Make the Most of HCCs: Part 2
Part 2: Explore more commonly under-coded conditions and bolster documentation.
Accuracy and specificity in diagnosis coding and medical documentation are critical in risk adjustment models. This second installment of our three-part series examines additional commonly under-coded conditions included in the Medicare hierarchical condition category (HCC) risk adjustment model, and discusses documentation strategies for improving diagnosis coding.
Major Depressive Disorder,
Bipolar, and Paranoid Disorders
Depression is a serious disorder affecting both the mind and body. Left untreated, the condition often becomes more severe and can damage all areas of a person’s life.
Doctors employ a variety of methods to diagnose depression, including a physical exam, lab tests, and psychological evaluations. Mental health providers use the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to diagnose mental health conditions.
Bipolar and manic disorders also are included in this category. These disorders are characterized by mood swings that can go from very high to very low. Conditions of this nature are usually treated with medication and counseling.
ICD-10 provides an increase in coding specificity within this category (as it does on a whole compared to ICD-9). The added volume of codes that are risk adjusted in the new code set is substantial. Physician documentation should state whether the episode is single or recurrent, the severity, with or without psychotic features, and remission status (partial or full). New concepts in ICD-10 include depressive reaction, psychogenic depression, and reactive depression. Codes now require more specificity for intentional self-harm and suicide attempts.
Rheumatoid Arthritis and
Inflammatory Connective Tissue Disease
Rheumatoid arthritis (RA) is an autoimmune disorder that occurs when the immune system mistakenly attacks its host. Considered a chronic inflammatory disorder, RA affects the lining of the joints, which causes painful swelling. The disease can affect other organs of the body, as well, including the skin, eyes, lungs, and blood vessels.
Signs and symptoms of RA include tender, warm, swollen joints, morning stiffness, firm tissue bumps under the skin of the arms, fatigue, fever, and weight loss. RA increases the risk of developing other diseases, such as osteoporosis, carpal tunnel syndrome, heart problems, and lung disease. There is no known cure for RA; treatment focuses on controlling symptoms and preventing joint damage. According to current American College of Rheumatology guidelines and clinical practice standards, patients with RA require initiation of disease-modifying anti-rheumatic drug (DMARD) therapy within three months of diagnosis.
RA can be difficult to diagnose in its early stages because the early signs and symptoms mimic those of many other diseases. There is no single blood test or physical finding to confirm the diagnosis. A diagnosis is made by physical exam, blood tests, and X-rays.
For documentation and coding purposes, it’s important to avoid the common pitfall of using a “rule out” diagnosis code. Do not use an RA code until a definitive diagnosis is made. Code the patient’s symptoms, such as pain in joints, until the diagnosis is confirmed.
Other common diagnoses in this category include polymyalgia rheumatic and sicca syndrome (Sjögren’s syndrome).
This category has more codes to choose from in ICD-10 than it had in ICD-9. This is due to the introduction of several new concepts: laterality, with or without organ or system involvement, and with or without rheumatoid factor.
Specified Heart Arrhythmias
An arrhythmia is an abnormal heart rhythm that occurs when the electrical impulses in the heart don’t function correctly. This causes the heart to beat too fast (tachycardia), too slow (bradycardia), or erratically.
Symptoms include palpitations, fluttering dizziness, shortness of breath, and fatigue. It’s not uncommon for a patient to be asymptomatic and to have the arrhythmia revealed only through a physical exam.
Arrhythmias can be caused by a number of different factors, such as:
- Scarring of heart tissue from a prior heart attack
- Coronary artery disease
- High blood pressure
- Drinking too much alcohol or caffeine
- Drug abuse
- Certain prescription medications
- Electrical shock or air pollution
Treatment includes antiarrhythmic medications, anticoagulant or antiplatelet therapy, cardioversion, ablation therapy, a pacemaker, an implantable cardioverter-defibrillator, and/or the Maze procedure.
It’s common for a patient with a heart arrhythmia to be stable because of medication treatment. In these cases, it’s important for the provider’s documentation to provide a link from the medication to the specific condition it’s being used to treat.
New concepts in ICD-10-CM include re-entry ventricular arrhythmia and junctional premature depolarization. Another notable change is that sick sinus syndrome now has its own distinct code (I49.5 Sick sinus syndrome). In ICD-9-CM, sick sinus syndrome fell under the larger category of sinoatrial node dysfunction (427.81 Sinoatrial node dysfunction). Sinoatrial node dysfunction includes a number of conditions that cause inappropriate atrial rates. Sick sinus syndrome refers to a type of bradycardia where the sinoatrial node does not function properly.
These are just a few of the categories in the Medicare HCC model. There is great opportunity for outpatient coders to have a very positive affect in their practice, as well as in our industry. Focusing on a few, simple documentation improvement strategies at a time will help to illustrate patients’ true severity of illness. Correctly documenting and coding diagnoses will ensure better patient care, as patients are more easily identified for care management by Medicare and other payers. This data ultimately serves to provide the industry with financial forecasting and planning, which drives care cost.
Colleen Gianatasio CPC, CPC-P, CPMA, CPC-I, is a risk coding and education specialist for Capital District Physician’s Health Plan. She enjoys teaching PMCC, auditing, and ICD-10 classes. Gianatasio is president of the Albany, N.Y., local chapter and a member of the National Advisory Board.