Diagnostic Specificity Is Key to Payment Accuracy for MA Plans

By Holly J. Cassano, CPC

Accurate payment under the Centers for Medicare & Medicaid Services (CMS) risk adjustment reimbursement model depends on diagnosis code specificity and reporting all current chronic conditions. A leading cause of incorrect and/or insufficient reimbursement from Medicare Advantage (MA) plans is deficient hierarchal condition categories (HCC) code reporting.

Evaluation and Management – CEMC

CMS has been accepting up to eight diagnosis codes since 2007. Unfortunately, many physician practices are either not aware of this, or their electronic health record (EHR) and/or clearinghouses allow only four to six diagnosis code entries for claims submission. A practice can instruct its coders to submit all co-existing chronic diseases documented at the time of service, but this is of no help if your EHR or clearinghouses won’t accept all of the diagnoses submitted.

Too Many Diagnosis Codes Cause Confusion

A Coding Edge reader—understanding the importance of reporting all active chronic conditions that co-exist at the time of service (TOS)—recently asked about proper processes for submitting diagnoses in the EHR, and what to do if you have to submit more than eight diagnoses on a claim form. Specifically, the reader asked, what happens if and when:

  • The physician treats patients with 10 or more diagnoses addressed during a visit?
  • Coders validate the first eight diagnoses listed in lieu of sequencing?
  • Providers do not sequence the diagnosis codes while listing more than eight diagnoses?

Educate the Vendor and Payer

First, contact your vendor and find out (verbally and in writing) the number of diagnosis codes the vendor will accept electronically per claim. Find out also if the vendor and payer will accept CPT® 99080 Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form, which may be used as an adjunct to a regular evaluation and management (E/M) office visit code to submit additional diagnosis codes for capturing chronic conditions.

Contact all MA plans with which the practice participates, and obtain in writing how many diagnosis codes each payer will accept. If the number is less than eight, ask if the payer will accept 99080 for the additional diagnosis codes (and get the reply in writing).

Inquire how many codes any commercial carriers accept in your practice to prevent future claims issues with the adoption of ICD-10, which will require even greater due diligence and coding specificity.

Sequencing Is Important

Sequencing can have a dramatic effect on payments if the nature of the presenting problem (NOPP) and subsequent co-existing conditions are either under-reported or incorrectly reported to an MA plan. The key to successful sequencing begins with an assessment and a plan. For example:

  • Determine the primary diagnosis by identifying the primary focus of care.
  • Determine which of the other diagnoses affect treatment and coexist at the TOS. Be sure to report these diagnoses (linking to other services isn’t necessary if only an E/M service is provided).
  • All pertinent diagnoses must be listed to justify the services rendered.

The CMS risk adjustment model was implemented to promote specificity and discourage vague or unspecified coding. ICD-10 will promote this, as well. To ensure compliance and receipt of accurate payments through proper identification of chronic diseases, implement a strategy now. Be sure payers recognize all the diagnoses reported, so you don’t suffer potentially harmful consequences to your practice down the road.

Holly J. Cassano, CPC, has been involved in practice management, coding, auditing, teaching, and consulting for multiple specialties for the past 16 years. She served two terms as an AAPC local chapter officer, maintains an online column for Advance for Health Information Professionals, and writes for Justcoding.com. She is the CEO of ACCUCODE Consulting, LLC and blogs for medicalcodingandbilling.org via Consumer Media Network (CMN). She works for Preferred Care Partners as a CDI specialist, based out of The Villages, Fla. You can reach her at accucodeconsultingllc@centurylink.net and follow her on Twitter@hollycassano.

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