All right, now we're going to segue into the ICD-10 and risk adjustment updates. All right, so what we're going to talk about, we're going to kind of do an overview of the diagnosis codes, guidelines, documenting and coding to support your medical necessity, importance of Z codes, factors influencing health status, understanding risk adjustment, HCC coding, all of the diagnosis codes that are risk adjusted, that are related to GI, talk a little bit about comorbidities and risk factors and risk adjustment with clinical examples. So question for you, true or false, if the patient is seen in the office and they have a specific risk factors that impact decision making during the encounter, the provider should also document and code those additional risks. Perfect. Yes, that's true. All right, we're going to talk about that not only to, again, support your level of service. Diagnosis, you know, risk adjustment, the diagnosis is pretty well the most important piece of information that's on your claim form. So when your payer receives a claim, you know, it tells them all the information. It tells them what you did, where you did it, who did it, et cetera. And obviously, you get paid based upon that CPT code you submit. But the most important thing is why are you doing it? You know, that's what they want to know. Does your documentation support medical necessity? All right, so this, I'm not going to go through this slide. These, Kathy had showed you those on the updates, but just keep in mind that whenever you get new ICD-10 codes, they're effective October 1st and they run through September 30th of the next year, okay? So, again, we did get some specifics for GI. That's always good. It's boring when we don't get any ICD-10 updates. I mean, we have to have some, right? We also have some cough diagnosis codes, adverse effects, et cetera. So not going to, that's just for all of, for your information. She also talked about the housing instability, homelessness, feud, insecurity, et cetera. So these are all just newer diagnosis codes. All right, so let's take a couple of those new diagnosis codes, though, and put them into a clinical scenario, right? Number one, a patient had an EGD done for ongoing issues with epigastric pain. Provider noted a polyp located in the G junction and gastritis in the stomach. Therefore, biopsies were taken with cold forceps. Pathology results showed a non-neoplastic inflammatory polyp and chronic gastritis negative for H. pylori. So diagnosis codes, K22.82, esophagogastric junction polyp, and then you've got your chronic gastritis and epigastric abdominal pain. Example number two, patient seen in GI clinic for heartburn and chronic cough. After the provider reviewed the patient's history and performed an examination, he decided to proceed with an upper endoscopy to rule out any GI source, okay? So that secondary diagnosis, chronic cough, that new diagnosis, R05.3. Number three, GI consulted in the hospital on a patient with feeding difficulties for evaluation of possible PEG-2 placement, R63.30 for feeding difficulties unspecified. And the last one, patient was seen in the ICU for hematemesis and acute blood loss anemia. Currently intubated and unable to provide any history. Patient is homeless and was found by a cyclist laying in the park with obvious bleeding from mouth. Ambulance was called. Patient was transferred to the ICU and intubated upon arrival. So diagnosis codes here, obviously the hematemesis, the acute blood loss anemia, and then Z59.00 for homelessness unspecified. All right, so some guidelines that I want to talk about. And these are just, you know, unfortunately, when the providers are out assigning diagnosis codes and looking up diagnosis codes, you guys don't get little prompters in the background that say, oh, well, this is a coding guideline, and you can't do this, and you can't code this with this, et cetera. So you have to kind of know some of these guidelines. And more so the coders, the billers, when they get denials back, they follow policy on these guidelines. They can give the providers appropriate feedback on this. So there are a couple of guidelines, and I can talk about all of them, but code first or use additional code, or a diagnosis that says in diseases classified elsewhere. All right, if you see any kind of description like that or a prompt like that, that just means that there should be a code ahead of the diagnosis code that you're using. And if you don't, and you bill that diagnosis code out, you're going to get a denial from the payer that says, uh-uh, you cannot code this as a primary diagnosis. All right, so a couple of examples of this. H. pylori, patient presents to the office to discuss test results. Her endoscopy pathology was positive for H. pylori, chronic gastritis. So primary diagnosis is going to be the gastritis, then the B96.81 for H. pylori, okay? If you try to submit B96.81 by itself on a claim, that will get denied by the payer that says not a primary diagnosis. Here's another one. Patient has alcoholic cirrhosis of the liver with esophageal varices here for EGD with banding of the varices, okay? So secondary varices is not a primary diagnosis. You have to code alcohol cirrhosis first. Then we have another guideline that's called combination coding. And what it means, it's two diagnoses in one ICD-10 code, all right? So it could be a diagnosis with an associated secondary process or manifestation or a diagnosis with an associated complication. All right, so a couple of examples for GI. All of our, a lot of our IBD codes have what we call combination coding. So it says patient seen as a follow-up in the office for ulcerative pancolitis currently having problems with rectal bleeding. So you would not assign rectal bleeding by itself because it's included in the diagnosis of K51.011. Patient seen as a follow-up for alcohol cirrhosis. He was noted to have ascites on exam, okay? So again, combination code K70.31, which is alcohol cirrhosis of the liver with ascites. Another patient seen as a new patient for IBSD and prescribed medication to help with current symptoms, recurrent symptoms. That is one diagnosis, IBD with diarrhea. I'm sorry, IBS with diarrhea, not IBD. We also have another one that's called excludes one. And this is probably the one we get the most denials on because we're don't, we don't know sometimes what codes cannot be coded together. And that's what it means is it's not coded here, all right? Patient admitted with GI bleed found to have bleeding duodenal ulcer treated with endoscopic control of bleed. Well, the only diagnosis you're going to build here is the duodenal ulcer with hemorrhage. You're not going to also code out GI bleed, K92.2, okay? You cannot code those two together. Here's another example. This one you may or may not have heard of yet or have seen denials on, but it has to deal with polyps, coding for colon polyps. So, patient presents for screening colonoscopy, found to have a sigmoid polyp removed by snare technique. Path was positive for hyperplastic polyp, okay? So, in this scenario, you're going to code K63.5 because it's a hyperplastic polyp. It's not a neoplasm. We have specific exclusions now for the K63.5 with the D12 codes. You cannot code both on the same claim line, okay? Well, what happens if you remember, you remove two polyps with a snare, and one of them is an adenoma, a D12 code, and one of them is a hyperplastic polyp, K63. Well, you can't code both of those. So, what you're going to do is code the D12. It's going to supersede that K code, site-specific D12 code, and then you can utilize your comment field, that box 19, and put, you know, hyperplastic polyp also removed. So, you give the payer that information. Just don't report those two diagnosis codes together. Here's another one, and I know Kathy kind of mentioned that. Well, she talked a lot about this on her screening talk. So, patient presents for open access screening colonoscopy and incidental diarrhea. Hmm. Further clarification is needed. Remember, when you look at the ICD-10 guidelines, it specifically says, right underneath the Z1211, for screening colonoscopy, it says, excludes one, encounter for diagnostic exam, code, design, or symptom. So, it's contradictory to report both. Here's more examples. Heartburn and dyspepsia cannot be billed together. Ascites, and then ascites with cirrhosis. Change in bowel habits cannot be reported with constipation and functional diarrhea. Other fecal abnormalities, so such as occult blood and stool, cannot be billed with melanin. Polyp of the stomach and duodenum, K31.7, cannot be coded with D13.1. Inflammatory polyps of the colon in ulcerative colitis cannot be reported with the D12 or the K63.5 codes. Rectal bleeding, K62.5, cannot be billed with GI bleed. And then, of course, we talked about the colon polyps. Now, if you look at K92.2, that's GI hemorrhage, that cannot be coded with a lot. So, basically, any more specific GI diagnosis that contains with bleeding or with hemorrhage, you know you're not going to report K92.2 with it. All right, documenting and coding for medical necessity. So, again, many practices are seeing increase in claim denials and rejections from payers that, you know, it could be invalid, it could be lax specificity, it could be a medical necessity denial. So, just make sure that you are coding to the highest degree of specificity. Make sure that the diagnosis code that you're ordering the procedure for meets medical necessity if the payer has a medical policy for that specific procedure. You know, when you're dealing with Crohn's and ulcerative colitis patients, if they're having complications or flares, make sure that you are signing those diagnoses of with other complications or with bleeding. They got to be specific. When we're dealing with infusions, okay, ulcerative pancolitis, so if the patient comes in, they have pancolitis, they're stable, they're just here for their infusion, it's appropriate to assign ulcerative pancolitis without complications. But just be sure and educate your nursing staff, your providers, that if you're doing infusions, use, you need to document and code the specific IBD code. A lot of payers are denying infusions when you use unspecified. Here's another one, and it has to do with GERD, all right. So, if you have a patient that has a longstanding history of GERD who presents for upper endoscopy due to persistent heartburn and epigastric pain, despite their therapy, the diagnosis codes are heartburn, epigastric pain, and GERD, okay. GERD alone does not support EGD. Why are you doing an EGD? If the GERD's stable, that's not an indication, but if they're having breakthrough symptoms, ah, there's your indication. Hemorrhoids, if you do any kind of hemorrhoid banding treatments or IRCs, making sure that you document the grade or stage of the hemorrhoid. Also, document symptoms the patient has related to those hemorrhoids. Also, should document if medical therapy has failed, and also discuss risk and benefits with the patient, make sure all of that is documented in your medical record. You know, when we do reviews, we see a lot of skimpy documentation on banding procedures. This is an actual procedure. It should look like a procedure note. Make sure you're specific and you detail it out. Sometimes I just see a one-liner note in the system. Here are some of those Z codes, and I'm not going to read all these to you just for the sake of time, but there's a lot of resistance to medications. There's dietary counseling codes. There's dependent on oxygen, et cetera. Anticoagulation or anticoagulants, NSAIDs, steroids, et cetera, those patients that are on long-term medications and that impact what you're doing or how you're treating your patient. Noncompliance, that's another big one. So, if you have a noncompliant patient, underdosing, there's also a diagnosis for personal history of failed moderate sedation, okay? So, make sure, just don't ignore the Z code. Sometimes, you know, we kind of put those on the back burner because it's just a status code, but it really can tell the story of what's going on with that patient. So, here's a dietary counseling example. So, patient comes in to see the dietician for nutritional counseling and weight management. She has a history of morbid obesity with a current BMI of 43. She was counseled today on diet modifications and given an exercise program, all right? So, you've got dietary counseling, morbid obesity, and then the BMI level. Another one, patient with a history of failed therapy with vancomycin presents for fecal transplant due to recurrent C. diff infection. So, you're going to have your C. diff colitis or C. diff recurrent as the primary diagnosis and the resistant to vancomycin as a secondary. Patient comes in for screening colonoscopy. She is on Coumadin and has been for years due to a chronic AFib. She is also on home oxygen for her longstanding COPD. You've got your screening, long-term, current use of anticoagulants, oxygen, chronic AFib, and COPD. And here's another one for that, again, back to that heartburn, breakthrough heartburn. Make sure you document symptoms and not just the patient has GERD if you're, you know, if you're trying to order a diagnostic procedure, et cetera. So, heartburn, GERD, and this patient says upon gathering a history from the patient, she admits that she doesn't take her Nexium as prescribed. She states that she often misses doses due to her financial situation and is unable to pay for refills. Hmm. Have any patients like that? You should report that diagnosis code. All right. It's like we're trying to do a good job. We're trying to treat our patients, but they're being noncompliant. All right. Let's talk a little bit about risk adjustment. And you might be overwhelmed with the amount of slides that I, that I'm about to go through. But most of the rest of these slides are literally the diagnoses that are risk adjusted for GI. All right. So, we're going to go through this pretty quickly. So, what is risk adjustment? It is a process by which Medicare reimburses the Advantage plans based on the health status of their members. All right. So, they take, they gather information for predicted health costs. They base this upon demographics, age and gender, as well as the health status. So, what they do as far as like being able to determine the health status of their members, risk adjustment data is pulled from diagnosis data reported from claims. And medical record documentation from your office, your hospital notes, your outpatient settings. All right. So, it ensures accurate and adequate payment based upon expected medical costs. So, each member is assigned a risk score based on this information. If the patient has a higher risk score, it represents a greater than average burden of illness. Lower risk is the healthier population or unspecified diagnosis codes being used. Incomplete chart documentation, things like that could falsely label that risk score for that patient. Each year, the risk adjustment score for the patient is reset, which makes sense. You know, if, you know, I may not have a diagnosis of diabetes this year, but I have a diagnosis of diabetes next year. Well, diabetes, a lot of the diabetic diagnosis codes are risk adjusted. HCC, which are hierarchical condition category, they are a grouping of clinically related diagnosis codes. Okay. So, those are also predicted in the calculations. So, what is your role? What is the point of this? The provider's role. Make sure you have a comprehensive health plan for each patient. Accurate and complete ICD-10 coding for each patient, each encounter. Coding to the highest level of specificity, making sure that you're signing your notes, making sure you're not copying, pasting, cloning. Do not use a problem list. Do not code from a problem list. Okay. A problem list kind of sits in the patient's record, and it's kind of a rolling total of all the different diagnosis codes the patient's ever had. Well, if some of those diagnosis codes aren't pertinent anymore, those should be falling off. So, again, if you pull a problem list into your note, it may be a falsely, you know, you may not be treating that diagnosis today. Make sure that you use a history of when it truly is no longer a diagnosis. So, patient had a cancer, it was treated, eradicated, doesn't have it anymore. Versus patient really didn't have a history of ulcerative colitis. It may be stable. It may be in remission, but they still have it. So, that's the difference. All right. So, I'm going to go through the rest of these slides really quick. All right. So, these are the diagnosis codes, GI-specific diagnosis codes that are risk-adjusted, and there is a score next to each diagnosis code. And that is the score that it gets, okay? So, it is expected to have what? A higher cost implication. The lower the score, it doesn't have as much. If the diagnosis code is not on this list, then that means that diagnosis is not risk-adjusted. So, a lot of your signs, symptoms, abnormalities, those diagnosis codes are not risk-adjusted. It's more of our chronic conditions. All right. So, hepatitis, all of your malignant neoplasms. Again, just going to scroll through this. You should have this information that you can go back and reference. Your stromal tumors, secondary malignancies, all of your alcohol abuse, use, and intoxication are risk-adjusted. Pretty high. It's a pretty high score, too. Varices, esophageal varices is risk-adjusted. Your gastric ulcers, duodenal ulcers, et cetera, all of those are risk-adjusted. All of your IBD, Crohn's, and ulcerative colitis are risk-adjusted. And you get into some of the more serious, you know, infarction of the bowel, ischemia, et cetera, those are all risk-adjusted. Very, very high. Necrotizing enterocolitis are risk-adjusted. Ileus, fecal impaction, peritonitis, all of your cirrhosis codes, hepatic failure, et cetera, are risk-adjusted. Autoimmune hepatitis, et cetera. Pouchitis, so these are probably the highest GI-specific diagnosis codes, the highest risk. Colostomy infection, hemorrhage, complication. What about gastrostomy? Gastrostomy malfunction, infection, hemorrhage, 188. Liver transplant failure, rejection. How about your patients that you just, they come to your office and you're going to change their G-tube? So there's not anything wrong with the G-tube, it just needs changed. Well, that diagnosis is Z43.1. Encounter for attention to gastrostomy, that's 188, even though there's nothing wrong with it. BMI, 40 and over are risk-adjusted. The patient that has a G-tube, it's just they have one in place, still 188. So you get the point, but those are all of those risk-adjusted diagnosis codes. Comorbidities and risk factors, there's a long list of comorbidities and risk factors. So again, when you're seeing that patient that may just have signs, symptoms, issues like that, things that aren't risk-adjusted, but their secondary, their chronic condition, et cetera, impacts your decision-making, that's when you want to pull that information in. So it not only affects your level of service, maybe the need for the patient to have the procedure done at the hospital, a need for a different level of anesthesia, you're also doing your good due diligence in reporting those risk-adjusted diagnosis codes. All right, so if you wanted more information on this, it's free to you. You can look it up, Google it, or you can follow this link on this last slide.

ICD-10

risk adjustment updates

diagnosis codes

medical necessity

Z codes

health status