough documentation and accurate diagnosis coding.

• Address all conditions present at the time of the encounter that require treatment or management.
• Report all chronic conditions that impact treatment or care, even if stable. This includes pertinent status codes.
• Explicitly state each diagnosis and provide documented evidence of support in the medical record.
• Capture all valid ICD-10 diagnosis codes in the appropriate order on the claim form. 

Always follow the current ICD-10-CM Official Guidelines for Coding and Reporting^[1] Refer to the Medicare Claims Processing Manual² for additional information.

1500 Claim Form Instructions (PDF) — Coming soon

Health Insurance Claim Form (PDF) — Coming soon

Documentation Requirements^[1]

Documentation must:

• Result from a face-to-face encounter with acceptable provider in an acceptable setting type.
• List the complete date of service (month/day/year).
• Contain at least two patient identifiers on EACH page of every document (Name, DOB, MRN).
• Include legible, handwritten signature with credentials or proper EMR electronic authentication.
• Explicitly state the diagnosis, and clearly document supporting evidence of an active/current condition.

Condition Assessment

Assess the status of conditions for which interventions are recommended or underway. Code all documented conditions that coexist at the time of the encounter/visit and require or affect patient care treatment or management.  This includes ongoing chronic conditions, even if stable.

Documentation from past dates of service may not be used to report codes for the current date of service.

Current/Active Diagnosis

MEAT and TAMPER are used as tools to help coders determine if a condition can be coded as current or active. At least one of the following elements must be present in at least one section of the medical record (Subjective, Objective, Assessment, Plan) to substantiate the presence of a condition:

• Monitor, Evaluate, Assess/Address, Treat
• Treat, Assess, Monitor/Medicate, Plan, Evaluate, Refer

"History Of"

Do not code conditions that have been treated or no longer exist. Documentation where the provider has used the term(s) “history of” will be coded using the appropriate diagnosis code for the historical condition. The condition should not be referenced as a “history of” if it is a chronic condition currently undergoing treatment.

Condition Lists

Conditions mentioned in Past Medical History or Active Problem List must be supported in another section of the medical record in order to verify the condition is active. The best practice is to include evidence of current review in the form of medication, referrals, order of lab tests, etc. in the assessment and plan.

Specificity

Document to the highest degree, and code to the highest specificity. The ICD-10 diagnosis code must match the wording used in documentation. Explicitly state the diagnosis and follow the official conventions and guidelines for coding and reporting.

Consistency

Be clear and consistent throughout the medical record when documenting details of a condition. A diagnosis cannot be validated when the record contains conflicting information.

Reporting

When a condition is assessed and documented in a face-to-face encounter, include the corresponding ICD-10 diagnosis code on the claim form submitted to the health plan.

Telehealth^[2],[3]

Telemedicine Visits provided via synchronous audio and video technology meet the face-to-face requirement for risk adjustment. Documentation must include that the visit was performed using interactive audio/video with real-time, two-way communications. Virtual Check-Ins, E-Visits, and Telephone Visits are not acceptable.

Resources:

[1] Documentation Requirements (PDF)

[2] Medicare has expanded telehealth coverage and eased current restrictions for the duration of the COVID-19 crisis. During this time, telehealth services that meet the face-to-face documentation requirements can be used for risk adjustment.

[3] Telehealth (PDF)

[4] ICD-10-CM Official Guidelines for Coding and Reporting (PDF)
The Official ICD-10-CM Guidelines^[4] are the authoritative source for diagnosis coding and documentation. Please refer to the current year’s guidelines for detailed instructions.  These guidelines and other information about risk adjustment can be found on CMS’s website. 

Follow the guidelines and assign the appropriate combination codes when reporting hypertension and another condition.^[1]

The relationship between hypertension, heart disease and chronic kidney disease is assumed when conditions are found together, unless explicitly documented unrelated.

Applies to conditions found in I50.-, I51.4-I51.7, I51.89, I51.9 Category I11 — Hypertensive Heart Disease

• Code separately only if  heart disease stated "Not due to hypertension."
• Use additional code from category I50, Heart Failure, if applicable

Category I12 — Hypertensive Chronic Kidney Disease (CKD)

• Code separately only if documentation specifies cause other than hypertension
• Use additional code to identify the stage of the CKD
• Also code dialysis status, if applicable

Category I13 — Hypertensive Heart and Chronic Kidney Disease

• Do NOT separately code for hypertension, heart disease, and chronic kidney disease or assign with codes from categories I11 or I12
• Use additional code for heart conditions I50.-, I51.4-I51.7, I51.89, I51.9
• Also code the appropriate stage of CKD (N18.- ) and dialysis, if applicable

For conditions not found under the term “with,” the relationship between hypertension and another condition must be specifically documented in order to code them as related.

Category I15 — Secondary Hypertension

Secondary hypertension is due to an underlying condition.

• Assign the code for the underlying condition and a code from category I15

Category I16 — Hypertensive Crisis

• Use a code from category I16 when hypertensive urgency, hypertensive emergency or unspecified hypertensive crisis is documented.
• Code also any identified hypertensive disease (I10- I15).

Category I27 — Pulmonary Hypertension

• Pulmonary hypertension is classified to category I27 — Other pulmonary heart diseases.
• Code any associated conditions or adverse effects of drugs or toxins also.

Hypertensive Cerebrovascular Disease

• Assign code from Categories I60-I69, followed by the appropriate hypertension code (I10-I15).

Hypertensive Retinopathy

• Code H35.0 — Background retinopathy and retinal vascular changes with the applicable code from Categories I10-I15.

Transient Hypertension

When a hypertension diagnosis has not been established, assign one of the following codes:

• R03.0 — Elevated blood pressure reading without hypertension.
• O13.- — Gestational [pregnancy-induced] hypertension without significant proteinuria.
• O14.- — Pre-eclampsia, for transient hypertension of pregnancy.

Reference:

[1] ICD-10-CM Official Guidelines for Coding and Reporting FY 2022

AMB21-AR-H-116 Updated on October 21, 2021

Ischemic Heart Disease^[1]

Atherosclerosis

Atherosclerosis is the buildup of fatty deposits, or plaque, within the coronary arteries. Plaque buildup causes narrowed or blocked blood vessels, which can lead to more serious conditions such as acute coronary syndrome and myocardial infarction.

Coronary atherosclerosis is categorized by the type of vessel in which it occurs:

• Native coronary artery
• Coronary artery bypass graft (CABG)
  • Autologous or non-autologous artery or vein
  • Other CABG
• Artery of transplanted heart

Atherosclerosis is also known as atherosclerotic heart disease (ASHD), coronary artery disease (CAD), or atherosclerotic cardiovascular disease (ASCVD).

RISK FACTORS:

• Diabetes
• Hypertension
• Poor diet
• Smoking
• High cholesterol
• Obesity
• Lack of exercise
• Age
• Gender
• Family history
• Poor dental health
• Stress

When documenting atherosclerosis, include the following:

• Location — Coronary artery involvement, vessel type
• Symptoms — Angina, shortness of breath, etc.
• Comorbid conditions — Hypertension, tobacco use, etc.

Angina

Angina is chest pain or discomfort caused when the heart muscle does not get enough oxygen-rich blood. It is usually a symptom of an underlying heart condition such as coronary artery atherosclerosis.  

SIGNS and SYMPTOMS:

• Chest pain or discomfort, pressure, squeezing, or fullness in the center of the chest.
• Radiating pain in the arms, neck, jaw, shoulder, or back.
• Nausea, fatigue, shortness of breath, sweating, or dizziness.

TYPES and SEVERITY:

• Refractory — chronic angina that does not respond to medical treatment or intervention^[2]
• Stable — Pain that is usually caused by exertion or excitement and stops when at rest or with medication.
• Unstable — Pain changes in frequency, duration and intensity. Does not go away with rest or medicine.
• Variant — Coronary vasospasm that occurs most often while at rest. Associated with transient ST-segment elevation.

When documenting angina, include the following:

• Type — Stable, unstable, etc.
• Cause — Presumed to be ASHD, note if there is another cause
• Timing/precipitating factors — Exercise, emotional stress, etc.
• Relieving factors — Medications, rest, etc.

Not all chest pain is angina.  “Angina” must be explicitly stated. Stable or asymptomatic angina that is controlled by a medication is an active condition and should be assessed, documented, and reported at least once per year. Use “history of” when the condition has resolved, and treatment is no longer needed.

Heart Disease Prevention and Management

Heart Disease Prevention and Management

Myocardial Infarction (MI)

Myocardial infarction, known as a heart attack, is the permanent, gross necrosis of the myocardium (heart muscle tissue death). An electrocardiogram (ECG) reading will differentiate an ST elevation myocardial infarction (STEMI), or classic heart attack, from a non-ST myocardial infarction (NSTEMI), sometimes called a mild heart attack.

A heart attack occurs when a blocked artery interrupts blood flow to a section of the heart. If the blockage is not treated quickly, that part of the heart begins to die. Symptoms may be immediate and intense but typically start slowy and persist for hours, days or weeks before a heart attack. Report in acute/post-acute care setting or following transfer to another acute setting.

CLASSIFICATON:^[3]

• Type 1 — Spontaneous
• Type 2 — Ischemic
• Type 3 — Unknown
• Type 4 — (3 subtypes, a-c)
  • a — Due to percutaneous procedure
  • b — Due to stent thrombosis
  • c — Due to restenosis
• Type 5 — Due to CABG
• Myocardial Injury — non-ischemic; acute or chronic

Cardiac arrest is triggered by an irregular heartbeat (arrhythmia) affecting the heart’s ability to pump blood to other organs.  Cardiac arrest occurs suddenly, often without warning.  It is reversible if treated within the first few minutes but is fatal without quick intervention.

ICD-10-CM

Category I20 — Angina Pectoris & Category I25 — Chronic ischemic heart disease

ICD-10-CM presumes a causal relationship between ASHD and angina when no other cause has been identified for the angina. These same conditions are coded separately when the provider has specifically documented a different cause for angina.^[4]

• I25.2, old MI — Healed myocardial infarction or MI older than four weeks (28 days).

Category I21 — Acute MI

• Type 1 — Initial myocardial infarction from onset up to four weeks (28 days) old.
• Unspecified AMI or unspecified type is assigned I21.9.
• Types 3-5 are coded I21.A9.
• Use code I5A for non-traumatic myocardial injury (acute, chronic, or non-ischemic)

Category I22 — Subsequent MI

• Occurrence of an acute MI within the four-week time frame of the initial acute MI.
• Code with a category I21 code.

Category I23 — Current complication following MI

• Must be coded with a Category I21 or Category I22 code.
• "Post-infarction angina” must be stated to assign (I23.7) as a current complication.

Category I24 — Acute ischemic heart disease

• Acute blood clots in the coronary arteries without myocardial infarction.
• Acute coronary syndrome (ACS).^[5]

References:

[1] Ischemic Heart Disease

[2] ICD-10-CM Category I25 expanded to include refractory angina effective October 1, 2022. FY2023 official coding guidelines and descriptions can be found at https://www.cms.gov/medicare/icd-10/2023-icd-10-cm

[3] CLASSIFICATON

[4] ICD-10-CM Official Guidelines for Coding and Reporting (PDF)

[5] Acute coronary syndrome (ACS)

AMB22-AR-H-164   Updated on November 10, 2022

Major Depressive Disorder^[1]

Major Depressive Disorder, also known as clinical depression, is a common mood disorder characterized by a depressive episode having five or more symptoms causing significant distress or impairment (not caused by substance abuse or other conditions) lasting two or more weeks. At least one of the five symptoms must be depressed mood or loss of interest.

Symptoms of Depression:

• Depressed mood
• Feelings of worthlessness or guilt
• Fatigue or low energy
• Insomnia or hypersomnia
• Significant change in weight or appetite
• Loss of interest or pleasure in most or all activities
• Psychomotor retardation or agitation
• Recurrent thoughts of death or suicidal ideation
• Poor concentration

Depression screening tools, such as the PHQ-9[2], are used to identify the presence and level of severity.

PHQ-9 Depression Scoring

Bipolar Disorder^[3]

Bipolar disorder, sometimes called manic-depressive disorder, causes extreme shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks. People with bipolar disorder experience periods of intense emotion, changes in sleep patterns and activity levels, and unusual behaviors. These distinct periods are called “mood episodes.” A provider would have to determine whether they may be the result of another cause (such as low thyroid, or mood symptoms caused by drug or alcohol abuse).

Symptoms of Mania:

• Talking more/faster than usual
• Inflated self-esteem (grandiose delusions)
• Extremely high energy and irritability
• More easily distracted
• Increased high-risk/reckless behavior
• Decreased need to sleep

Symptoms of Hypomania:

• Increased restlessness and irritability
• Extremely low energy and fatigue
• Decreased self-esteem
• Difficulty concentrating or making decisions
• Lasting sad, anxious, or empty mood
• Disturbance in sleep/wake cycle

Symptom Profile^[4]

SCHIZOPHRENIA

This disorder affects the way a person thinks, feels and acts. It makes it difficult to differentiate what is real and what is not. Symptoms vary by severity and type. All symptoms may or may not be present in individuals with the condition.^[5]

Symptoms of Schizophrenia:

• Hallucinations
• Delusions
• Lack of focus
• Difficulty completing tasks
• Extreme, disorganized thoughts
• Movement disorders
• Impaired memory
• Unmodulated speech

Coding and Documentation

Major depression and bipolar disorders are classified by their features (type, severity, and presence of psychosis).² Symptoms can manifest differently from person to person. A patient’s complete overall health status requires accurate, detailed documentation of the provider’s assessment. ^[6]

Condition Status

• Active/Current — Provider assessment confirms the condition exists and the diagnosis is documented in the medical record. A patient can have a current diagnosis without being actively involved in treatment.
• “History of” — Patient has previously been diagnosed, the condition has completely resolved, and treatment is no longer needed. Past medical history (PMH)

Avoid using non-specific terms and unspecified codes when details of the condition are known.

Applicable to the current Bipolar Episode. ^[7]

•  Manic Episode (F30.-)

Single manic, hypomanic or mixed bipolar episode.

• Type 1, Type 2, or Mixed (F31.-)
  • Type 1 — Manic episodes (extreme up) lasting one week or longer. May also experience depressive episode for at least two weeks.
  • Type 2 — Hypomanic episodes (extreme low) for four days and depressive episodes for two weeks.
  • Mixed — Meets criteria for manic and depressive episodes almost every day for at least one week.

Applicable to the most recent Major Depressive Episode

• Single episode (F32.-) — By definition, “single episode” applies to the first episode and initial diagnosis of major depressive disorder. Single — Only one (1) in number, unique, sole*
  ICD-10-CM CODE UPDATE: ^[8]
  • Z32.A — Depression, unspecified — Applies to Depression, not otherwise specified (NOS)

Report F32.9, only if “major depressive disorder, single episode, unspecified severity, presence of psychosis unspecified” supported by provider documentation in the medical record.

• Recurrent episode (F33.-) — “Recurrent” applies to each subsequent episode and following encounter after the initial episode has resolved. Recurrent — Repeated; persistent; intermittent*

* Note: Sourced definitions^[9]

Severity:

• Mild — five or six symptoms with mild disability, normal function requires substantially more effort than usual.
• Moderate — 7-9 symptoms with moderate functional impairment.
• Severe — 7-9 symptoms with major disability, inability to function in relationships with others and/or usual activities of day-to-day life.
• In remission — Patient has responded to treatment and no longer meets the criteria for clinical depression. The condition may or may not be currently managed by long term antidepressant medication and/or therapy services.
  • Partial remission – No or minimal symptoms for less than two months
  • Full remission – No or minimal symptoms for two months until treatment is complete and/or condition has resolved.
    

With or Without Psychotic Features

Specify the type and nature of the psychotic features:

Delusions/Hallucinations

Mood-congruent: Consistent with typical depressive theme

• personal circumstance
• guilt,
• shame,
• inadequacy
  

Mood-incongruent: Not consistent with typical depressive themes

• Thought insertion — Other persons thoughts in your head
• Thought broadcasting — Others can hear your thoughts
• Control — Own actions are under outside contro

Additional Classifications

• Persistent Mood Disorders (F34.-) — Symptoms present for most days during the past two years not meeting all criteria for major depressive or bipolar disorder.
  • Cyclothymia — Alternating and recurring periods of depression and hypomania
  • Dysthymia — Persistent depression without psychosis. Mild to moderate chronic depression
• Schizophrenia (F20.-) - Categorized by the manifestation: 
  • Paranoid
  • Disorganized
  • Catatonic
  • Undifferentiated
  • Residual
  • Other and unspecified
• Category F01-F09 — Mental disorders due to known physiological conditions·       Schizoaffective Disorders (F25.0) — Characterized by having symptoms of both schizophrenia and mood disorders (depression, bipolar disorder) alternating from delusions or hallucinations to the predominant mood disorder symptoms during the active period of the condition.

• Category F10-F19 — Mental and behavioral disorders due to psychoactive substance use. 

Behavioral Health Provider Types Valid for Risk Adjustment Reporting

Provider Specialty Codes describe the kind of medicine physicians, non-physician practitioners or other healthcare providers/suppliers’ practice.

• Provider Specialty Code & Description
  • 26 - Psychiatry
  • 27 - Geriatric Psychiatry
  • 62 - Psychologist
  • 68 - Clinical Psychologist
  • 80 - Licensed Clinical Social Worker
  • 86 - Neuropsychiatry
  • D5 - Opioid Treatment Program

Provider Credentials signify a health care provider is a licensed practitioner and the area of specialization.

• Provider Credential & Description
  • LISW - Licensed Independent Social Worker
  • LCSW - Licensed Clinical Social Worker
  • MD, DO - Psychiatry
  • Ph.D. - Doctor of Philosophy, can also be psychologists
  • PSY.D -Doctor of Psychology
  • PMHCNS-BC - Adult Psychiatric-Mental Health Clinical Nurse Specialist
  • PMHNP-BC - Psychiatric-Mental Health Nurse Practitioner

References:

[1] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Fifth edition, 2013

[2] The Patient Health Questionnaire Screener Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute

[3] Bipolar Disorder

[4] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Fifth edition, 2013

[5] 2022 ICD-10-CM Diagnosis Code F25 Schizoaffective disorders

[6] International Classification of Diseases 10^th Revision Clinical Modification ICD-10-CM Official Guidelines for Coding & Reporting

[7] Codes for Depression (F32-F33) and Bipolar (F30-F31) are not reported together.  See “Excludes 1 & 2” category guidelines.

[8] Effective 10/1/2021

[9] Dictionary

AMB21-AR-H-144 Updated on November 15, 2021

Neoplasms and Cancer^[1]

A neoplasm is an abnormal growth or mass of cells called a tumor. Tumor growth, or behavior, can be benign (non-cancerous) or malignant (cancerous). Benign tumors grow in one place and do not spread to other body parts. Malignant tumors grow, spread, and invade other body parts (metastasis).

Types of Cancer

Cancer can start almost anywhere in the human body. Primary cancer refers to the origin of a malignant neoplasm. Metastatic cancer, or secondary cancer, is the formation of a new tumor in a secondary site from the metastasis of the primary cancer.     

Cancer is usually classified by the location it started (i.e. lung cancer, colon cancer, breast cancer, etc.) or the type of cell where it was formed.

• Carcinoma — Epithelial cells, cells covering inside or outside surfaces
• Sarcoma — Bone and soft tissue, includes muscle, fat, blood and lymph vessels, tendons and ligaments
• Leukemia — Bone marrow
• Lymphoma — Lymphocytes (T cells & B cells), white blood cells
• Myeloma — Plasma cells
• Melanoma — Melanocytes, melanin producing cells (pigmented tissue such as skin or eyes)

Detection & Staging

Cancer staging is based on the extent of the tumor. Laboratory studies of blood, urine, and stool to detect abnormalities that may indicate cancer. Imaging tests such as X-rays, CT, MRI, ultrasound, and fiber-optic endoscopy help determine the suspected cancer’s location and size. A biopsy can confirm the diagnosis of most cancers, and other tests can provide specific information about the cancer.

The stage of cancer indicates information about the location, cell type, size, and grade, and if it has spread to a different part of the body. A cancer is always referred to by the stage it was given at diagnosis regardless of progression or regression.

Cancer Treatments

Treatment depends on the cancer type, and how advanced it is. Malignant tissue can be removed with surgical excision or treated using targeted therapy, precision medicine, or stem cell transplant.

Targeted Therapy — Use of drugs to attack specific types of cancer cells with less harm to normal cells.
Precision Medicine — Use of genetic and environmental proteins to treat the cancer
Stem Cell Transplant — Cancerous bone marrow is replaced with healthy bone marrow from a donor.

Coding & Documentation^[2]

Clearly document all know details of the patient’s condition. This should include:

• Behavior — Malignant, Benign,
• Location — Site specific (cell type, anatomical location, laterality)
• Type — Primary, Secondary (include cancer stage) 
• Status — Active, In remission, "History of"

Tips:
For active cancers, document the current treatment. If patient has refused treatment or is under watchful waiting, document the reason and disease progress.

If the patient receives adjuvant therapy, indicate if it is for treatment or prophylactic purposes.

Also report the type of cancer treatment used:

• Radiation Therapy (Z51.0)
  
• Chemotherapy (Z51.11)
  
• Immunotherapy (Z51.12)
  
• Hormone Therapy (Z79.890)

ICD-10-CM Guidelines^[3]

When assigning the diagnosis for neoplasms and cancer, refer to the Neoplasm Table found in the alphabetic index first, unless the histological term is documented (ex. Adenoma). The terms “lump” or “mass” should never be indexed to the neoplasm table. The index directs a coder to see “mass” instead.

• Neoplasm that overlaps two or more contiguous sites should be coded (overlapping lesion) unless specifically classified elsewhere.
• When treatment is directed at the malignancy, make the malignancy the principal diagnosis.
• If the encounter is solely for the administration of chemotherapy, immunotherapy, or radiation therapy, assign a code from category Z51- first.
• When treatment is directed toward a secondary site only, the secondary neoplasm is designated as the principal diagnosis.

Active vs. Historical

Documentation should clearly indicate and provide support for the current condition.

Do not code “history of” when cancer is currently active or assign a code for active cancer if the disease has been treated and no longer exists.

Report a code for active cancer when documentation supports:

• Current treatment or patient’s refusal of treatment
• Further treatment is directed towards site of excised malignancy
• Watchful waiting

History of cancer should be reported as personal history of malignant neoplasm with the appropriate code from category Z85- when documentation supports:

• Malignancy has been removed, treatment was completed or and/or patient is being monitored for a recurrence.
• There is no evidence of disease and no further treatment being directed towards site.
• Adjuvant therapy is for prophylactic purposes.

Leukemia, multiple myeloma and malignant plasma cell neoplasms, have codes indicating whether the cancer has achieved remission status, or is in remission.

• Z85.6 Personal history of leukemia is only used when the physician documents that the patient has been completely cured

Reference
[1] National Cancer Institute

[2] The Web's Free 2022 ICD-10-CM/PCS Medical Coding Reference

[3] ICD-10-CM Official Guidelines for Coding and Reporting (PDF)

AMB21-AR-H-109 Updated on October 18, 2021

Pregnancy^[1]

Pregnancy is the period between conception and delivery in which a fetus develops inside the uterus. This time is divided into trimesters.

• 1st Trimester: Less than 14 weeks
• 2nd Trimester: 14 weeks-28 weeks 
• 3rd Trimester: 28 weeks-delivery

Gestational age is the age of the developing fetus. It begins on the first day of the mother’s last menstrual period and ends at birth (~40 weeks). Document the gestation in weeks and days

Childbirth begins with the true onset of labor and ends after the delivery of the baby and placenta. This is divided into three stages for vaginal deliveries.

1st Stage:

• Begins with onset of contractions.
• Ends when cervix is dilated 10 cm.

2nd Stage:

• Begins when cervix is fully dilated.
• Ends with delivery of baby.

3rd Stage:

• Begins after the baby is delivered.
• Ends after placenta delivery.

Key Terms

• Puerperium — The approximately 6 week period after delivery when the mother’s body adjusts back to a non-pregnant state.
• Products of conception — Tissues that develop during pregnancy (fetal tissue, placenta tissue, etc.).
• Ectopic — A pregnancy that implants outside of the uterus.
• Abortion — Premature induced or spontaneous passing of the products of conception
  • A spontaneous abortion, or miscarriage, is the spontaneous loss of the fetus before the 20^th week of pregnancy.
  • A missed abortion refers to a delayed miscarriage.
  • A threatened abortion refers to a hemorrhage in early pregnancy.
• Perinatal — The period of time before birth through the 28th day following birth.
• Congenital — A condition that is present from birth.

Coding and Documentation

It is important to document condition details to the highest known degree so the diagnosis can be coded to the highest specificity. Documentation should include:

• Patients' pregnancy by week of gestation.
• Normal or high-risk pregnancy and reason for being high-risk, if applicable.
• Underlying or pre-existing conditions.
• Number of fetuses, if multiple, and number or alpha assigned to each (e.g., 1-8, A-H).
• Delivery outcome and location of delivery.
• Normal, full-term, uncomplicated.

Specify any complications and fetal presentation.

Include the diagnosis in the Assessment and Plan when a condition and the supporting evidence is documented during a face-to-face encounter. Include the ICD-10 Diagnosis Code for all documented conditions on the claim form. This includes chronic conditions, even if stable.

Encounter for Delivery:

Category O80

•  Full-term, uncomplicated, vaginal delivery

Category O82

• C-section without indication

Fetal Presentation:

Category O64

• Breech
• Face
• Brow
• Shoulder
• Compound
• Other malposition

Labor & Delivery Complications:

Category O69

• Cord around neck
• Entanglement
• Prolapse

Category O70

• First-fourth degree perineal laceration

Category O71

• Rupture of uterus during labor

ICD-10-CM Guidelines for Coding & Reporting^[2]

Chapter 15 — Pregnancy, Childbirth, and the Puerperium (O00-O9A)

• Chapter 15 codes have sequencing priority over codes from other chapters.
  • Use additional codes from other chapters to further specify conditions when applicable.
  • Use codes O00-O9A only on the maternal record, never on the record of the newborn.
• A code from Category Z34, Encounter for supervision of normal pregnancy, should be used as the first-listed diagnosis for routine outpatient prenatal visits when no complications are present.
  • Report code Z33.1, Pregnant state, incidental, when pregnancy is documented as incidental to the encounter instead of codes from Chapter 15.
  • It is the provider’s responsibility to state that the condition being treated is not affecting the pregnancy.
  • The provider’s documentation of the number of weeks may be used to assign the appropriate code identifying the trimester.
• A code from Category O09, Supervision of high-risk pregnancy, should be used as the first-listed diagnosis for routine prenatal outpatient visits for patients with high-risk pregnancies.
  • Use only during the prenatal period.
• Use applicable Chapter 15 codes for complications during the labor or delivery episode as a result of a high-risk pregnancy.
  • When there is an “in childbirth” option for the obstetric complication being coded, the “in childbirth” code should be assigned.
  • Code the appropriate encounter for full-term uncomplicated delivery if there are no complications during the labor or delivery episode.
  • Other Chapter 15 codes may be used in conjunction with these codes, if appropriate.

References:

[1] ACOG Topics

[2] 2022 ICD-10-CM Guidelines (PDF)

AMB21-AR-H-148 Updated on November 16, 2021

Preventive visits are an important part of the process of keeping patients healthy. These visits improve quality of care and patient health outcomes by identifying patients who need disease management and intervention.

Annual Physical Exams^[1]

Annual Physicals or Routine Comprehensive Physical Exams (CPE) are performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury.  The extent and focus of exam depends on the age and gender of the patient. An annual CPE includes an appropriate history/exam with risk counseling and/or intervention

Exam Description and CPT^© Code:

How should diagnosis codes be reported?^[2]

Category Z00 includes codes for Routine Health Exams with or without abnormal findings and should be the primary diagnosis. Report additional codes, if applicable, for pre-existing and chronic conditions, as well as newly discovered conditions and/or abnormalities documented during the routine exam, regardless of whether the finding requires an additionally reported service.

Follow the current year’s Official ICD-10-CM Guidelines for Coding and Reporting

What can be reported with the CPE?

Tobacco smoking cessation counseling and substance abuse screening/intervention are included with CPE. Refer the current year’s CPT® Code book for further guidance and to view other services covered at the time of a preventive medicine exam.

Can preventive visits be performed on the same day as another visit?

A separately identifiable E/M service may be performed if prompted by symptoms or chronic conditions assessed during the AWV/CPE. Select the appropriate level of E/M services based on the following:

• The level of the medical decision making as defined for each service.
• The total time for E/M services performed on the date of the encounter.

Append modifier -25 to the E/M service (99202 – 99215) when performed on the same day as CPE (99381-99387, 99391-99397)

References:
[1] ICD-10-CM Official Guidelines for Coding and Reporting (PDF)

All services provided require medical record authentication. Signatures may be handwritten or electronic. Rubber signature stamps are not acceptable, unless an exception has been granted due to a physical disability.

Manual Signatures:

• Legible, hand written signature with credential — No date of signature required
• Hand-written signature or initials if provider name/credential on pre-printed progress note
• If the names of two or more physicians are listed on the note, then the provider must have his/her name identified, such as pre-printed name/credential.
• Initials over a typed or pre-printed name with credential.
• “Scribble,” as long as acceptable provider name with credentials is indicated.
• Digitalized signature: Handwritten and scanned into computer must be legible or provider name with credentials must be on record.

Electronic Signature Elements:

• Authentication    
• Practitioner’s name
• Credentials noted
• Date signed *must be within 180 days of date of service
• “Last Updated” is an approved electronic signature date as long as the electronic signature wording is an approved authentication.    
  • If elements of the electronic signature are not met in its entirety, an attestation is needed.
  • Practitioner credentials can be pre-printed anywhere within the DOS.

Transcribed Records:

• Provider Signature authentication statement
• Provider name
• Provider credentials
• Date note signed:
  • Note: To identify a transcribed note, look for indicators such as “Transcribed by,” “Date dictated (DD),” and/or “Date Transcribed (DT).”

Authentication Examples
(Not all inclusive)

• Accepted by
• Completed by
• Electronically signed by
• Released by
• Acknowledged by
• Confirmed by
• Electronically verified by
• Reviewed by
• Approved by
• Digitally signed by
• Encounter sign-off by
• Signature on file
• Authenticated by
• E-authenticated by
• Finalized by
• Signed
• Authorized by
• Edited by
• Generated by
• Signed by
• Closed by
• Electronically generated
• Performed by
• Validated by

Reference: Medicare Program Integrity Manual (PDF)

Medical records must be maintained in a way that adheres to applicable regulations, accreditation standards, professional practice standards, and legal standards.^[1]

The medical record is a legal document that:

• Provides evidence of care provided (or not provided) to the patient.
• Should accurately depict past events.
• May reflect upon professional credibility.

Medical Record Entry Standards

Written Documentation

• Write legibly in permanent ink.
• Put Patient ID number on each page.
• Sign, initial, and date (month, day, year, and time) each entry.
• Make entries as soon as possible.
  • Don’t make entries in advance.
  • Do identify late entries.
• Document all facts relevant to an encounter using specific, factual, and objective language regarding:
  • Patient condition
  • Course of treatment and response to treatment
  • Rationale for deviating from standard treatment, when applicable
  • Test results and/or consultations as well as notes that you reviewed
  • Informed consent/refusal
• Don’t leave blank areas on a page.
• Don’t squeeze in late entries.
• Don’t use personal or non-standard abbreviations.
• Don’t erase or block out information.

When correcting an entry error in a paper chart, remember to:

• Draw a single line through entry errors (make sure original entry is still legible).
• Write “mistaken entry.”
• Use first initial and last name.
• Write the correct entry as close as possible, but not over it.
• Sign and date the entry (including time).
• DO NOT alter the original entry or “black it out.”

EMR Documentation

• Use only approved abbreviations, acronyms, and symbols.
• Don’t cut and paste information from one EMR data field to another.
• Link each data field in the EMR to the patient by name and health record number.
• Each entry and signature must be associated with a date and time stamp.
• Preserve all electronic data, emails, phone messages, and computer records.
• Don’t delete information.

When correcting an error in an EMR, keep in mind:

• Every entry should be date, time, and author stamped.
• The original entry should still be viewable.
• Note the reason for the correction.
• If a hard copy is printed, the hard copy must also be corrected.

Documentation Guidelines for Risk Adjustment

Administrative Requirements

• There must be at least two patient identifiers on each page.
  • Name
  • DOB
  • Unique identifier (e.g., MRN, SSN, Account number, HICN)
• All documentation must be legible and signed by the provider rendering the services and include that provider's credentials. ^[2]

Manual Signatures

• A legible, handwritten signature with credentials.
  • No date of signature is required.
• A handwritten signature or initials if provider name or credentials are on a pre-printed progress note.
• Initials if written over a typed or pre-printed name with credentials.
• “Scribble” is allowed as long as an acceptable provider name with credentials is indicated.
• Digitalized signatures that are handwritten and scanned into computer must be legible or a provider name with credentials must be on record.

Electronic Signatures

• Authentication
• Practitioner’s name
• Credentials noted
• Date signed* must be within 180 days of date of service

***Medicare only***

An attestation is needed If all elements of the electronic signature are not met.

*** Marketplace only***

The EMR signature does not have to be dated or accompanied by a valid authentication statement. The provider’s credentials can be found anywhere in the record (e.g., next to signature or pre-printed within the practice’s stationary).

Acceptable Types of Documentation

Documentation stemming from a face-to-face encounter with an acceptable provider type is required for risk adjustment submissions. Acceptable types of documentation include the following:^[3]

• Progress note - Should include session start and stop time, treatment type and frequency, diagnosis, treatment plan, symptoms, prognosis, and progress. The SOAP note format is common.

Subjective - Individual’s thoughts, feelings, or revelations

Objective - Provider’s observations and factual data

Assessment - Clinical impression and interpretation of subjective and objective

Plan - Treatment plan or next steps

• Treatment summary - Should include a very brief narrative that includes general reason for treatment, basic description of client symptoms, treatment plan goals, session modality/frequency, length of sessions, progress, and prognosis. Treatment summaries often follow the DAP note format.

Data - Facts observed by provider

Assessment - Provider’s clinical impression and interpretation of the data

Plan - Plan to meet treatment goals

NOTE: Psychotherapy notes (or process notes) may include the providers thoughts and feelings about the session or other sensitive information pertaining to the patient’s personal life and must be kept separate from the rest of the patient's chart

• Telemedicine Visits provided via synchronous audio and video technology meet the face-to-face requirement for risk adjustment. Documentation must include that the visit was performed using interactive audio/video with real-time, two-way communications. (Virtual Check-Ins, E-Visits, and Telephone Visits are not acceptable.^[4])

Quick Tip: When submitting handwritten documentation for risk adjustment purposes, consider using pre-printed note or stationery that includes the provider’s printed name and credentials. If there are multiple providers listed, circle the name of provider rendering service.

Acceptable Provider Types

Risk adjustment documentation submissions are only accepted from approved provider types. Acceptable behavioral health specialty and credential types include the following:

Best Practices for Coding & Documentation

• Code all documented conditions that coexist at the time of the encounter/visit and require or affect patient care treatment or management.  This includes ongoing chronic conditions, even if stable.
  • Assess the status of conditions for which interventions are recommended or underway.
  • Documentation from past dates of service may not be used to report codes for the current date of service.
• Assess and document diagnosis for all chronic conditions at least once per calendar year, for as long as the condition exists.
• MEAT and TAMPER are used to help coders determine if a condition can be coded as current or active. At least one of the following elements must be present in at least one section of the medical record to substantiate the presence of a condition.

  Monitor Evaluate Assess/Address Treat

  Treat Assess Monitor/Medicate Plan Evaluate Refer

  • Conditions mentioned in Past Medical History or Active Problem List must be supported in another section of the medical record to verify the condition is active.
  • Include evidence of current review in the form of medication, referrals, order of lab tests, etc. in the assessment and plan.
• Do not code conditions that have been treated or no longer exist.
  • The condition should not be referenced as a “history of” if it is a chronic condition currently undergoing treatment.
  • Documentation where the provider has used the term(s) “history of” will be coded using the appropriate diagnosis code for the historical condition.
• When a condition is documented in a face-to-face encounter, include the corresponding ICD-10 diagnosis code on the claim form.
  • Document to the highest degree, and code to the highest specificity. The ICD-10 diagnosis code must match the wording used in documentation.
  • Explicitly state the diagnosis and follow the official conventions and guidelines for coding and reporting.
• Be clear and consistent throughout the medical record when documenting details of a condition. A diagnosis cannot be validated when the record contains conflicting information.

Reference:

[1] American Health Information Management Association, e-HIM Work Group on Maintaining the Legal EHR, “Update: Maintaining a Legally Sound Health Record—Paper and Electronic,” Journal of AHIMA 76, no.10 (2005): 64A-L.

[2] https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c03.pdf#page=44

[3] Psychotherapy notes, sometimes called process notes, may include the providers thoughts or feelings about the session and other sensitive information pertaining to the patient’s personal life and must be kept separate from the rest of the patient's chart.  https://www.apa.org/monitor/feb03/hipaa

[4] Synchronous audio/video telemedicine requirements are applicable to Medicare risk adjustment only. Marketplace allows reporting of conditions documented during Virtual Check-Ins, E-Visits, and Telephone only visits.

Overview

Epilepsy is a disorder of the brain. People are diagnosed with epilepsy when they have had two or more seizures. There are many types of seizures, and a person with epilepsy can have more than one type of seizure. The signs of a seizure depend on the type of seizure. Sometimes it is hard to tell when a person is having a seizure. A person having a seizure may seem confused or look like they are staring at something that isn’t there. Other seizures can cause a person to fall, shake, and become unaware of what’s happening around them.

Types of Seizures^[1]

Generalized seizures affect both sides of the brain. Characteristics of certain seizures are outlined below:

• Absence seizures (petit mal): staring and subtle body movements; occur in clusters and cause a brief loss of awareness; often occur in children
• Atonic seizures: loss of muscle control, sudden collapse or falling down
• Myoclonic seizures: sudden, brief jerks or twitches of the arms and legs
• Tonic seizures: intense stiffening and contraction of the muscles
• Clonic seizures: associated with repeated or rhythmic, jerking muscle movements; usually affect the neck, face, and arms
• Tonicclonic seizures (grand mal): comprise two stages — a tonic phase and a clonic phase; most dramatic type of epileptic seizure and can cause an abrupt loss of consciousness, body stiffening and shaking, and sometimes loss of bladder control or biting of the tongue

Focal seizures (partial seizures) are located in just one area of the brain.

• Simple focal seizures affect a small part of the brain. These seizures can cause twitching or a change in sensation, such as a strange taste or smell.
• Complex focal seizures can make a person with epilepsy feel confused or dazed. The person will be unable to respond to questions or direction for up to a few minutes.
• Secondary generalized seizures begin in one part of the brain, but then spread to both sides of the brain. In other words, the person first has a focal seizure, followed by a generalized seizure.

Causes^[2]

Infancy

• Congenital brain defects
• Genetics
• Down syndrome

Throughout Life

• Autism
• Medical conditions
• Head injuries
• Brain tumors

Elderly

• Alzheimer’s disease
• Stroke

Symptoms

Because epilepsy is caused by abnormal activity in the brain, seizures can affect any process the brain coordinates. Seizure signs and symptoms may include:

• Temporary confusion
• A staring spell
• Uncontrollable jerking movements of the arms and legs
• Loss of consciousness or awareness
• Psychic symptoms such as fear, anxiety, or deja vu

Symptoms vary depending on the type of seizure. In most cases, a person with epilepsy will tend to have the same type of seizure each time, so the symptoms will be similar from episode to episode.

Treatment

• Medication
• Vagus nerve stimulator
• Surgery
• Dietary changes

Diagnosis

• Blood tests — help discount other reasons for seizures, like genetic conditions or infections
• Neuropsychological tests — test speech, thinking, and memory skills to see if those areas of the brain have been affected by seizures
• Electroencephalogram (EEG) — records electrical activity in the brain
• Computerized tomography (CT) scan, positron emission tomography (PET) scan, magnetic resonance imaging (MRI) — show any abnormalities in the brain structure
• Functional MRI (fMRI) — shows which part of the brain uses more oxygen when the person speaks, moves, or does certain tasks
• Magnetic resonance spectroscopy (MRS) — creates an image to help compare how different parts of the brain work
• Single-photon emission computerized tomography (SPECT) — helps identify where seizures start in the brain

Complications

• Difficulty in learning in kids
• Psychological issues
• Permanent brain damage
• Aspiration pneumonia
• Pregnancy complications
• Injuries

Coding & Documentation Best Practices

Monitor, Evaluate, Assess, Treat (MEAT)

Any disease or disorder reported for a patient should be supported by documentation showing that the condition was monitored, evaluated, assessed, or treated (MEAT) during the encounter. For seizures/epilepsy, evidence of MEAT might include the following documentation:

Monitoring

• Feelings of fear or anxiety
• Temporary confusion

Evaluation

• Jerky movements in arms and legs
• Loss of consciousness

Assessment 

• Disease control
• Efficacy of treatment

Treatment

• Referrals to/notation of specialists involved in care, such as neurologists
• Order tests: EEG, MRI, CT
• Patient education, such as:
  • Seizure characteristics
  • Medication and diet

Current vs. Historical

Do not describe current seizure(s), seizure disorder, or epilepsy as “history of.” In diagnosis coding, the phrase “history of” means the condition is historical and no longer exists as a current problem. Do not document past seizure(s) or seizure disorder as current if the condition has resolved, has not recurred, and is no longer being treated.

ICD-10-CM Categories^[3]

Category R56, convulsions not elsewhere classified

Seizures or convulsions that are not identified as epilepsy or as a seizure disorder classify to category R56.

Category G40, epilepsy and recurrent seizures

Conditions in category G40 represent specific and precise diagnoses rather than a sign or symptom of another ill-defined disease or condition.

• Fourth, fifth, and sixth characters are added to specify the particular type of epilepsy or recurrent seizures, whether the condition is intractable, and with or without status epilepticus.

Conditions that classify to the epilepsy and recurrent seizures category G40 are:

• Seizure disorder
• Epileptic seizure(s)
• Epileptic attack
• Fit (NOS)
• Epileptic convulsion(s)
• Epilepsy Post-traumatic seizures/post-traumatic epilepsy

Post-traumatic seizures (PTS) and post-traumatic epilepsy (PTE) are complications from traumatic brain injury (TBI). PTE refers to recurrent and unprovoked PTS that occur at least one week after TBI.

• Post-traumatic seizures code to R56.1, which excludes post-traumatic epilepsy (G40.---).

Coding Examples

Example 1

Documentation: Patient is a 28-year-old female with known seizures followed by neuro

Coding Index Path: Seizure(s) See Also Convulsions

ICD-10-CM code(s): R56.9

Example 2

Documentation: Patient is a 28-year-old female with known generalized idiopathic intractable epilepsy followed by neuro

Coding Index Path: Epilepsy > Generalized > Idiopathic > Intractable

ICD-10-CM code(s): G40.319

Example 3

Documentation: Patient presents with history of partial complex seizures. Current seizure medication includes Topamax®.

ICD-10-CM code (s): G40.209

Comments: An anticonvulsant medication is being taken to prevent a recurrence, as this is treatment rath

Reference:

[1] https://www.cdc.gov/epilepsy/about/types-of-seizures

[2] https://www.mayoclinic.org/diseases-conditions/seizure/symptoms-causes/syc-20365711

[3] https://www.cms.gov/files/document/fy-2023-icd-10-cm-coding-guidelines-updated-01/11/2023.pdf (PDF)

Sepsis, Severe Sepsis, and Septic Shock^[1]

Sepsis is the immune systems extreme response to an infection. The chemical released into the bloodstream by the immune system attack the body instead of fighting the infection.  Sepsis can quickly lead to tissue damage, organ failure and death. Early identification and treatment is critical.

• Septicemia or sepsis — Bacterial, viral or fungal infection in the bloodstream, also called blood poisoning.
• Inflammatory Response Syndrome (SIRS) - Systemic inflammation due to a blood born infection or other non-infectious cause such as trauma or injury.
• Severe Sepsis — Sepsis with systemic organ dysfunction, hypoperfusion (reduced blood flow) or hypotension (low blood pressure).
• Septic Shock — Severe sepsis with extreme, persistent hypotension and circulatory failure. 

Signs and Symptoms

Sepsis may cause any of the following:

• Rapid breathing and heart rate
• Extreme pain or discomfort
• Shortness of breath
• Fever, shivering, or feeling very cold
• Confusion or disorientation
• Clammy or sweaty skin
• Nausea and vomiting
• Blotchy, pale, or discolored skin

Coding and Documentation

There is no single diagnostic test or comprehensive clinical criteria for sepsis.  The diagnosis requires clinical judgment of the provider based on evidence of infection and organ dysfunction.^[2]

The level of detail in the documentation impacts coding and reporting accuracy.

• Identify the infectious agent or causal organism as well as the related infectious or non-infectious condition.
• Document the severity of the condition and including the organ(s) affected with the nature and severity of dysfunction.
• Specially state the causal relationship (due to/cause of) between sepsis and:
  • Other infectious conditions
  • Non-infectious conditions
  • Post-procedural infections

To determine the proper code sequencing:

• Clearly state the reason for the hospital admission or the primary diagnosis.
• Note whether sepsis is present on admission or if it developed after admission, if not the cause.

Sepsis would not typically be assigned in the outpatient setting due to the acute nature of the condition.

Diagnosis Code Sequence

With Localized Infection

With Non-Infectious Condition

Due to Post-procedural Infection

ICD-10-CM GUIDELINES^[3]

Refer to ICD-10-CM Official Guidelines for Coding and Reporting and review conventions in the tabular list:

• First, code for the underlying systemic infection. Use A41.9 Sepsis, unspecified organism, when the infection is not identified.
• Then use the appropriate codes to identify severe sepsis and septic shock.
• Additional code(s) for the associated acute organ dysfunction are required.
• Never assign severe sepsis or septic shock as principal diagnosis.
• Do not code severe sepsis unless severe sepsis or associated acute organ dysfunction is documented.
• Negative labs do not rule out sepsis when there is clinical evidence of the condition.
• Query provider when:
  • Clinical evidence of sepsis is present with negative or inconclusive labs
  • “Urosepsis” is documented

References:

[1] Sepsis, Severe Sepsis, and Septic Shock | Principles of Critical Care, 4e | AccessMedicine | McGraw Hill Medical

[2] Hospital Toolkit for Adult Sepsis Surveillance (PDF)

[3] 2022 ICD-10-CM Guidelines (PDF)

AMB21-AR-H-147 Updated on November 16, 2021

What Are Social Determinants of Health?

Social determinants of health are the conditions in the environments where people are born, live, learn, work, play, and age. These social factors can create significant barriers for a person’s wellness and health.

Who Can Collect SDoH Data?

Any member of a person’s care team can collect SDoH data. This includes providers, social workers, case managers, patient navigators, and nurses.

Why Is it Important to Collect SDoH Data?

This data allows our organization to develop and execute a coordinated and evidence-based strategy to improve population health.

Risk Adjustment Documentation and Coding Best Practices

The ICD-10-CM codes included in categories Z55–Z65^[1] and Z75^[2] identify non-medical factors that may influence a patient’s health status, such as their socioeconomic situation, including education and literacy, employment, housing, lack of adequate food or water, or occupational exposure to risk factors like dust, radiation, or toxic agents.

When providing services to a member, if social determinants are observed, the appropriate ICD-10-CM code(s) should be submitted on a claim. Including SDoH ICD-10 Z codes on the claims you submit will help to better strategize and address the social needs of our members.

The table below shows supplemental diagnosis codes and should not be used as the admitting or principal diagnosis code(s) to indicate the medical reason for the visit. The codes listed here are not all inclusive.

Supplemental diagnosis codes

The above material is for informational purposes only and is not intended to be a substitute for a physician’s independent medical judgment. Physicians and other healthcare providers are encouraged to use their best medical judgement based on all available information and the condition of the patient in determining the best course of treatment.

[1] Persons with potential health hazards related to socioeconomic and psychosocial circumstances Z55-Z65

[2] Problems related to medical facilities and other health care Z75-

AMB22-AR-H-157 Updated on November 10, 2022

In the 5^th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the American Society of Addiction Medicine created a category called substance use disorders. This category combines the concepts of “substance abuse” and “substance dependence” into a single disorder, measured on a continuum from mild to severe.

Diagnostic Criteria^[1]

DSM-5 defines substance use disorder as a problematic pattern of substance use leading to clinically significant impairment or distress, as manifested by at least two of the following occurring in a 12-month period:

DSM-5 Criteria for Substance Use Disorders

1. Substance is often taken in larger amounts or over a longer period of time than was intended.
2. Persistent desire or unsuccessful efforts to cut down or control substance use.
3. Great deal of time spent in activities to obtain the substance, use the substance, or recover from its effects.
4. Craving or strong desire to use the substance.
5. Recurrent use resulting in failure to fulfill major role obligations at work, school, or home.
6. Continued substance use despite persistent or recurrent social or interpersonal problems.
7. Important social, occupational, or recreational activities are given up or reduced because of substance use.
8. Recurrent substance use in situations in which it is physically hazardous.
9. Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
10. Tolerance, as defined by either of the following:
    • A need for markedly increased amounts of the substance to achieve desired effect
    • A markedly diminished effect with continued use of the same amount of substance
11. Withdrawal, as manifested by either of the following:
    • Characteristic withdrawal syndrome for the substance
    • Use of the substance or closely related substance is taken to relieve or avoid withdrawal symptoms

Note: Symptoms of tolerance and withdrawal occurring in the context of appropriate medical treatment with prescribed medications (e.g., opioid analgesics, sedatives, stimulants) are specifically not counted when diagnosing a substance use disorder. Furthermore, the DSM states:

“The appearance of normal, expected pharmacological tolerance and withdrawal during the course of medical treatment has been known to lead to an erroneous diagnosis of addiction, even when these were the only symptoms present.”

Use, Abuse, and Dependence

Unlike DSM-5, ICD-10-CM continues to employ the concepts of substance abuse and substance dependence.

Substance abuse represents a maladaptive pattern of drug-taking, which may include detriments to social functioning, to physical well-being and/or to mental health in patients who have not yet reached a state of physical dependence.

Substance dependence is defined as a chronic mental and physical condition related to the patient's pattern of drug-taking that is characterized by behavioral and physiological responses, which may include:

• A compulsion to take the drug in order to experience its psychic effects, or to avoid the discomfort of its absence.
• An inability to stop the use of the drug despite strong incentives.
• Physical dependence (i.e., tolerance and withdrawal).

When documenting substance use disorders, include the following:

• Severity — Mild, moderate, etc.
• Pattern of use — Continuous use, in remission, relapsed, etc.
• Substance-induced mood/psychotic symptoms — Depression, hallucinations, anxiety, etc.
• Current presentation — Intoxication, drunkenness, withdrawal
• Treatment plan — Rehabilitation, maintenance therapy (specify drug), AA, etc.

Drug dependence in context of appropriate medical treatment — Physical dependence (i.e., tolerance and withdrawal) can develop with the chronic use of many drugs. This can include prescription drugs, even if taken as instructed. ICD-10-CM does not distinguish between this normal, expected response and other forms of drug dependence. Any type of drug dependency (i.e., prescribed, non-prescribed [illicit], physiological and/or behavioral) is coded similarly.

The “substance use disorders” of DSM-5 are reported in ICD-10 as follows:

When use, abuse, and dependence of the same substance are documented in the encounter note, only one code should be assigned based on the following hierarchy:

ICD-10-CM Code Selection

The presence of a condition can’t be assumed, even if evidence is present in the medical record. It requires the provider’s clinical judgment and explicitly stated diagnosis. The diagnosis code reported must match the documented diagnosis assessed by the provider.

Identify the substance:^[3]

• Alcohol  (F10)
• Stimulant (F15) (non-cocaine)
• Opioid (F11)
• Hallucinogen (F16)
• Cannabis (F12)
• Nicotine  (F17)
• Sedative/Hypnotic/Anxiolytic (F13)
• Inhalant (F18)
• Cocaine  (F14)
• Other Psychoactive Substance (F19)

The severity is determined by the number of symptoms present in the individual.

• Mild — 2-3
• Moderate — 4-5
• Severe — 6 or more
• In remission — Remission occurs when none of the criteria for substance use disorder (except craving) for at least three months.
  • Early remission: more than three to less than 12 months
  • Sustained remission: more than 12 months

Further specify any applicable detail:

• Environment or method of achieved remission
  • “In a controlled environment” — When the individual in remission is in a supervised residential setting where access to alcohol and controlled substances is restricted
  • “On maintenance therapy” — When the individual in remission is being maintained on a prescribed medication (e.g., agonist, partial agonist, agonist/antagonist, or full antagonist)
• Association with intoxication or withdraw
• Presence of induced manifestation or complication
  • Delirium
  • Perceptual disturbance
  • Anxiety
  • Sexual dysfunction
  • Sleep or mood disorder
  • Persisting amnestic disorder or dementia
• Detailed clinical diagnosis and treatment plan/condition management

References:

[1] American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association, 2013.

[2] DSM-5 Criteria for Addiction Simplified

[3] 2022 ICD-10-CM Codes for Mental and behavioral disorders due to psychoactive substance use (F10-F19)

[4] ICD-10-CM Categories F10-F19 have been expanded to include substance and alcohol use in remission effective October 1, 2023. FY2023 official coding guidelines and descriptions can be found at https://www.cms.gov/medicare/icd-10/2023-icd-10-cm

AMB21-AR-H-146 Updated on November 16, 2021

A Cerebrovascular accident (CVA), also known as a stroke, occurs when there is an interruption to blood flow that supplies oxygen to the brain.^[1] There are two different types of strokes:

• Ischemic Stroke —  Blockage of blood vessel in the brain due to a blood clot or stenosis.
• Hemorrhagic Stroke — Bleeding into the brain caused by a broken blood vessel.

A stroke is an emergent event that requires treatment in an acute care setting.^[2]

Residual or late effects (sequelae) caused by a stroke may be present from the onset of a stroke or arise at ANY time after the onset of the stroke. Some conditions develop slowly and exist over extended periods. Others develop suddenly and last only a few days or weeks.

A transient ischemic attack (TIA) is a temporary episode of neurologic dysfunction caused by ischemia without acute infarction. It is sometimes referred to as a mini stroke because the symptoms are similar to that of a stroke. The symptoms can resolve within minutes, or can last up to 24 hours.

Documentation

Detailed documentation is necessary for proper code selection:

• Specify the location or source of hemorrhage and its laterality.
• Specify the source of occlusion and the vessel affected.
• If applicable, identify the specific neurologic or cognitive deficit, identify the affected extremity and laterality and whether it is the dominant or non-dominate side, and specify the type of event as the causing of the sequelae.

Key Terms:^[3]

• Stenosis — narrowing
• Occlusion — complete or partial obstruction
• Thrombosis — stationary blood clot lodged in vessel
• Embolism — blood or other clot carried through vessel
• Meninges — protective membranes surrounding the cerebral cortex (brain)
  • Dura matter (outer), Arachnoid (middle), Pia matter (inner)
• Epidural — between dura matter and skull
• Subdural — between dura matter and arachnoid
• Subarachnoid — between arachnoid and pia matter
• Precerebral arteries — vertebral, basilar, carotid
• Cerebral arteries — anterior, middle, and posterior

Coding

Assign the most specific code as appropriate according to documentation. More than one code may be assigned if specific code is available for separate locations. Watch for parenthetical notes found in the tabular list (e.g., excluded conditions, coding sequence, etc.).

Acute conditions must only be reported when present and actively being treated. Chronic conditions should be reported when treatment is required and/or affects care.  Once a condition has resolved, it should no longer be reported as active.

ICD-10-CM Codes^[4]

• Category I60 — I62: Non-traumatic cerebral hemorrhage
• Category I63: Cerebral Infarction
• Category I65 — I68: Other cerebrovascular disorders and diseases
• Category I69: Sequelae of cerebrovascular disease

Acute conditions found in Category I60-I67 are applicable to the initial event.

After discharge from acute care, the condition is classified by:

• Sequela (late effects) found in Category I69.
• Personal history of CVA or TIA without residual deficits, Z86.73.
  • Transient cerebral ischemic attack, G45.9 should be reported at the time of initial diagnosis. Refer to personal history of TIA and CVA without residual deficits,  Z86.73 for subsequent encounters.
  • See Category S06 for Intracranial hemorrhage due to accident or injury (traumatic).
  • See Category I97 & G97 for guidance on intraoperative and postoperative events. Causal relationships must be clearly documented.
  • Use Additional code to identify presence of:
    • Alcohol abuse and dependence (F10.-)
    • Exposure to environmental tobacco smoke (Z77.22)
    • History of tobacco dependence (Z87.891)
    • Hypertension (I10-I16 )
    • Occupational exposure to environmental tobacco smoke (Z57.31)
    • Tobacco dependence (F17.-)
    • Tobacco use (Z72.0)

NOTE: The information listed here is not all inclusive and is to be used as a reference only. Please refer to applicable coding and documentation resources for the current year.^[5]

References:

[1] Medical Definition of Cerebrovascular accident

[2] Cerebrovascular Disease

[3] Stroke

[4] The Web's Free 2022 ICD-10-CM/PCS Medical Coding Reference

[5] ICD-10

Peripheral vascular disease (PVD) describes any disorder of the blood vessels outside the heart and chest or disorders that affect blood flow through the arteries and/or veins.

Peripheral vascular disease (PVD) is also known as:

• Peripheral artery disease (PAD)
• Peripheral arterial insufficiency
• (Intermittent) Claudication
• Peripheral angiopathy
• Spasm of artery

ICD-10-CM code I73.9 — Peripheral vascular disease, unspecified is assigned for all conditions listed above when documented in the medical record.^[1]

Arteriosclerosis is the hardening of the arteries. Atherosclerosis is a pattern of arteriosclerosis in which the artery narrows due to the buildup of plaque (fatty deposits) inside the artery the wall.^[2]

These conditions are applicable to ICD-10-CM Category I70:

• Arteriolosclerosis
• Arterial
• Arteriosclerosis
• Arteriosclerotic vascular disease
• Arteriovascular degeneration
• Atheroma
• Endarteritis deformans or obliterans
• Senile arteritis
• Senile endarteritis
• Vascular degeneration

PVD due to atherosclerosis should be documented, if applicable, to correctly assign codes with higher specificity. Note: Atherosclerosis of extremities; unspecified refers to type, not location.

Signs and Symptoms^[3]

Examples include:

• Claudication — Foot, calf, buttock, hip or thigh pain or discomfort when walking that is relieved by rest.
• Cyanosis — Bluish discoloration of the skin resulting from poor circulation.
• Femoral or Carotid bruit - vascular murmur sound heard over a partially occluded blood vessel on auscultation.
• Slow healing wound or skin infection
• Slow capillary refill
• Numb/painful sensations in extremities
• Atrophic skin changes
• Decreased nail growth
• Abnormal or diminished pedal pulses
• Non-pressure ulcer
• Toes or feet appear pale or discolored
• Ischemic rest pain

Abnormal physical exam findings must be confirmed with diagnostic testing.^[4]

• Ankle brachial index (ABI)
• CT angiogram (CTA)
• Doppler ultrasound
• MRI

Other vascular diseases:

• Aneurysm
• Deep vein thrombosis
• Varicose veins
• Chronic venous insufficiency
• Critical, limb-threatening ischemia

Complications and Interventions

Early interventions can the lower the risk of complications.^[5]

Complications:

• Limited mobility
• Infection
• Amputation
• Heart attack

Interventions:^[6]

Lifestyle Changes:

• Healthy diet
• Regular exercise
• Lose weight
• Quit smoking

Medications:

• Statins
• Vasodilators
• Anticoagulants

Procedures:

• Angioplasty
• Stents
• Endarterectomy
• Thrombolysis (CDT)

Coding and Documentation

Include the following details in the medical record:

• Cause (e.g., atherosclerosis, stenosis)
• Location of vein/artery affected (leg, foot, heal, ankle, calf, thigh)
• Laterality — specify left, right or bilateral
• Status of the artery (e.g., native, bypass graft, autologous, non-autologous biological)
• Complications such as rest pain, intermittent claudication, ulceration (document ulcer site) or gangrene.

Document diagnostic test results and any clinical findings that support PVD along with disease status and treatment plan.

Also include the following details, when applicable:

• Risk factors (e.g., tobacco use, high cholesterol, morbid obesity)
• Counseling provided to patient (e.g., smoking cessation)
• Co-morbidities such as HTN, DM, and CAD with disease status and treatment plan.

References:

[1] 2022 ICD-10-CM Diagnosis Code I73.9

[2] Atherosclerosis

[3] What Is Vascular Disease?

[4] Everett Stephens, MD. Peripheral Vascular Disease Guidelines. [Updated 2017 Dec. 31]. In: Medscape [Internet]. 1994–2020 by WebMD LLC. Peripheral Vascular Disease Guidelines 

[5] Smith DA, Lillie CJ. Arterial Occlusion, Acute. [Updated 2020 Apr. 23]. In: StatPearls [Internet]. Treasure Island (FL): Stat Pearls Publishing; 2020 Jan. Acute Arterial Occlusion. Attribution 4.0 International (CC BY 4.0) 

Hepatitis means inflammation of the liver. Toxins, certain drugs, some diseases, heavy alcohol use, bacterial or viral infections can cause hepatitis. Hepatitis is also the name of a family of viral infections that affect the liver.

Viral Hepatitis Types^[1]

Acute viral hepatitis generally resolves within a few months from the date of onset. In other cases, the disease becomes a long-term or chronic illness.

Chronic hepatitis is classified as inflammation caused by viral hepatitis lasting longer than six months. If left untreated, chronic hepatitis can cause serious health problems, including liver damage, cirrhosis, liver cancer, and even death

• Hepatitis A — Caused by ingesting contaminated water or food. Highly contagious, can also be contracted from close contact with an infected person or object.
• Hepatitis B — Spread through bodily fluids during sexual contact or through blood transfusions
• Hepatitis C — Blood-borne, spread through direct contact with infected blood. Primarily transmitted by needles shared among drug abusers, blood transfusion, hemodialysis and needle sticks, can also be transmitted by sexual contact
• Hepatitis D — Also known as delta, cannot occur in the absence of Hepatitis B.  Hepatitis B with delta agent is the most severe form of (acute and chronic) hepatitis^[2]
• Hepatitis E — Acute condition caused by ingesting contaminated food or water, which does not lead to chronic hepatitis

The most common types are Hepatitis A, Hepatitis B, and Hepatitis C. Hepatitis A and E are acute in nature and do not lead to chronic hepatitis. Hepatitis B, C, and D viruses can cause chronic, sometimes lifelong conditions.

Signs and Symptoms

Signs and symptoms of viral hepatitis may or may not be present. Only lab tests can confirm which viral agent is present. Symptoms can include:

• Nausea          
• Vomiting       
• Loss of Appetite
• Jaundice        
• Abdominal pain       
• Dry mucous membranes
• Malaise/fatigue        
• Anorexia        
• Ascites
• Hepato-jugular reflex          
• Firm/enlarged liver
• Palmar erythema

Diagnostic Testing

Hepatitis A (HAV)

• Hepatitis A surface antibody (HAV IgM) test detects the first antibody produced by the body when it is exposed to Hepatitis A. It detects early or recent infections and diagnoses the disease in people with symptoms of acute hepatitis.

Hepatitis B (HBV)

• Hepatitis B surface antigen (HBsAg) is present in acute and chronic infection.
• Anti-Hepatitis B core antigen (Anti-HBc IgM) is only positive during the acute phase of the infections.

Hepatitis C (HCV)

• There is no acute infectious phase serological testing available.
• Confirmation of infection determined by Anti-Hepatitis C (Anti-HCV) for initial screening, which can be confirmed with more specific testing through polymerase chain reaction (PCR) and/or nucleic acid testing (NAT).

HCV Screening &Test Results^[3]

HCV Antibody Test:

Non-reactive/Negative, HCV not present

Never had HCV

Recent HCV infection

• 2–9 mos. to produce antibodies

Weak immune system

• Unable to produce antibodies

Reactive/Positive,  HCV present (need add’l test) 

• Possible current HCV infection
• History of HCV
  • Virus cleared naturally
  • Virus medically treated/cured

HCV RNA Viral Load Test:

Undetectable, No HCV found in bloodstream 

• Spontaneously cleared
• Medically cured
• Recently infected,  less than two weeks
• Within lower limit of detection (LLOD)
  • vVaries, can be as low as <5 IU/mL

Detectable < LLOQ, HCV present in bloodstream less than lower limit of quantification (LLOQ) 

• Amount too small to measure

Detectable

• HCV present in bloodstream

Other Chronic Hepatitis and Related Conditions

• Autoimmune hepatitis — Caused by the body’s own immune system attacking hepatic cells of the liver, typicClly due to genetic predisposition or environmental exposure.
• Lobular Hepatitis — Affects one or more of the four lobes (caudate, quadrate, left, right) of the liver.
• Hepatomegaly — Enlarged liver
• Hepatic fibrosis — Chronic injury or inflammation causes a buildup of scar tissue.
• Hepatic cirrhosis — Late stage of hepatic fibrosis with changes to the organ structure. —Caused by many liver diseases and conditions, such as hepatitis and chronic alcoholism.
• Hepatocellular carcinoma — Most common form of liver cancer, which is caused either by genetic predisposition, hepatitis, or underlying cirrhosis.

Coding and Documentation

 Detailed documentation is necessary for proper code selection.

• Identify the type of hepatitis
• Indicate the acuity — Chronic, acute, with/without hepatic coma, with/without delta agent
  
  • If viral hepatitis is not specified as acute or chronic, assign the appropriate code for unspecified viral hepatitis from Category B19.
  • Viral hepatitis in remission, any type, code to Hepatitis chronic, by type.
  • For patients who have had a liver transplant, document and report the appropriate transplant status code and document any anti-rejection drugs if appropriate.
• Specify the causal agent or behavior that led to the acquisition of hepatitis.
• Refrain from using the term “History of” if a patient still has an active viral infection.
• Document treatment and follow up.

ICD-10-CM Code Selection^[4]

Chronic hepatitis NEC:

(See Category K73) 

• Persistent
• Lobular
• Active 
• Other

Hepatic Failure:

(See Category K70 – K72, K76)

• Acute, chronic, alcoholic, unspecified
• Portal hypertension 
• Hepatorenal syndrome
• Hepatopulmonary syndrome

Cirrhosis:

(See Categories K70, K74)

• Primary/secondary biliary
• Alcoholic with/without ascites
• Unspecified

Related Conditions:

• Auto-immune hepatitis (K75.4)
• Jaundice (R17)
• Malignant neoplasm of liver (C22-)
• Alcoholic liver disease (K70.9)
• High risk sexual behavior (Z72-)

Reference:

[1] What is Viral Hepatitis?

[2] Hepatitis D

[3] Hepatitis C Virus (HCV) Diagnostics (PDF)

[4] Diseases of Liver

AMB21-AR-H-145 Updated on November 15, 2021

• 2023 ARHome Quick Reference Guide
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• Ambetter CAHPS HOS Survey Best Practices (PDF)
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