Connect Archives

April 2013

Friday, April 12, 2013

RISK ADJUSTMENT FACTORS (RAF) TIPS (CHAPTER 1)

CMS uses patient diagnoses to determine compensation paid to the health plans with which HFNI is contracted. The diagnoses must be documented in the progress notes of the patients’ medical records every year. The diagnoses must be documented with specificity, related conditions, treatments, and progress.

Here are a few tips to help you document thoroughly for a diagnosis-based compensation plan versus a procedure-based compensation plan.

1. Always report, and discuss, “chronic conditions” (e.g. atrial fibrillation, CHF, rheumatoid arthritis, COPD, old MI, Diabetes Mellitus and its complications) at least once each year.
• TIP: Review the patients “problem list” for chronic conditions that have not been reported and coded, at least once yearly.
• TIP: Review and document all chronic conditions at medication refill appointments. Document results from labs, tests, and consults at the next encounter.
• TIP: Review ongoing prescription drugs for hints that a chronic medical condition has not been reported and coded (e.g. beta blocker use for “old MI”).
• TIP: Always report special “patient status” codes (e.g. stroke residual effects, paraplegia, colostomy, amputations) at least once each year.

2. Always report the highest degree of diagnostic certainty for each visit or service. It does not matter if the “final” diagnosis is something else (e.g. if your working diagnosis is “angina”, use that code instead of non-specific chest pain until angina is excluded).
• TIP: “Rule Out” ICD9 codes do not exist.

3. If a problem is due to another, make that clear with specific ICD9 coding. For example, if peripheral neuropathy is due to Diabetes, use the code for diabetes with that complication (250.6x), not Diabetes and Peripheral Neuropathy separately and unlinked. If you aren't sure of the coding, write it out, e.g. “Diabetes complicated by peripheral neuropathy”. This would result in reporting codes 250.6x, diabetes with neurologic manifestations, and 337.1, peripheral autonomic neuropathy. Similarly, always report conditions that are the cause the current clinical problem (e.g. the decubitus or chronic skin ulcer that causes cellulitis or sepsis).
TIP: How to link them together. Use the following linking terms to join the dependent condition to the primary causative condition.
o With
o Secondary to
o Diabetic….
o Due to
o Associated with
• Tip: The following do not link diabetes with a manifestation
• Slash
• Dash
• Comma
• You may document the manifestation immediately without listing the higher level of manifestation category. i.e. instead of writing “DM with Renal manifestations”, which does not specify the manifestation, use “DM w/CKD” to be more concise.

4. Code “metastatic [type] cancer — site [specify]” when appropriate. Do not use codes for cancer at two different sites (e.g. lung and brain) when the patient has metastatic cancer involving lung and brain.

5. ICD9 codes for Trauma, Motor Vehicle Accidents, Falls, and Substance Abuse (e.g. alcohol) also risk adjust payments and should be reported.

HEALTHSPRING UPDATE REGARDING TRANSITION OF CLAIMS PROCESSING

You were previously notified by Health First Network that the claims address and referral process for Healthspring Medicare Product would be changing effective 4/1/13.

Due to circumstances beyond our control the effective date of that change has been delayed indefinitely. We will notify you as soon as a new date has been determined.

Please feel free to contact Jenny Caillouet at 850-438-4487 with any questions or concerns.

HEALTH FIRST NETWORK IS MOVING

Health First Network is moving to its new location at 2929 Langley Avenue Ste. 103. Please note our new mailing address is PO Box 6480, Pensacola, FL 32503.

ICD-10 IMPACT ASSESMENT SURVEY NOW AVAILABLE

In preparation for the nationwide ICD-10 implementation date of 10/01/2014, the Agency for Health Care Administration, along with its fiscal agent, HP Enterprise Services, has issued an invitation to Medicaid Providers to participate in a series of short ICD-10 surveys to assist AHCA to better understand Provider concerns and needs as all parties work toward a successful implementation.

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WELLCARE NEW PREFERRED GLUCOMETER BRANDS FOR 2013

Wellcare health plan has notified Health First Network that the new preferred glucometer brands for 2013 are Roche (Accuchek) and Abbott (Freestyle and Precision). In an effort to let each office have up to 12 meters available for their patients, Abbott Health Care Profession has an assortment of meters available for free to offices. Please see the meter form for details. Remember that additional test strips for these meters will require a prescription.

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NEW PHYSICIANS JOINING THE NETWORK

Health First Network would like to welcome the most recent physicians to join the Network:

Paul Brooks, DPM Podiatry
Edwin Roberts, DC Chiropractic
Sylvia Harris, MD Internal Medicine
Padmaja Cherukuri, MD Hospitalist
Mark Ates, MD Family Practice
Philip Ham, DO Family Practice
Ibrahim Fahdi, MD Cardiology/Cardiovascular Disease
James Natalie, MD Physical Medicine and Rehabilitation
Obioma Ogbonna, MD Family Practice

** To determine which health plans each physician is participating in check the “Find A Doctor” section on the HFNI website.