Know Your Role in the NCQA Patient-centered Medical Home Process

Know Your Role in the NCQA Patient-centered Medical Home Process

As a medical coder, you are a valuable asset to clinicians who are part of the NCQA-PCMH team.

To understand how you can help in the National Committee for Quality Assurance (NCQA) patient-centered medical home (PCMH) process, first you need to know what it is and how it has expanded to vulnerable populations. Then you’ll see how medical coders play an important part in identifying disparity of care groups. Through detailed ICD-10 reporting of Z codes, you can help ensure those patients receive the best healthcare possible.

PCMH Recognition and Recent Changes

According to the NCQA website:

The patient-centered medical home is a model of care that puts patients at the forefront of care. PCMHs build better relationships between patients and their clinical care teams. Research shows that PCMHs improve quality and the patient experience and increase staff satisfaction—while reducing health care costs. Practices that earn recognition have made a commitment to continuous quality improvement and a patient-centered approach to care.

Level I, II, and III are no longer assigned upon renewal or initial accreditation. The NCQA has changed to a yearly, continuous process of quality improvement. Accredited practices will now attest to guidelines and standards on a yearly basis utilizing the Q-Pass system. Reports and evidence are loaded to the Q-Pass system throughout the year. The final yearly check-in, just prior to a renewal date, now includes live interaction with an assigned NCQA reviewer who remotely dials into your electronic health record (EHR) system. The session takes place with those primarily responsible for the re-accreditation process.

Your Role in the Transition Process

Certified medical coders can play an important role in the NCQA-PCMH transition process. Our ability to interpret and stay abreast of governmental regulations and standards, as well as create billing and coding compliance policies and procedures, gives us an advantage when working with the NCQA-PCMH team. We teach, audit, and are detail-oriented. This affords us a unique opportunity to assist the PCMH population health and quality improvement management team in identifying certain subsets of populations.
Population health management has always been a vital part of the PCMH process. Revised NCQA-PCMH standards have expanded emphasis on identifying vulnerable populations (disparity of care). Healthy People 2020 defines health disparity as:

… a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.

The ICD-10 changes, effective Oct. 1, 2018, relating to Z code categories Z55-Z65 Persons with Potential Health Hazards Related to Socioeconomic and Psychosocial Circumstances provides an example of one of the ways coders have a seat at the PCMH team table.

Identify Disparity of Care

Typically, we look at our Medicaid, uninsured, and elderly population. We may run reports by age and insurance. With the ability for a non-provider to now document certain Z code categories, we can identify in-depth issues within other subsets of populations that previously were hard to identify. Identification can be as simple as adding certain questions to your patient intake form. It’s not recommended to add all of these categories to your patient intake form or in your EHR social history elements, but rather add questions that are meaningful and can glean additional information you haven’t documented in the past.
Example 1: I live in a farm community. The ability to question a patient about “exposure of toxic agents in agriculture,” Z57.4 Occupational exposure to solids, liquids, gases or vapors in agriculture, would be pertinent. It is something that most providers do not take into account under social history. Occupation (farmer) may be the only notation. After you work with the EHR team and the PMCH team to determine additional, relevant questions that pertain to their specific population, you can help to train the provider or medical assistant in the proper use of these codes. When you are in the chart performing an audit and note that one or more of these conditions has been documented but not assigned a Z code, you can bring this to the attention of whoever has sign-off privileges and the ability to add this code(s) to the non-billable historical summary in the EHR system.
Example 2: If you have a practice that has a patient population experiencing job loss due to recent, widespread layoffs in your town, asking certain applicable questions from some of the Z categories (see the accompanying sidebar Social Determinants of Health, Z Codes) on the intake form is a good way to identify resources to help your patients. That is what the medical home is all about.

Follow the Guidelines

According to ICD-10-CM Official Guidelines for Coding and Reporting for FY 2019, General Coding Guidelines – I.B.14:

Documentation by Clinicians Other than the Patient’s Provider
Code assignment is based on the documentation by patient’s provider (i.e., physician or other Code assignment is based on the documentation by patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis).
There are a few exceptions, such as codes for THE Body Mass Index (BMI), depth of non-pressure chronic ulcers, pressure ulcer stage, coma scale, and NIH stroke scale (NIHSS) codes, code assignment may be based on medical record documentation from clinicians who are not the patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis), since this information is typically documented by other clinicians involved in the care of the patient (e.g., a dietician often documents the BMI, a nurse often documents the pressure ulcer stages, and an emergency medical technician often documents the coma scale). However, the associated diagnosis (such as overweight, obesity, acute stroke, or pressure ulcer) must be documented by the patient’s provider. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient’s attending provider should be queried for clarification.
For social determinants of health, such as information found in categories Z55-Z65, Persons with Potential Health Hazards Related to Socioeconomic and Psychosocial Circumstances, code assignment may be based on medical record documentation from clinicians involved in the care of the patient who are not the patient’s provider since this information represents social information, rather than medical diagnoses.
The BMI, com scale, NIHSS codes and categories Z55-Z65 should only be reported as secondary diagnoses. Note: Refer to ICD-10 Official Guidelines for Coding and Reporting to identify, which codes may be assigned as principal or first-listed diagnosis only, secondary diagnosis only, or principal/first-listed or secondary (depending on the circumstances).
Based on documentation, assign as many codes as necessary to fully explain each healthcare encounter. Since patient history information may be limited, use ANY available documentation to assign the appropriate external cause of morbidity and Z Codes. (Patient questionnaire, asking the question(s), etc.)

If you want to learn more about your role in this process, visit and ask for a copy of their current Standards and Guidelines. Show the clinician leaders at your organization that you are a valuable asset to the NCQA-PCMH team.

Social Determinants of Health, Z Codes
Z55.0      Illiteracy and low-level literacy
Z55.1      Schooling unavailable and unattainable
Z55.3      Underachievement in school
Z55.8      Other problems related to education and literacy
Problems related to inadequate teaching
Z55.9      Problems related to education and literacy, unspecified
Academic problems NOS
Z56.0      Unemployment, unspecified
Z56.2      Threat of job loss
Z56.3      Stressful work schedule
Z56.4      Discord with boss and workmates
Z56.5      Uncongenial work environment
Difficult conditions at work
Z56.6      Other physical and mental strain related to work
Z56.81    Sexual Harassment on the job
Z56.82    Military deployment status
Z56.89    Other problems related to employment
Z57.0      Occupational exposure to noise
Z57.1      Occupational exposure to radiation
Z57.2      Occupational exposure to dust
Z57.31    Occupational exposure to environmental tobacco smoke
Excludes exposure unrelated to employment (Z77.22)
Z57.39    Occupational exposure to other air contaminants
Z57.4      Occupational exposure to toxic agents in agriculture
Z57.5      Occupational exposure to toxic agents in other industries
Z57.6      Occupational exposure to extreme temperature
Z57.7      Occupational exposure to vibration
Z57.8      Occupation exposure to other risk factors
Z57.9      Occupational exposure to unspecified risk factor
Z59.0      Homelessness
Z59.1      Inadequate housing
Lack of heat
Restriction of space
Technical defects in home preventing adequate care
Unsatisfactory surroundings
Z59.3      Problems related to living in residential institution
Z59.4      Lack of adequate food and safe drinking water
Inadequate drinking water supply
Z59.5      Extreme poverty
Z59.6      Low income
Z59.7      Insufficient social insurance and welfare support
Z59.8      Other problems related to housing and economic circumstances
Foreclosure on loan
Isolated dwelling
Problems with creditors
Z60.0      Problems of adjustment to life-cycle transition
Empty nest syndrome
Phase of life problem
Problem with adjustment to retirement
Z60.2      Problems with living alone
Z60.3      Acculturation difficulty
Problem with migration
Problem with social transplantation
Z60.4      Social exclusion and rejection
Exclusion and rejection on the basis of personal characteristics, such as unusual physical appearance, illness or behavior
Z60.5      Target of (perceived) adverse discrimination and persecution
Z60.8      Other problems related to social environment
Z62.21    Child in welfare custody
Institutional upbringing

Developing Healthy People 2020, The Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020:
ICD-10-CM Official Guidelines for Coding and Reporting for FY 2019, General Coding Guidelines – I.B.14.

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Joanne Renee Irvin, CMPE, CPC, CEMC, CPCO, AAPC Fellow, is director of special projects at Prospect CT Medical Foundation, Inc., Eastern Connecticut Medical Professionals. She is an American College of Medical Practice Executive Fellow- Nominee, and a member of the Hartford, Conn., local chapter.

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