Three Ways to Ensure Maximum Reimbursement From Medicare Advantage
In order to receive the highest level of reimbursement available for care provided, medical practices must be diligent in capturing correct data on medical charts and applying the right diagnosis codes on claims. There are 70 sections in the Hierarchical Condition Categories model (HCC) used by Medicare which correlate currently to approximately 3,000 ICD-9-CM codes. October 1, 2015 is the date set to transition to the updated ICD-10-CM, which will be comprised of 68,000 codes. In addition IDC-10-PCS will list 76,000 procedural codes. Here are three essentials to guarantee successful reimbursement:
1. Meet All Medical Record Requirements
The medical record is the primary supporting document for all claims. It must:
- Assess health status
- Re-assess chronic conditions at least once a year
- Document all conditions in record
- Support codes recorded on claim
- Be as specific and thorough as possible
- Be based on a face-to-face encounter
Since the ICD-9-CM codes are derived from the information contained in the medical record, it must be complete. Include the reason for the visit, symptoms, abnormal test results, all co-existing acute and chronic conditions and a diagnosis.
2. Use Correct Language
It is imperative that providers and coders use language consistent with coding requirements. Since some categories in the HCC model can override others, misuse of a phrase and the resultant improper coding could mean loss of or lowered reimbursement. For example, the words “History of” in coding means the condition no longer exists. If a provider documents that a patient has a history of a condition, and that condition is actually chronic, the coding will indicate that the condition has been resolved, instead of being ongoing. It is important as well to distinguish between the assessment of a condition and its plan. Words used for assessment include:
- Stable
- Improved
- Tolerating meds
- Deteriorating
Examples for plan are:
- Monitor
- D/C meds
- Continue current meds
- Refer
The need for clarity cannot be overstressed. Avoid indefinite language such as “probable” or “possible,” as these words will make it difficult to select a precise code.
3. Get Ready for ICD-10-CM
The transition from ICD-9-CM to ICD-10-Cm has been delayed a number of times, but it will come. The update is designed to increase the specificity of diagnosis. The basic structure of the code is as follows:
- Characters 1-3 cover the category of the disease
- Character 4 is the etiology or origin of the disease
- Character 5 is the body part affected
- Character 6 is the severity of the illness
- Character 7 is at present a placeholder for further detail
In order to get appropriately reimbursed, it is more important than ever for health providers to employ a winning combination of excellent documentation and precise coding. Professional coders stay on top of the changes and know how to translate medical records into successful claims, allowing practitioners to focus on what they do best. HCC Coders has the certified coders and software programs that can help your practice receive proper payment