Understanding How to Document Chronic Problems Will Maximize Reimbursement
Older patients often suffer from more than one chronic condition at a time, including common ailments such as Type II Diabetes Mellitus, Chronic Obstructive Pulmonary Disease (COPD), cancers and many others. In addition, like anyone else seniors may experience acute illness from time to time. With the Hierarchical Condition Categories (HCC) model, some categories will override others in the assessment process. It is critical to understand the importance of “first-list” diagnosis to creating a document that will support full reimbursement for treatment.
Code Everything That is Current
A patient visit may focus on continued treatment for an ongoing medical issue or it may need to address a new and acute symptom. In all cases, documentation is required for all conditions that coexist. In other words, everything that is happening at the time of the encounter goes into the report, even if the reason for the visit is to address only one complaint. Health situations that have already been fully resolved are the only things not coded.
First Diagnosis Takes the Lead
How a diagnosis is positioned makes all the difference when a claim is being assessed. If a diabetic patient comes to a visit suffering from leg pain or numbness, the “first-listed diagnosis” should be leg pain or numbness, and not simply diabetes. The acute symptom or the pain is the primary reason for the visit, and as such is judged differently in the hierarchical model than a general diagnosis of a chronic issue. In another scenario, a first-listed diagnosis of wheezing and chest pain in an emergency room visit would be more likely to receive full payment than a diagnosis of asthma.
Avoid Being an Outlier
Centers for Medicare and Medicaid Services (CMS) has vast databases relating to services billed to Medicare which it uses to analyze coding and billing practices nationally. An assessment factor for payment relates to how many times a patient is treated in an outpatient setting for a chronic illness. The cost of treatment per diagnosis will become an outlier, increasing the possibility that the claim will be challenged. Conversely, physicians will frequently be so concerned about being audited that they will code for lesser services than are provided, and receive inadequate reimbursements as a result.
Working With a Coding Professional
It is a clinician’s lament that being a good doctor should not have to involve hours upon hours of filling out Medicare claims. It is only prudent that doctors understand the essential framework of diagnosis coding, especially when it comes to documenting concurrent conditions in their elderly patients. It is smart business, however, to engage a professional coder to meet the complex and changing requirements for Medicare claims submission. Contact HCC Coders and see how we can help.