Hello, everyone, and welcome to a presentation on 2022 ICD-10 Updates and HCC Risk Adjustment for Gastroenterology Practices, sponsored by the American Society for Gastrointestinal Endoscopy and the ASGE Foundation Beyond Our Walls Campaign. My name is Michelle Akers, and I will be your moderator for today's call. The presenter for today's call is Kristen Vaughn. Kristen is a national consultant with over 16 years of coding and billing experience, and this includes gastroenterology, pulmonary, critical care, immunology, rheumatology, hematology, and hospital specialties, plus seminar instruction, auditing, and on-site consulting. Her background includes extensive experience in a teaching university, and she currently is a full-time consultant trainer with Ask Mueller Consulting. Her presentations have included organizations such as AGA and ASGE, and she is the co-author of several workbooks and programs specific to gastroenterology. She is a certified professional medical auditor and certified ICD-10 trainer, and also answers the coding email for ASGE. Before we get started, just a few housekeeping items. There will be a question and answer session at the close of the presentation. Questions can be submitted at any time online by using the question box on the right-hand side of your screen. If you do not see the question box, please click the white arrow in the orange box located on the right side of your screen. And please note that the webinar is being recorded and will be posted in GILeap, ASGE's learning management platform, in approximately one week. As a registrant for this webinar, you will have access to the recording, and the slides for this presentation will also be in GILeap and are available for downloading in the handout section on the right side of your screen. At this time, I would like to turn the webinar over to Kristen. Kristen? Thank you, Michelle, and again, thank you to the ASGE for allowing me to give this webinar today on ICD-10 and risk adjustment diagnosis coding. So we have, if you look at the objectives, we have several things to cover today. We're going to talk, obviously, about the new diagnosis codes for 2022, and we do have some specific to GI this year. We're going to talk about some COVID-19 diagnosis codes. Now, these were new effective January 1st of this year, but I felt that we should put it in the material just to give you the reminder that those diagnosis codes are out there related to COVID. We're going to go through the guidelines for ICD-10. I think this is an important piece of knowing ICD-10 and familiarizing yourself with the guidelines because most of the time when your providers are out selecting diagnosis codes based upon whether they're doing an endoscopy or they're doing a visit, they don't get the guidelines kind of in a little gray box, a little prompt or a little light bulb. They're just at the mercy of looking at the diagnosis code and selecting it. We're going to go through some of the guidelines and talk about some of those denials you may get back from the payer if the diagnosis code is either invalid or diagnosis codes cannot be billed together, things like that. We're going to talk about being specific, so documentation to support medical necessity. We have to be as specific as we can be when we are not only documenting our indications on our endoscopy reports, but also our visits in our assessment and plan of care. I always bring this into my material. If you listened to me last year on ICD-10, I brought it in again this year. It's the importance of those Z codes, which are factors influencing health status of the patient. Then we're going to transfer over to a different topic of risk adjustment HCC coding, how it relates to how we document the list of those diagnosis codes, and clinical example of what an assessment and plan, how it would factor into risk adjustment assignment by Medicare. With that being said, we'll go ahead and dive in. Some of the new diagnosis codes, and if you notice at the top of this slide, you will see the total of ICD-10 codes we have now are 72,748 diagnosis codes. That's a lot. That's why our payers are picking up on the fact that, you know what, we have all of these diagnosis codes, a lot of them are specific, so there is no excuse to be nonspecific unless, of course, you're dealing with a symptom abnormality, something that you just don't know why the patient's having it, and you need further workup. Again, 72,748 diagnosis codes. There were 159 new diagnosis codes added for the year, 32 deleted, 20 revised. Again, if you look at this first list of diagnosis codes, you will see there's a lot of diagnosis codes specifically related to GI. We have toxic encephalopathy, other, and unspecified. Those are going to be G codes. We also have a new diagnosis for esophageal polyp, esophagogastrojunction polyp. Since they expanded upon that K22.8 diagnosis, we now have a new additional digit for other specified disease of the esophagus. As of today, since today is September 28th, these are not in effect until October 1st. For today, if I assign an other specified diagnosis, it's just K22.8 right now. In a couple days, it's going to be K22.89, so keep that in mind because I know that's a diagnosis code that we assign a lot, especially on our endoscopy reports. We have brand new and a list of several diagnosis codes for intestinal metaplasia, gastric intestinal metaplasia. It's all broken down by either unspecified or if there is dysplasia found or without dysplasia. Low grade, high grade, and then without, and then it goes into where. Where is the metaplasia? Is it in the antrum, the body, the fundus, the cardia? That should all be very detailed on pathology results. If your providers take a biopsy to rule out metaplasia and it comes back positive, we should know the location and if there is any kind of dysplasia. Take a look at these diagnosis codes. They're a little challenging. Most of the codes that we deal with, it's alphanumeric. This is alphanumeric, alphanumeric. K31.A0, A11, A12, and so forth and so on. Be careful when you're doing data entry. Those of you that have billers, they're entering the charges into the system. Make sure those diagnosis codes get entered correctly. The last one on here, it's an intestinal involvement disorder, M35.08. I don't expect we'll see this diagnosis code used a lot, but it's there. We also have some new symptom diagnosis codes. Remember your signs, symptoms, abnormalities, your abnormal testing, all of those diagnosis codes begin with R. We have new diagnosis codes for cough. We've expanded it to not just cough, but we've got acute, cough, subacute, chronic, cough syncope, other, and unspecified. Those are R05 category. Then we have new diagnosis codes for feeding difficulties. Right now, if we see a patient for feeding difficulties, there's only one code for feeding difficulties and that's R63.3. We're expanding that out to unspecified, pediatric feeding disorder acute, pediatric feeding disorder chronic, and other feeding difficulties. There is another abnormal diagnosis, so another R, 79.83, and that's abnormal findings of blood amino acid level. Then we have a bunch of T codes. The T codes, these are the drugs, et cetera, that cause adverse effects, accidental overdose, intentional, et cetera. These are adverse effects of cannabis. If you notice the A, the D, the S, we don't deal a lot with A, D, and S when it comes to GI. I think the main diagnosis code that we use that have an A, D, and an S assigned to the end of the diagnosis code deals with foreign body removals. A means initial encounter. This is the first time I'm seeing the patient for this initial problem. A D is subsequent, so it's a follow-up of that situation. Sequelae means chronic condition, so it's a chronic issue from this adverse effect. Just a little insight to what an A, a D, and an S is. We have the adverse effect of cannabis and adverse effect of synthetic cannabinoids. Those are all brand-new diagnosis codes. U09.9, that is a post-COVID-19 condition unspecified. I got to looking at that diagnosis code, and I'm like, well, I'm not really sure what we would use it for. Surely if your patient has a post-COVID condition, we know what it is, and it's not just unspecified, but there you have it. It's a .9. Anytime you see a diagnosis that ends in .9, it's pretty well nonspecific. It's going to be a nonspecific diagnosis code. All right, take a look at the new Z codes we have, and remember, we have a subject on, we have a couple slides on factors influencing health status of the patient. Those are Z codes, and what it means is it's not necessarily a condition I'm treating or a symptom or an abnormality. It is a status. You know, if the patient's homeless or there's inadequate drinking supply, housing instability, other social economic circumstances, okay? Those are those Z codes, and think back to the beginning of the year when we got new E&M guidelines for the office, okay? Think about that. What's the new medical decision-making chart? Well, if you look under moderate risk category, all right, there is a new bullet under moderate risk that now says diagnosis or treatment limited by social determinants of health. These are some of the diagnosis codes that reflect social determinants of health. So if you're seeing a patient, you're treating them, and for whatever reason, their social or economic situation limits you, all right, to workup, anything like that that you're dealing with the patient, be sure to document that and add that as a last diagnosis code because it helps support your moderate risk if you're billing a higher level of service. So just keep that in the back of your mind. These are really good diagnosis codes to use for that specific reason. Here's another one, and I actually came across a note a couple weeks ago that I had to deal with, and it's that Z71.85. It's further down on the slides, and it says Encounter for Immunization Safety Counseling. And there was actually a patient that came in to see the provider in the office, and they were going to be traveling to another country. And so they came in to speak with the physician to make sure that in that other country, you know, are they vaccinated from COVID? How many cases do they have currently of COVID? What are the traveling restrictions to this other country? And that was really all that the visit was about. So this is an appropriate code for that, Encounter for Immunization Safety Counseling, all right? Then we have another Z code, Personal History of Suicide Behavior and Personal History of Non-Suicide Self-Harm, all right? So that's it. That's a look at your new diagnosis codes. So the more GI-specific diagnosis codes I put into some clinical scenarios for you. So for the first one, example one, patient had an EGD done for ongoing issues of epigastric pain. Provider noted a polyp located at the GE junction and gastritis in the stomach. Therefore, biopsies were taken of both with cold forceps. Pathology results showed a non-neoplastic inflammatory polyp and chronic gastritis, negative for H. pylori. So how you would code this EGD with biopsies out is primary diagnosis, K22.82, that's your new code, esophagogastric junction polyp, followed by the chronic gastritis without bleeding, and then the epigastric pain to support why we did the procedure. Example number two, patient seen in GI clinic for heartburn and chronic cough. After the provider reviewed the patient's history and performed an exam, he decides to proceed with an upper endoscopy to rule out any upper GI source, okay? So again, diagnosis R12, and then the new diagnosis R05.3 for chronic cough. Example number three, GI consulted in the hospital on a patient with feeding difficulties for evaluation of possible PEG tube, R63.30, feeding difficulties unspecified. Example number four, 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 and the patient was transferred to the ICU and intubated upon arrival. So diagnosis codes, of course, you're going to build a primary diagnosis codes of hematemesis K92.0, and then D62 for acute blood loss anemia, and then Z59.00 for homelessness unspecified. All right. So now we're going to talk a little bit about COVID, okay? COVID-19. So these diagnosis codes, they were kind of an emergency category because they were effective January 1st of this year. You know, typically the diagnosis codes don't go into effect until October 1st of each year. So these were kind of an emergency, okay? Obviously with all the COVID cases, we're seeing patients for COVID, we're screening for COVID. So this is the biggest diagnosis code that you guys would probably use for GI practices, Z11.52. All right. So let's say the patient's going to have a procedure done or they're going to be seen and you're going to test them for COVID prior to this is your diagnosis. We also have contact with and suspected exposure to COVID, which is another Z code. We now have a diagnosis for personal history of COVID-19, Z86.16. We have multisystem inflammatory syndrome. It's an M code. Other specified systemic involvement of connective tissue, another M code. So these are all again, secondary to COVID. And then pneumonia due to the coronavirus, J12.82. All right. So let's talk a little bit about guidelines for ICD-10. So remember when we were going through the objectives, what we're going to talk about today. Keep in mind that these codes go in effect October 1st and run through September 30th of your 2022. All right. And again, when your providers or whether they're in the office, the endoscopy center, the hospital, whatever electronic medical record format that they are using or platform that they're using, there's really not any helpful hints that they have when they're looking and choosing diagnosis codes and they're searching. All right. So they don't have guidelines in the background. They're just at the mercy of, okay, I'm going to search for this diagnosis code and hope it's right. But what happens is, especially if you're in a practice where you do not have a coder looking at every single encounter that goes out the door, we get denials back from payers that say, oh, you know, these codes can't be billed together. Or there's a combination code that you should be using or lack specificity. And there's all kinds of denials that we're starting to get because payers are really starting to pay attention to the coding guidelines that are set forth by ICD-10. So we're going to go through the more important guidelines for some of the diagnosis codes that we deal with. All right. The first one is called what we call it manifestation or etiology coding guideline. And what this means is it's either code first or use additional code. Or it can say, or the diagnosis description could say in diseases classified elsewhere. All right. So that means if you see any of those terms next to a diagnosis code, that means this is not a primary diagnosis. It's a secondary. All right. So if we assign this code, it's because you need a primary to go with it. You cannot code this as a primary. And what happens is if we accidentally assign the code as primary, payers going to kick it back and say, eh, this is not a primary diagnosis code. OK. So let's put that into play. What does that mean for GI for us? H. pylori, I bring this one up every year because I'm still seeing practices reach out to us and say, hey, we're trying to use the diagnosis of H. pylori and it comes back denied. And so my question back is, well, do you have a primary diagnosis assigned to that? Oh, nope, we don't. That's your problem. You cannot code H. pylori by itself. OK. So here's an example. Patient presents to the office to discuss test results. Her endoscopy pathology was positive for H. pylori chronic gastritis. All right. So in this scenario, you have to code the gastritis primary and the H. pylori as a secondary. Another one has to deal with your alcohol cirrhosis. OK. If you're dealing with patients that have cirrhosis, you should not be just assigning one diagnosis of primary varices. That's not correct. It's a secondary. You treat secondary varices because of their liver condition. All right. So patient has alcohol cirrhosis of the liver with esophageal varices here for EGD with endoscopic banding of the varices. So diagnosis K70.30 goes before I85.10 for the secondary varices without bleeding. We also have another guideline out there that's called combination coding guidelines. It's when a single diagnosis is used to explain two things. All right. So it's a diagnosis with an associated secondary problem or process or a complication. Some tips here. Assign only the combination code when that code fully identifies the diagnostic condition involved. Multiple coding should not be used when the classification provides a clear and clearly identifies all those elements documented in the diagnosis. But when the combination code lacks necessary specificity, then you can use an additional diagnosis to explain that secondary code. So we'll give you some examples. Ulcerative colitis and Crohn's disease. Both of those diagnoses or issues have combination codes because they have with complication or without complication. So this patient was seen as a follow-up in the office for ulcerative pancolitis, currently having problems with rectal bleeding. So diagnosis code you're going to assign is ulcerative pancolitis with rectal bleeding. And that's it. You're not going to assign an additional diagnosis of rectal bleeding by itself because it's part of the description of this combination code. Same with the next scenario. Alcohol cirrhosis and if the patient has ascites. One diagnosis code is all you're going to use. K70.31. IBS is another diagnosis that is combination code. So if the patient has IBSD, you're going to assign one diagnosis of K58.0, which is IBS with diarrhea. You're not going to carve out the diarrhea and code it separately because it's included in that diagnosis. Now, this is another one. And I think this is the guideline that we get the most denials on. And it has to deal with diagnosis codes that cannot be reported on the claim together. And again, if I'm a provider seeing a patient in the hospital and I'm out assigning diagnosis codes, the doctor doesn't know that this code can't be billed with that code and this, that and the other. So it's important for the billing staff to kind of have this, keep a list of the more common diagnosis codes that can't be billed together. That way, if they come through on the claim for the provider or before we do charge entry, we know that one of those diagnosis codes will fall off and we don't want to include both of those together on the claim. So these are some examples of diagnosis codes for GI that cannot be billed together. So a patient admitted with a GI bleed, found to have a bleeding duodenal ulcer, treated with endoscopic control of bleed. So the only diagnosis you would code is K26.4 for the ulcer with bleeding. Sometimes I see a diagnosis K92.2 for GI bleed also included and you cannot code that with the K26.4. All right, some more examples. This one's a big one. This one actually came out last year. So it's a fairly new guideline for us, but it has to do with your colon polyps. All right, so patient comes in for screening colonoscopy and found to have a sigmoid polyp removed by snare. Pathology was positive for a hyperplastic polyp, okay? Well, in that scenario, you're going to assign K63.5 because that is the diagnosis for colon polyp or hyperplastic, a non-neoplastic polyp, okay? Now, if you look up K63.5 in your ICD-10 book, you're going to find it excludes one note for the D12 codes. You cannot code both of them together. All right, and right underneath that exclusion, there's a tip that they give you. It says, assign K63.5 when documentation states hyperplastic colon polyp regardless of the site of the colon. Slow-growing hyperplastic polyps are not precancerous and are classified different from benign or adenomatous polyps. So I get the question, well, what happens if my doctor did an endoscopic procedure? They find two different polyps. One's a hyperplastic polyp, one's an adenoma. You're telling me you cannot code both of those together. Correct, I'm telling you you can't code those both together. So my answer to that is code the D12 code. The neoplasm is more significant and it's site-specific. All right, you can always use your, on a claim form when you submit a bill to the payer, there is a, what we call, we refer to as box 19, which is free text. It allows you to type in anything, any information you want to give the payer in addition. Okay, and you can type in hyperplastic polyp K63.5 also removed by SNARE. So if you want to include it, you could include it in box 19, but you cannot code both of those diagnosis codes on the same claim. You're gonna get a denial back from the payer that says they can't be billed together. Oh, here's another one. This is a big old issue. Patient presents for open access screening colonoscopy and incidental diarrhea. Hmm, can't happen. Screening means no symptoms, no abnormalities. So further clarification needed by the provider to determine if this should be a diagnostic colon prior to submitting the claim. Because if you look up Z1211, which is screening colonoscopy, there is an excludes one note right underneath it that says encounter for diagnostic exam, code, sign, or symptom. Okay, so you can't code both. Here are some more ICD-10 exclusions. You've got heartburn is excluded from dyspepsia. Ascites, again, I gave you that scenario in that combination coding scenario where R18 is, which is the, that is the diagnosis for just ascites. So it might be a patient that doesn't have a known liver condition. We don't really know why they have ascites, but they do. Okay, but if it's in cirrhosis or in hepatitis, you're gonna use those diagnosis codes instead. Change in bowel habits is R19.4. You cannot code that with constipation or functional diarrhea. R19.5 is other fecal abnormalities. And so we use this diagnosis code a lot for occult blood and stool. So if you do a stool study and it comes back positive, all right, that's your code. It cannot be coded with melana, K92.1. All right, so the differences between those two, R19.5 is a test, K92.1 is a symptom. I'm actually, you know, passing blood in my stool. Big difference. Another one, back to polyps, K31.7, which is polyp. Just polyp of the stomach and duodenum. It is excluded from your adenoma of the stomach, which is D13.1. All right, colitis. Let's talk a little bit about inflammatory polyps in ulcerative colitis. This means that the patient has a diagnosis of ulcerative colitis and there's multiple inflammatory polyps found during endoscopy. The provider may not even remove all of them because typically there's so many that, you know, it would be a very long procedure if they actually tried to biopsy every single one of them. But they'll do random, okay? That diagnosis code is K51.4 and then it expands out, okay? This is not just a solitary adenomatous polyp, not in ulcerative colitis, D12.6, or this is what typically confuses coders and billers, is provider does a colonoscopy, removes a colon polyp. The polyp, one polyp comes back as an inflammatory polyp. If it's one solitary inflammatory polyp and the patient does not have a diagnosis of ulcerative colitis, that diagnosis is K63.5. I see a lot of coders and billers assigning K51.40 when an inflammatory polyp comes back on pathology. If that patient doesn't have ulcerative colitis, you should not be assigning the K51 diagnosis code or you just label the patient with ulcerative colitis. Very important to know the difference between the three of those. K62.5, so this is rectal bleeding. You cannot bill that with GI bleed or melana, which makes sense. And then we talked about the K63.5 with the D12 and the K51.40. There's your melana with the positive stool findings. Now, this is the one I wanted you to look at and this is one that kicks back a lot from the hospital side. And it's K92.2 and I know I gave you an example of this with the gastritis. But look at all of the diagnosis codes it kicks back on. All right, so just remember this. If when you look up your diagnosis code, if it includes the description of with bleeding, you do not assign K92.2 with it. All right, so gastritis with bleeding, rectal bleeding, AVM, so angiodysplasia with bleeding, any diverticular disease with bleeding, gastritis and duodenitis with bleeding, any peptic ulcer, whether it's the stomach ulcer, duodenal ulcer, any of them that include with hemorrhage, you are not to assign K92.2 with it. All right, document and code for medical necessity. So, you know, when you do a service, whether you're scoping a patient, you're billing a visit, you're billing a consult, whatever you're billing, infusion, all right, whatever you're billing, the payer gets all of the information that you provided to the beneficiary on a claim form. That is how they pay you, all right? They get, you know, the date of service, what you did, who did it, where you did it, The most important piece of information sitting on that claim is that primary diagnosis. That is what they look at before they pay you, okay? So if you get it, let's say you do an upper endoscopy and it comes back denied for medical necessity, it's because the diagnosis code that you used in the primary position does not support medical necessity for their, based on their policies, all right? So, or you're just being lazy and assigning a completely nonspecific vague diagnosis code. All right, so we get a lot of those denials back. And we always recommend to keep up-to-date on payer policies, ICD-10 revisions and changes, communicate, all right? So if your billing department is getting denials back for this certain diagnosis for your endoscopy procedures, they should be communicating that back to everybody, okay? Not just saying, oh, that's, oh, they don't pay for that, move on. You need to make sure to tell the providers because if the providers continue to order these tests for that same reason, you're always gonna get the same outcome, communication. Right, so providers have got to be specific. Crohn's and ulcerative colitis. Back when we were on ICD-9, we only had about eight diagnosis codes for both Crohn's and UC. We have over 100, all right? Those are those combination codes or without complications, et cetera. So when your patient comes in to the office or whatever, and they're having a complication or a flare, it's important to document that information, not only in your HPI, but bring it down into your impression and plan, okay? A lot of times when I'm looking at documentation, I see all this flare information in the HPI and then the impression and plan just says Crohn's disease and that's it, all right? No, you've got to bring those pieces down into the assessment and plan. So this first one, it says patient with a history of Crohn's of the large intestine presents for rectal bleeding with rectal bleeding, left lower quadrant pain and diarrhea. All right, so diagnosis codes. K50.111, Crohn's disease of the large intestine with rectal bleeding and then the one with other complications and those complications were the left lower quadrant pain and diarrhea. All right, be sure the provider is specific as to a true flare or a true complication so the correct codes are assigned. All right, so one thing that I tell providers is that if this is a true complication or flare of the disease, not only bringing that down into your impression and plan, but assigning the correct diagnosis code. This is gonna support a higher level of service versus your Crohn's or ulcerative colitis patient that's doing well and not in a flare. All right, it's going to justify maybe a higher level of service. It can justify if you need to shorten the patient's infusion schedule from eight weeks down to six weeks and you're trying to get that approved from the payer or you're putting them on a different biologic and you're trying to get that approved from the payer. So keep that in mind that we're not just you know, making you do this just because we wanna be mean. It's because these are the specific issues that the payers are seeing and they want the specific details to support why you're changing meds or supporting a higher level of service, et cetera. Patients that are having infusions. Okay, so if you've got your IBD patients that come in for their infusion, now most of the time your doctors, your nurse practitioners, they're not the ones infusing the patient. It's your nurses. So your nurses have to be educated on the fact that they need to, when they're documenting the infusion, you know, whenever it includes the medication, the start and stop times, et cetera, they need to document a diagnosis on that infusion and it better be specific. Payers are routinely denying any infusion when we assign a diagnosis of Crohn's unspecified or ulcerative colitis unspecified. You have to be specific. All right, here's another issue that we come across. And that kind of threw this into a clinical example. It says patient with a longstanding history of GERD who presents for upper endoscopy due to persistent heartburn and epigastric pain despite a three month trial of therapy. So you've got three diagnosis codes here. R12, R10.13 and GERD, K21.9. So if, and I'm sure those of you listening in that deal with commercial payers that have preauthorization requirements for upper endoscopy, you've run into this scenario where the only diagnosis code that your provider gives you is GERD. GERD alone does not support the need for an endoscopy. Symptoms do, or the fact that they are no longer, their PPI is no longer working, okay? So just think about that when you document, when you get to your endoscopy and you document for the indications or you're ordering it during the clinic visit, be specific. For those of you listening in or practices listening in that actually do banding hemorrhoids in the office or even in the ASC, be specific as to the grade or stage of hemorrhoid that you're banding. Also, you need to document symptoms the patient's having. So for this example, we have patient presents for followup of rectal bleeding and pain. Rectal exam confirmed grade two internal hemorrhoids. Patient was tried on topical creams which has not helped with the ongoing bleeding and pain. Recommend patient now undergo banding ligation procedure. Risk and benefits were discussed with the patient. So for the diagnosis codes for this procedure, I'm going to assign K64.1 for grade two hemorrhoid and K62.89 for the rectal pain. So keep in mind documentation for hemorrhoid treatments must include any symptoms the patient has related to known hemorrhoids, that medication therapy failed and risks and benefits were discussed with the patient. I don't see very good detail to support why that patient's coming back in for a banding. Okay, so make sure you're documenting all of those points, not only in your clinic visit, but your actual banding ligation procedure. All right, so Z codes, these are the factors influencing health status of the patient. So the first few Z16, these are resistance to, you know, if the patient has a resistance to a medication. So you put them on a medication, it's not working, you need to do something different, okay? Another good one to know is halfway down Z53.8, procedure not carried out because of contradiction, contraindication, okay? So that is a diagnosis you should be assigning as secondary for like your discontinued colonoscopies or your discontinued EGDs to help support why we stopped the procedure, why we're gonna bring the patient back. Dietary counseling, patients that come in with supplemental oxygen, they're at higher risk for procedures, they require a deeper level of sedation, those things, okay? So you may not be managing their COPD or whatever the reason they're on oxygen, but the fact that they're on oxygen affects the treatment plan that you're giving to the patient. That is a good secondary diagnosis code to use. Another big one, and I do see most GI practices or providers pick up on this diagnosis, Z79.01. It's your patients that have, they're on long-term anticoagulant therapy. All right, that's a good diagnosis code to use. It affects again, the endoscopic workup for those patients. Your impression and plan should reflect that if you're doing an endoscopy on those patients. NSAIDs, that's another one. I don't see this diagnosis code assigned a lot, but patients that are popping ibuprofen daily and you're thinking they have an ulcer, that's a good secondary diagnosis code to use. Antibiotics, insulin, there's a diagnosis for long-term inhaled steroids, systemic steroids, aspirin, opiates. There's all kinds of diagnosis codes for long-term current use. How many of your patients are non-compliant? All right, whether it's they're not following your diet recommendations, they are not taking their medications as directed, they are not following up with their endoscopic therapy. So those are some, there's Z91 diagnosis codes. Failed sedation, this is another good one, Z92.83. It's the description's personal history of failed moderate sedation. So think about that. Okay, you might have a patient that you're seeing in clinic, you do an endoscopic, you know, you do an endoscopy or you're wanting to do an endoscopy on them. They might not necessarily have any comorbidities or risk factors, but they might've failed moderate sedation in the past. So now you're going to do monitored anesthesia care on them. Good diagnosis code to use. All right, so let's take a look at some clinical scenarios. This is a very important one, and it has to deal with if you are addressing obesity, okay? I'm not talking about the patient that has a history of obesity or whatever, and you're not addressing that today, but if you actually address it and it's in your plan of care, you need to make sure that you assign the BMI level as well in addition, okay? So dietician sees the patient for nutritional counseling and weight management, has a history of morbid obesity. Her current BMI is 43, and she was counseled today. So we have that dietary counseling diagnosis, morbid obesity, and then the BMI level. Another example, patient has a history of failed therapy with vancomycin, presents for fecal transplant due to recurrent C. diff infection, okay? That, I'm telling you, that diagnosis code, if any of you listening ever tried to preauthorize or verify eligibility for fecal transplant, it's like you're going around in circles. The payer doesn't know what it is. They won't authorize it. They don't really understand the scenario. You probably need a nurse or someone to explain to them why you're trying to preauthorize this service, why they're having it done, and it's not just because they keep getting C. diff. It's because the medication that we also have been putting the patient on failed, okay? So two diagnosis codes there. Here's your screening colonoscopy patient and the Coumadin, okay? So they have Coumadin use. They have AFib. They have COPD, okay? So if those impact my decision-making, I'm going to code them all. Here's one. Here's an example of noncompliance, okay? So the patient comes into clinic. She has heartburn symptoms. She has a diagnosis of GERD. Says upon taking a history from the patient, she admits that she does not take her Nexium as prescribed. She says she often misses doses due to her financial situation because she is unable to pay for her refills. All right, so you've got heartburn, GERD, and intentional underdosing of medication due to financial hardship. And, you know, with the providers, it's easy for me to say, okay, you need to document this. You need to code this. You need to assign that. And sometimes it's hard to find some of these diagnosis codes. So before I go into risk adjustment, I'm just going to give you some tips on searching for diagnosis codes. And I'm going to talk about the more common ones. Abdominal pain, that's a big one. No payer likes R10.9, which is unspecified abdominal pain in the primary position. Okay, so providers that are listening in, don't, when you're trying to find a diagnosis code, don't type in abdominal pain. Search by the quadrant or search generalized, okay, because that's the start of the description of abdominal pain. Another diagnosis code is abnormal LFTs. Okay, so if a patient comes in, you're seeing them for abnormal LFTs. Don't search the computer with abnormal liver tests. Search it by the abnormality. For example, if it's an abnormal transaminase level, just type in transaminase. You're going to get the correct diagnosis code. All right, so keep that in mind when you're assigning diagnosis code. The noncompliance codes, simply type in the word noncompliance, those Z codes are going to pop up. All right, now we're going to kind of shift over to risk adjustment. And there are several slides in here, but I'm going to go through them very quickly because they're just a simply a list of diagnosis codes that are risk adjusted. So I'm going to talk about what is it. So if you're not familiar with risk adjustment, it is the process by which Medicare CMS reimburses the advantage plans based on the health status of their members. All right, so whether you have a UnitedHealthcare advantage plan or Humana advantage plan, any of those plans, Medicare puts money into those plans. They don't know, so they, you know, back before this came out, they really didn't know how to accurately, you know, give them the accurate payments. And so they came up with what they call risk adjustment. And it's predicted health cost expenditures for their members by adjusting payments based on demographics and health status. So risk adjustment data is pulled from the diagnosis codes that are submitted on your claims. And this is from your practice, so your office, your hospital, and your outpatient setting. So basically, everywhere you practice, this affects you, okay? Each member is assigned a risk score based upon the demographics and the health status. The higher the risk represents members that are at greater than average burden and illness, so they're sicker. If it's a lower score, it's either a healthier patient or inadequate, incomplete chart documentation or incomplete or inaccurate diagnosis coding. Each year, that score is reset, okay? That way, they keep it accurate. So this year, I might not have diabetes, but next year, I might get a diagnosis of diabetes. Diabetes is risk-adjusted, so that's why they reset it every year to be more accurate. So then we have what we call HCC, which is hierarchical coding or condition category. So these are all clinically-related diagnosis that have similar cost implications. So when you go, and I'll give you the link at the end, when you look up these diagnosis codes, they give you the list of the diagnosis codes that are risk-adjusted, the score and the HCC grouping for that score. So what is your role as a provider? What is your role for this information? Unfortunately, you don't get paid any more money. It's not some kind of additional payment that you're going to get on your claim. It's just helping to assign that risk-adjustment score correctly. So you should have a comprehensive health plan for your patient, accurate and complete diagnosis coding, coding to the highest level of specificity, which we've been talking about for the last 45 minutes. If your documentation is missing, incomplete or inaccurate, then the risk-adjustment is not correct. Cloning, all right, cloning is a big issue. If you're copying and pasting all of your records, they're not going to be accurate. If you are coding from a problem list, that can be a false representation of risk-adjustment because a problem list kind of sticks with the patient. All right, it's basically anything and everything the patient's ever had. Don't use a problem list for your assessment because some of those diagnosis codes are irrelevant for why you're seeing the patient today. Focus on what did you address first and also were there any comorbidities or risk factors that impacted my medical decision-making for this patient today, okay? Pay attention to history of, okay? If you document a history of something, that means in an auditor's eyes or Medicare's eyes, that means it no longer exists, the cancer has been eradicated, the polyp has been removed, et cetera. Those are just some examples, so make sure that you're not saying history of ulcerative colitis because, again, that could be viewed as a history where a patient pretty well always will have ulcerative colitis. All right, so the next few slides, I'm going to go through these pretty quickly because, again, these are for you to have, all right? If you heard me talk last year on this, you got the same exact list. They have not changed, and the risk scores have not changed. I just looked them up recently, and they're the same scores. But what this means is if your patient has a diagnosis of hepatitis C, they are in that risk-adjusted category, all right? Signs, symptoms, and abnormalities are not risk-adjusted, so vomiting, weight loss, fatigue, abdominal pain. None of those diagnosis codes are risk-adjusted because those aren't considered chronic. These are more chronic conditions or conditions that, what? Cost, make the cost go up, all right? So you've got hepatitis, candidyl esophagitis is six, neoplasms, all the way from the esophagus all the way down to the rectum, okay? So I'm just going to go through these very quickly. And that, again, that number beside each of these diagnosis codes is the risk score for that diagnosis, all right? So pancreas, we're still in the neoplasms, pancreas, spleen, other sites. Stromal tumors are also risk-adjusted. Secondary neoplasms are risk-adjusted. Malignant carcinoids are risk-adjusted. Now, take a look, I'm going to stop at this slide, and it has to deal with you when GI providers see patients for gastroparesis, all right? If the patient has a diabetic gastroparesis, please document that and assign E11 point, either E10.43 for type 1 diabetes or E11.43, which is typically what we see, that's what we typically see is type 2 diabetes, all right? Assign that with the gastroparesis. If you only assign gastroparesis, that diagnosis code alone is not risk-adjusted, but gastroparesis due to diabetes, et cetera, that's risk-adjusted. All of your malnutrition diagnosis codes are risk-adjusted. The obesity, there's two obesity diagnosis codes that are risk-adjusted, morbid obesity and severe obesity with hypoventilation. All of your alcohol abuse, use, and dependence are risk-adjusted. Not only that, they have a very high score, and I mean, think about it, you know, how many of your patients that are chronic alcohol abusers, you know, their organs, obviously the liver, but it affects the liver, the heart, the kidneys. There's so many things that the alcohol can damage as far as your organs are concerned, so that's why they're high. So I'm just gonna scroll through, we're still on the alcohol diagnosis codes. Varices, your primary and your secondary, they each have a score of 27. All of your ulcers are risk-adjusted. So whether it's an acute ulcer or a chronic ulcer with bleeding or without bleeding, they're all risk-adjusted. All of your Crohn's and ulcerative colitis patients have a risk-adjusted score. Okay, so I'm gonna go through these real quick. Now this slide, we're probably not gonna see these patients a lot. This is probably more for your surgeons, but if you're dealing with ischemia of the bowel and farction of the bowel, those are very high scores, 107. Enterocolitis, ileus, okay. Also fecal impaction, ileus, toxic megacolon, peritoneal abscess, all of your cirrhosis and liver diseases, they're all risk-adjusted. Hepatitis, autoimmune hepatitis, portal hypertension, chronic pancreatitis is risk-adjusted, acute pancreatitis is not. Just keep that in mind. Let's talk about pouchitis, that's 188. That's the highest GI-specific diagnosis code that's risk-adjusted. Okay, gastrostomy. If you have patients that have G-tubes and there's complications, there's hemorrhage, infection, malfunctions, very high, 188. If you are looking at Z43.1, attention to G-tube. So if the patient comes into the clinic for a G-tube change, it's just time to change it, there's really nothing wrong with it. Z43.1 should be assigned, that's 188. BMI of 40 and over are risk-adjusted. If your patient just has a G-tube status, they just have a G-tube in place, you're not really doing anything with it, it's still risk-adjusted with 188 points. Okay, so keep that in mind when you are seeing these patients. Here, there's a list, I'm not gonna read all these to you, you can read them. These are the comorbidities and risk factors that are risk-adjusted. So remember, you might not be seeing a patient for a chronic condition, you might be seeing them for symptoms, et cetera, but their comorbidity or their risk factors increase your decision-making, okay? That's when you want to include them in your impression and plan of care. So here's an example. This was a patient in the hospital, says hemopositive stool and a significant decrease in hemoglobin in this 90-year-old female who was admitted with significant current pulmonary issues including COPD exacerbation and acute congestive heart failure. At this point, I do believe we should proceed with an EGD and possibly even a colonoscopy depending upon the patient's hemoglobin and hematocrit. I would like to get her pulmonary status to stabilize and then we will perform that EGD. Patient is at risk for procedure-related complications secondary to her other conditions, all right? So we're gonna break this down for the risk scores. Hemopositive, so the first two diagnosis codes are obviously sitting on the claim primary because that's what we saw the patient for. They're not risk-adjusted diagnosis codes, but COPD exacerbation is, acute congestive heart failure is, the other two are not as well. So that's why it's important to include those when they impact your medical decision-making, all right? If you wanna see the current list, the link below takes you right to the risk adjustment. You click on the year, the current year, and it will be a downloaded Excel file that you can keep on your desktop. All right, at this time, I'm gonna turn it back over to Michelle and see if we have any questions. Thank you, Christian. And we do have a few questions that we will get to, but I just wanted to thank everyone for joining us today on this webinar. And before we move to the question and answer session, a few notes about coding and reimbursement-related resources. The last webinar in the series will be on December 7th. So make sure you log in and have the opportunity to participate in the Q&A session and hear it live. So at this time, we're going to address some questions from the audience. And as a reminder, you can submit a question through the question box. If you do not see the question box, please click the white arrow. And the orange box located on the right side of your screen, it's towards the bottom. So Christian, our first question is, our provider performed EGD with necrosectomy. We billed unlisted. And he also placed it in the area where the necrosectomy was performed. Can we bill for the stent 43266 in addition to the unlisted code? Yes, that's correct. You want to bill the stent. You want to bill the stent in addition. So you're going to bill the 48, I believe it's 48999 for your unlisted, and then you're going to bill the 43266 for the stent. That's correct. Thanks. Our next question is, when risk factors are discussed during a patient encounter that can potentially support a higher level of service, do you suggest we include those diagnoses on the claim for billing? Yes, so we were talking a lot about risk factors and this, that, and the other, and it kind of plays into that risk adjustment role. So make sure not only to document it in your assessment and plan, but make sure that when you are assigning your diagnosis codes, you're obviously going to assign the primary as your GI diagnosis, but include those comorbidities as a second, third, fourth diagnosis. You can actually fit up to 12 diagnosis codes on a claim. Great. Our next question is, I understand that we shouldn't document screening and symptoms on the procedure. However, what diagnosis codes would you use for the visit when addressing both screening and let's say constipation? Sorry. In that scenario, so let's say, you know, you have a patient that comes in for a visit prior to screening and they say, oh, by the way, doc, I've got constipation too. And you address the constipation with, let's say, let's say you tell the patient, you know, take Miralax, increase your water intake, your fiber, whatever, exercise. Then at that point, it no longer is more, it's no longer like a visit prior to screening. You're going to actually assign the level based upon the diagnosis of constipation that you address. But then when you go to order the colonoscopy, you're only ordering it for screening purposes because you're not doing the colonoscopy for constipation. So you kind of have to make it very clear. I worked up the constipation for this, and then, but I'm still, you know, going to order screening colonoscopy. Thanks, Kristen. I think this is our last question, and that is, I see some providers document screening for varices as indications for upper endoscopy procedures. What diagnosis code can we use for this, especially when there is nothing found? Should the provider include the patient's liver condition? Yeah, that's a good one. If, okay, so just so you know, if the payer or an auditor looks at your endoscopy indications, and the only thing sitting there is screening for varices, that is basically not medically necessary. There is no such thing as screening for varices. So why are you screening for it? It goes back to the why. Does that patient have symptoms, or do they have a known liver condition? So that's what you want to be sure and document, not just a vague screening for varices. Thanks, Kristen. And thank you all for joining us today. We certainly hope this information is useful to you and your practice. If you have any questions regarding today's webinar, please contact me via the email on the slide. And ASGE has designated this webinar for a maximum of 1.0 AMA PRA Category 1 credits. As stated earlier, the recording of this webinar will be available in approximately one week on ASGE's GILeap for access to you. And when visiting GILeap, you will complete an evaluation of the webinar and claim your credit. Your input will help us on improving future webinars. This concludes our webinar, and stay tuned for more future educational opportunities from ASGE. Thanks, and have a safe and great day. Thank you, Michelle.

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