Question HCC 140 Renal Failure

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I wondered if someone who has worked in the Risk Adjustment setting or who has their CRC could clarify the questions below.

Pt dx and documentation include the following in the OP setting and recent IP Hospitalization:

ESRD on HD- N18.6/Z99.2 (HCC 136)
Renal Failure-chronic N19 (HCC 140)
Anemia in ESRD- N18.6/D63.1 (HCC 136)

As a standard rule the physician should code all documented conditions that co-exist at the time of encounter that require or affect pt care tx or management.....

If all of the above listed dx apply to a patient, is it necessary to code both ESRD and Renal Failure in Risk Adjustment? I have read the two terms are interchangeable and have a provider wondering if this is duplication (ESRD & Renal Failure) or if she should capture both dx.

Someone who has ESRD on HD truly has Renal Failure and are in need of transplant.

In terms of specificity, is it appropriate to code both (ESRD & Renal Failure) in this situation or is just one dx needed?

Does 136 or 140 trump the other in terms of HCC categories?

Thank you kindly,
Myla Grabenstein, CPC, CHONC
 

rmwinder

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Anemia in CKD - D63.1 doesn't risk adjust, so there's no need to pick it up unless you're doing full capture.
ESRD - N18.6 (HCC 136) instructs to also capture the dependence on dialysis, like you have above - Z99.2 (HCC 134)
Z99.2 actually trumps N18.6. Z99.2 has no instructional note to capture the level of CKD...it is implied.
Renal Failure - Chronic is redundant and is only a CMS - HCC PACE/ESRD Model Category risk adjustment code, and I am not familiar with that model and why you need to pick up N19.

So for the regular CMS HCC Model Category I would only pick up Z99.2 because it trumps N18.6.

Someone correct me if I am wrong.
 
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Ok, thank you! We are actually a PACE organization, should have mentioned that before...

I greatly appreciate your feedback. Yes, that is the issue that Renal Failure is redundant with ESRD but wondered if it possibly trumped something else in the list.

I just finished taking the CRC course through AAPC and I was hoping for a bit more information about the "trump" lists. Would you happen to have a good source even if it is for the regular CMS HCC Model? I know the basics for the DM category, etc. but would really like to dig in a little more. :)

I see one of your credentials is CRC, do you work in Risk Adjustment currently?

Thanks again!
Myla
 

sconnell08

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Hi Myla,

Great questions! In this scenario, are you coding for the physician or are you capturing for risk adjustment only? If you are capturing for the physician, then I would stick with ESRD/HD and anemia. Once codes that risk adjust are submitted, there is a processing system at CMS that will do the trumping for you. However, if you are capturing strictly for risk adjustment, then I would capture HD (HCC 134) since it trumps ESRD (HCC 136). Chronic renal failure would not be captured and should be discussed with the provider to be removed, as the renal failure is inherent of ESRD.

On a side note, most patients that are further along in the disease process of CKD (> stage 3) will often have secondary hyperparathyroidism as well. Therefore, I would look in the encounter to see if there are any clinical indicators for that condition. If so, then you would be able to query the physician for further clarification of said condition.

Below, you will find a document that will provide you with a hierarchical or trump list.

Announcement of Calendar Year (CY) 2019 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter

The list can be found on p.p. 86-87.

Let me know if you have any other questions. Best wishes with your studies and preparations for the CRC examination.
 

rmwinder

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Ok, thank you! We are actually a PACE organization, should have mentioned that before...

I greatly appreciate your feedback. Yes, that is the issue that Renal Failure is redundant with ESRD but wondered if it possibly trumped something else in the list.

I just finished taking the CRC course through AAPC and I was hoping for a bit more information about the "trump" lists. Would you happen to have a good source even if it is for the regular CMS HCC Model? I know the basics for the DM category, etc. but would really like to dig in a little more. :)

I see one of your credentials is CRC, do you work in Risk Adjustment currently?

Thanks again!
Myla
Hi Myla,
Yes, I am an Auditor for a large payer, working strictly in Medicare Risk Adjustment. What would you like a source for? CMS info in general, or the Hierarchy chart?
Here's a link to the CMS Managed Care Info file. Chapter 7 is Risk Adjustment. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS019326.html

Hopefully that helps. If you need something different, just ask.
 
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Hi Schuyler,

Thank you for the information on ESRD, this is very helpful. I think I learn something new everyday in regard to Risk Adjustment :)

We do submit dx treated, monitored, assessed, etc. for all conditions at the time of face-to-face assessment and I work with our providers to ensure they are capturing diagnosis to the appropriate level of specificity. I am conducting retrospective and concurrent internal audits for our providers and educating them on inconsistencies/variances in diagnosis.

My original trumping question arose more for my own knowledge than anything else, thank you again.

I really appreciate all your help!
Myla
 
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