We will move on to ICD-10 and risk adjustment updates, okay, so ICD-10, probably the most important piece of information that is on that claim is why you did it, diagnosis codes, all right, so we're going to talk about some of the nuances for the diagnosis codes. So we're going to quickly go through the 2023 ICD-10 codes because Kathy already went over those with you. Overview of the ICD-10 guidelines, there are guidelines out there, there are certain things that we have to follow when we are submitting diagnosis codes. We're going to talk about documenting and coding to support medical necessity, nonspecific diagnosis codes to avoid, coding for personal histories versus current conditions, Z codes, which we've kind of been talking about a lot today. Risk adjustment and ICD-10 questions, all right, so again, here are the new codes, just going to quickly go through these because we've already seen these, all right. We have a total 73,673 ICD-10 codes, all right, so a couple of examples utilizing those new diagnosis codes. Number one, patient seen in the hospital for follow-up of alcohol cirrhosis with hepatic encephalopathy. On exam today, the patient has significant amount of ascites, we'll order paracentesis for tomorrow, all right, so you've got case 70.31, alcohol cirrhosis with ascites and hepatic encephalopathy, that new diagnosis code. Number two, patient seen in the clinic for follow-up of ulcerative pancolitis, patient is doing well with her six-week infusion schedule, we'll repeat labs and monitor for any iron or vitamin deficiencies, okay, so you've got ulcerative pancolitis without complication and long-term current use of immunosuppressive biologic agents, that's that new code. All right, so ICD-10 guidelines, I'm not going to go through all the guidelines with you, that takes all day to do, but I'm going to go over the more important ones, and this is information that your providers don't get, whenever they're selecting and looking up diagnosis codes in the system, they don't have little prompts that say, oh, you got to code this first or, oh, you can't use this as a primary or, oh, you can't code these two diagnosis codes together, so we kind of have to, you know, if you don't have someone looking at these claims or a clearinghouse or whatever, a good clearinghouse, you might get denials for some of these issues, so we're going to take a look at some of these guidelines, so when you're dealing with what we call a manifestation or ideology, that means something has to go first, okay, you will see code first or use additional code and in diseases classified elsewhere, so some of those kind of verbiages when you're looking in your actual ICD-10 book, so certain conditions have both an underlying ideology and multiple body system manifestations due to that underlying ideology, for such conditions, ICD-10 has a coding convention that requires the underlying condition be first primary, followed by the manifestation, so again, you know, you would have prompts, use additional code or code first, so here's a couple of examples, so patient presents to the office to discuss test results, her endoscopic pathology was positive for H. pylori chronic gastritis, all right, so we cannot code H. pylori primary because it's as the cause of diseases classified elsewhere, so that means there needs to be the gastritis primary, here's another example, patient has alcoholic cirrhosis of the liver with esophageal varices here for EGD with endoscopic banding of the varices, okay, so primary diagnosis, alcohol cirrhosis of liver without ascites, secondary varices without bleeding, I8510, okay, make sure you guys are assigning secondary varices, not the primary varices, we don't usually treat primary varices, it's usually a patient that has some sort of liver condition, combination codes, this is when one code exists to identify two different issues, okay, two diagnosis or an associated secondary process or associated complication, all right, so here's a couple of combination coding examples, and we have quite a bit in GI actually, patient seen as a follow-up in the office for ulcerative pancolitis currently having problems with rectal bleeding, all right, so you're not going to assign ulcerative pancolitis without complications and then rectal bleeding, you're going to assign the one diagnosis code because it includes both descriptions, patient seen as a follow-up for alcohol cirrhosis, he was noted to have ascites on examination, so same thing, one code to identify both issues, patient seen as a new patient for IBSD and prescribed medication to help with current symptoms, so there's IBS with diarrhea, this is probably the most important guideline that we need to know about, and it's called the excludes one note, and what that means is you cannot code both of those codes together, all right, and you will get a denial from the payer if it doesn't stop before it goes out to the payer, you will get a denial saying invalid diagnosis coding or can't, you know, diagnosis codes can't be reported together, denials like that, we should not be getting denials for this type of issue, we should be taking care of that before it gets to the payer, all right, but sometimes we don't know this if we, again, we don't have eyes looking at every single note and claim that goes out the door, so here's an example of an excludes one situation, patient admitted with GI bleed found to have a bleeding duodenal ulcer treated with endoscopic control of bleed, the only diagnosis code you are going to code is K26.4, because it includes hemorrhage, if you try to code GI hemorrhage in addition, K92.2, the claim is going to deny or can't code both of these together, here's another example, patient presents for screening colonoscopy and found to have a rectal polyp removed by snare technique, pathology was not reviewed to confirm histology, okay, well, that means I'm stuck with rectal polyp, K62.1, right, you cannot code adenomatous rectal polyp with a unknown type rectal polyp or non-adenomatous rectal polyp, patient presents for open access screening colonoscopy and incidental diarrhea, and I know Kathy hit this one on our last talk, if you look in your ICD-10 book at the back, Z1211, it states encounter for diagnostic examination code, sign or symptom, okay, so it's one or the other, cannot be both, and again, that's a no-no, we're not saying screening and incidental anything, it's either screening or it's diagnostic, you got to pick, don't let the payer pick for you because you know what they're going to pick, they're going to pick diagnostic, that's less money they have to pay, but more money your patients have to pay. All right, so some other excludes notes that you may not realize, this first one's a big one that I see all the time when we do reviews, heartburn and epigastric pain, how many of your patients have heartburn and epigastric pain together? Many of them, but another description for R10.13 is dyspepsia, and if you're not specifying it as functional dyspepsia, then you have to code R10.13 and that is not allowed to be billed with heartburn. If I would say in a in a case like this, if you really truly are doing a diagnostic EGD for heartburn and the patient having epigastric pain, I would code epigastric pain before the heartburn. R18, ascites, so any code that says ascites in, alcohol cirrhosis, alcohol hepatitis, you're not going to carve out the ascites, it's excluded from one another. Change in bowel habits is R19.4, and it cannot be coded with constipation or functional diarrhea. Stool studies, okay, so blood in the stool is different than a stool study, okay, so other fecal abnormalities is your stool study abnormality, R19.5, and it cannot be coded with the actual symptom of blood, K92.1. Now here's another polyp example, K31.7 cannot be coded with adenomatous polyp of the stomach, D13.1. Ulcerative colitis, if you have a patient that has a diagnosis of ulcerative colitis and they have inflammatory polyps, which multiple polyps everywhere, okay, your diagnosis is K51.40 or whatever it is if there's complications, right, this is, but make sure guys, if you are reading through an endoscopy report and your doctor removes one polyp, let's say it's screening colonoscopy, one polyp's removed, pathology shows it's an inflammatory polyp, that is not K51.4, okay, that is K63.5. You don't want to label a patient with colitis if they don't, ulcerative colitis if they don't have it, so be careful on that coding, but it's excluded from the adenomatous colon polyps and the hyperplastic or just polyps of colon unspecified, K63.5. Rectal bleeding, K62.5, you cannot build GI bleed or melano with rectal bleeding, it's one or the other, and this is a big one, this is a big problem that I see on, mostly I see it on clinic notes and even in the hospital too when I'm doing reviews, is the chief complaint says rectal bleeding, then the HPI says there's blood in the stool, and then we go back to rectal bleeding and the impression and plan, you got to pick. Obviously melano, blood in the stool is a lot more significant than rectal bleeding, so you've got to make sure you're specific and don't kind of contradict yourself from one to the next. Yes, the patient's probably going to say I've got rectal bleeding, but you know obviously through talking to them, taking a history and everything, it might actually be, oh actually yeah, I'd see it in my stool as well, so just make it one or the other. Polyp of colon, K63.5 cannot be billed with the D12 codes, and we struggle with this as coders because what happens if I have a snare, I do a snare of an adenomatous polyp, but I do a biopsy of a hyperplastic polyp, and I'm trying to bill multiple procedures. I'm billing the snare and the biopsy with the 59. Well, the thing with that is you're going to report the D12 code. Now some payers may allow you to bill the K63.5 because it's on that second line of the claim, but I've also heard practices say it doesn't matter. If those two codes are on that claim, they'll kick it out, so you kind of have to watch for these denials if you get them, but in that scenario, let's say the payer doesn't want both of them on the claim. You're going to bill the D12 code. That's more significant. That's an adenoma that requires the patient to come in at shortened intervals for surveillance, okay? So what do you do? You bill that, and then you can put in your box 19, that free text area, hyperplastic polyp located in the ascending colon was also removed by cold forceps, okay? So you're indicating it, but you're not pulling that diagnosis code through, and then K92.2, look at all of the diagnosis codes that you cannot bill with it, okay? So you're going to want to bill all of, you would want to bill the diagnosis code that's actually in excludes one because it's more specific. So if you have any kind of gastritis that's bleeding, AVM that's bleeding, diverticulate, diverticular disease with bleed, gastritis, ulcers, anything that says with bleeding, K92.2 is left off of that claim. Z08 and Z09, so we had that question earlier that came through that said, you know, this payers are denying for when I use Z86.010 as a primary diagnosis. What they're doing is they're following ICD-10 guidelines. So if you think, if you're listening and going, yeah, that sounds familiar, I think we have gotten denials on that. That's what they want. They want the Z09 in the primary position. So we have Z08 and Z09. Z08 is for encounter for follow-up exam after completed treatment for a malignant neoplasm. So if the patient has a personal history of colon cancer, you may have to use Z08 primary to that. And again, personal history of colon polyps, peptic ulcer disease, things like that, you're going to use Z09 primary to that. Now, if you guys are using the personal history polyps and such as primary diagnosis codes, and you're not getting any denials or anything like that, then just, you don't have to use these. But again, if you are, and they're saying it's not a primary, then that's what they want. They want that Z08 or Z09 in the primary position. So documenting code for medical necessity. We are seeing increase in claim denials for medical necessity, lack specificity, things like that. So just be specific. Make sure that, and I know it's frustrating, especially when you have, you're seeing 20 patients in clinic, and then you've got a bunch of procedures to do, and then you've got to go to the hospital to do it. And it's frustrating sometimes when you're trying to find a diagnosis code. In the EMR, you type in something and guess what happens? Oh, here's 100 diagnosis codes to pull from. Good luck, right? Well, we talk about pulling in list of favorites. That way, using your buzzwords. That way, when you go to search that diagnosis code, again, it's right there for you, and it's specific. So we talked about Crohn's and ulcerative colitis. Those are what we call combination codes. When your patients that have Crohn's or UC come in with complications, they're not at their baseline, they require you to do a workup, switch medication, whatever, you need to make sure and say that. What are those complications? So patient with history of Crohn's, large intestine, presents with rectal bleeding, left lower quadric pain, and diarrhea. So we have one for rectal bleeding, but the pain and diarrhea you're going to use the other complications and then you're going to code out what those complications are. Now, sometimes there's no complication. I'm just here for my Remicade infusion. I'm stable. I'm doing well. I have no, you know, I have nothing going on. Then you're going to do the without complication. You know, just make sure you are not routinely assigning ulcerative colitis. I don't know. Crohn's, I don't know. Those 0.9 diagnosis codes will get you. If you know, document it. Patient with a long history of GERD, who presents for upper endoscopy due to persistent heartburn and epigastric pain, despite a three-month trial of PPI therapy. Okay, this is a really good one when you are ordering your upper endoscopies for GERD. I see GERD all the time and that is it. That does not necessarily support doing an EGD because the assumption is GERD is at bay with their PPI therapy. So if they're coming in with breakthrough symptoms, those symptoms or again, PPI therapy is not working. That needs to be documented. Many of our commercial payers have diagnostic EGD policies. They require pre-authorization as well. So they won't even let you do it until you get a pre-authorization. And if you're trying to get pre-authorized for GERD only, you may not get an authorization. So all about being detailed and specific. Those of you that treat hemorrhoids, guys, if you're billing for hemorrhoid banding or any kind of hemorrhoid procedure, document the grade or the stage and code it. And also symptoms that the patient is having as well. Just because the patient has a hemorrhoid doesn't mean you need to treat it or remove it. Okay? You have to, the patient should be symptomatic. They should be having issues with it. So documentation for hemorrhoid treatments must include any symptoms related to those hemorrhoids that medication therapy failed and risks and benefits were discussed with the patient. Oftentimes I don't see this very clearly documented. Comorbidities and risk factors. I kind of talked about that multiple times in the E&M talk. Document patient comorbidities and risk factors when they impact your decision making. This supports your higher levels of services, but it also starts medical necessity for why the patient needs an elevated level of sedation, anesthesia, or that they have to be done at the hospital. It also helps support HCC and risk adjustment, which I'll talk about in just a minute. So here's an example. Patient presents new, for a new evaluation of epigastric pain and bloating. Decision was made to proceed with an outpatient EGD. Patient is at increased risk for this procedure due to her underlying COPD, CAD, and severe obesity. All right. So question. Anemia NOS is generally an approved diagnosis code that supports medical necessity for upper and lower endoscopy. Is that true or false? All right. False is correct. Good job. You see, we tried not to make these polling questions like really, really, really difficult. But yes, anemia unspecified is not generally approved for any kind of endoscopy. It usually has to be iron deficiency anemia or acute blood loss anemia, things like that. All right. So this takes me into nonspecific codes to avoid. R10.9, all of you listening in, if you are a provider listening in, okay, you should never, ever assign this diagnosis code. You're a GI provider. If your patient is coming in for pain, you're going to know where it's at. It can be generalized. That's a code. It's better than I don't know. R10.9, don't use it. And most of the time, it's very well documented in your note, but you can't find the code. That's when I talk about using your search, use your buzzwords, use your list of favorites. Talked about this already, Crohn's and ulcerative colitis. If you know, document it. Infusions, and I know Kathy is going to talk a little bit about this a little later on, but infusions are huge. We don't want infusions to ever get denied. And payers, if you bill an infusion with a nonspecific IBD code, they're going to deny it for medical necessity. So who does the infusion documentation? It's not the doctor. It's usually the nurse. So does the nurse know how important it is to be specific in their notes? Now, if you don't know, and there's a lot of patients that you're kind of back and forth with the diagnosis of Crohn's versus UC, you're just not sure, there is a diagnosis code for indeterminate colitis. And that is appropriate. It's specific until you know for sure which one it is. There's your unspecified anemia, usually not on coverage determination for endoscopies. Okay. Now, if you're bringing in the patient to clinic for unknown anemia, then it's appropriate to use it. But then you should eventually know what type you're dealing with. Personal history versus current condition, just going to comment on this. Make sure, guys, when you are bringing your patients back and they do have a personal history, do not code or do not select the diagnosis for a current malignancy or a current polyp. Do the personal history. If it has been previously excised or eradicated, and there is no further treatment, that is a personal history, not a current condition. So for example, patient comes in for follow up of a GERD. They also note a personal history of colon cancer treated three years ago. Okay, so I can code it, but I'm going to code that secondary and as a personal history, not a current condition. And again, sometimes if your EMR is not set up to be savvy like that, and you're busy and you're just selecting codes, you may accidentally select that code. But to the payer, that means the patient has cancer right now. So again, be careful. We don't want to label patients with things that they don't have. All right, importance of Z codes. So we talked about the social determinants, but we also want to make sure and, you know, document if the patient's resistant to any kind of antibiotics. Procedure not carried out because of contraindication. That is a good secondary diagnosis for your discontinued procedures. Long-term current drug therapy. So we talked about that visit prior to screening, and if you're truly managing that medication, this is the diagnosis code you would report. Noncompliance. Okay, they're very specific on their noncompliance. It could be dietary, it could be due to a medication underdosing due to financial reasons, age-related debility, etc. Personal history of failed moderate sedation. That is a good diagnosis code to use on, let's say you have a typically healthy patient, they really don't have risk factors, but last time you gave them conscious sedation, it wasn't good turnout. Okay, so that's a good code to use for MAC. Here's a couple of quick case studies. So if you've got a patient coming in for to see the dietician for nutritional counseling and weight management, you can do the dietary counseling, morbid obesity. When you use a diagnosis code of morbid obesity, make sure you are also coding their BMI. That is an ICD-10 guideline. This is a good one for your fecal transplants. So a patient with a history of failed vancomycin therapy presents for fecal transplant due to recurrent C. diff. So recurrent C. diff goes first, resistance to vancomycin goes second. Screening colonoscopy, she's on Coumadin, chronic AFib, on oxygen, and those are all the potential diagnosis codes you could report, just depending upon the scenario and if you're managing or you're just saying this patient is an increased risk, etc. Patient presents to clinic for breakthrough heartburn, has a long history of severe GERD. Upon gathering history from the patient, she admits that she misses doses. She doesn't take her Nexium because she's unable to pay for refills. So heartburn, GERD, and then the non-compliance diagnosis. All right, risk adjustment. This is, I'm going to just go through this very quickly. I'm just going to kind of sum up what risk adjustment is. So it's a process by CMS and other payers can have risk adjustment as well, but it's a process by which CMS reimburses Medicare Advantage plans by assessing the health status of their members. Okay, so what it is, is the risk adjustment data is pulled from claims, diagnosis codes on claims. All right, so we're painting a picture of how sick this patient is or how healthy the patient is. And obviously, the sicker the patient, the more money is going to be spent. So it ensures accurate adequate payment based upon expected medical costs. Each score is reset each year, each, sorry, each member score is reset each year. Here's some documentation tips on CMS's guiding principle. I'm not going to read all this to you. It's just making sure that you code everything that you address, be specific, do your cause and effect relationships, make sure you're coding a current diagnosis, if you're still treating it, managing it's chronic, not a personal history. And then, again, avoid unspecified diagnosis codes, make sure all those diagnosis codes that you're documenting are also transmitted to the claim. So I'm going to go through these really quick. These are our risk adjusted diagnosis codes. Okay, not everything we treat is risk adjusted. The symptoms we treat, things like that are not risk adjusted, because the assumption is it's going to eventually go away. These are chronic issues that have cost implications. All right, so just going to go through these real quick. Hepatitis, your malignancy codes, all from the mouth to the bottom. We've got your carcinoma of the liver, you have malignant neoplasms of the pancreas, and then stromal tumors are also risk adjusted, secondary malignant neoplasms are risk adjusted. Okay, diabetes. Okay, so do you guys see patients with diabetic gastroparesis? Okay, so gastroparesis alone is not risk adjusted, but diabetic gastroparesis is. Malnutrition, etc. Okay, so I'm going to quickly just go through all these. All your alcohol abuse use dependent codes are risk adjusted, those are actually a fairly high. Varices, all of your ulcer codes, Crohn's, ulcerative colitis, all of them. All right, then we're getting into more surgical infarctions, etc., of the intestines, necrotizing enterocolitis, ileus. Anyway, you can read these, you have this list. These are available on Medicare's website as well. Our highest risk adjusted diagnosis codes have to deal with your enterostomies, your gastrostomies, things like that. So if you've got a gastrostomy that you're treating, or even if it's time to replace it, they have it, all of those are still risk adjusted. BMI 40 and over is risk adjusted. Here are your comorbidities. So you may not, again, you may not be treating primary a diagnosis that's risk adjusted, but their secondary issue is. Okay, but again, you only need to document those when they impact your plan of care. All right, so impression. This is an example of a risk adjustment issue. Hemopositive stool and a significant decrease in hemoglobin in this 90-year-old female who is 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 colon, depending upon the patient's hemoglobin and hematocrit. I would like her pulmonary status to stabilize, and at that point, we'll perform an EGD. Okay, she's at risk because of COPD, acute CHF, effusions, hypertension, and the advanced age. All right, so what's risk adjusted here? Well, the two issues we're seeing the patient for are not, but all our secondary issues are. All right, so we want more information on here. Medicare actually has the 2021 mappings out, and you can get that information on their website. All right, thank you, guys, and I think now I'm going to turn it over to Kathy, and she's going to talk about ancillary services.

ICD-10 coding

risk adjustment

diagnosis codes

specific coding

medical necessity

comorbidities

Z codes