ulcer - MultiCultural IPA

Ingenix InSite
User Group
October 12, 2010
Approval Code: IN1070
Ingenix InSite User Group: Welcome
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Ingenix InSite User Group: Agenda
10:00 AM – 10:05 AM
10:05 AM – 10:10 AM
10:10 AM – 10:20 AM
10:20 AM – 10:30 AM
10:30 AM – 10:45 AM
10:45 AM – 11:00 AM
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InSite Operations Announcements
Report Selection Tool
Changes to the CMS-HCC Payment Model and Impact on RAF
Focus on: Peripheral Vascular (Arterial) Disease
InSite Operations Announcements
Presented By
Susan Rick
InSite Business Operations Manager
InSite Operations Announcements
 Data Refresh Update
InSite Mid-month data refreshed September 20th
• Data refresh may not impact all InSite users
• Mid-month data refresh will not replace the normal monthly data
Next monthly data refresh is targeted for October 18th
 October 8th, 2010 – InSite Updates
October Ingenix Insider
Report Selection Tool
© Ingenix, Inc. 5
InSite Report Selection Tool
Presented By
Francesca Siciliano
InSite Business Analyst
InSite Report Selection Tool
 Report Selection Tool
© Ingenix, Inc. 7
Changes to CMS-HCC Payment Model
for 2011 and Impact on RAF
Presented By
Loren Maddy
Director, Analytics
 Medicare Advantage Reimbursement is a Function
of Bid (Ratebook) and RAF
– Estimated 2011 Net Impact: -1.6%
• Ratebook:
– No Ratebook changes for 2011
• RAF:
– Impact of CMS Changes on Otherwise Equal
RAF is -1.6%
» FFS Normalization: -1.6%
» No other CMS changes for 2011 Pmt Yr
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2011 Estimated CMS RAF Change
National Growth Percentage (Minimum Update)
Latest Trend
Based on CMS
Final Ratebook
Source / Drivers
2011 Final CMS Ratebook Announcement
Budget Neutrality adjustment was scheduled to be completely phased
out in 2011; However, due to legislative changes, CMS elected to keep
the 2011 Rate Book unchanged from the 2010 Rate Book. As a result
the 2011 Rate Book contains the same adjustment for Budget
Neutrality as the 2010 Rate Book, so the 2010 to 2011 revenue trend is
FFS Normalization Change
FFS Normalization is applied to reflect a difference in FFS coding
patterns in the data driving the payment year vs. the data used to
calibrate the risk model.
RAF scores are divided by this amount to arrive at the RAF score per
2010 FFS Normalization: 1.041
2011 FFS Normalization: 1.058
Change: -1.60%
Increase in FFS to MA Coding Intensity Adjustment
FFS to MA Coding Intensity Adjustment was not recalibrated for 2011
Recalibration of Coefficient
Coefficients were not recalibrated for the 2011 payment year
Subtotal: CMS Trend
Budget Neutrality Change
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Impact of CMS Changes on RAF:
FFS Normalization & MA Coding Pattern
2008 Pmt Yr 2009 Pmt Yr 2010 Pmt Yr 2011 Pmt Yr
Age/Sex RAF component
Special Status RAF component1
CHF (HCC 080)
Vascular Disease (HCC 105)
COPD (HCC 108)
CHF/COPD Interaction
HCC RAF component
Total RAF
FFS Normalization factor
FFS to MA Coding Intensity Adj %
Adjusted Total RAF
Assumes member is a 75 year old Community male w ho is Medicaid eligible
© Ingenix, Inc. 11
New ICD-9 Codes added to CMS-HCC
Payment Model
Presented By
Pam Holt
Manager, SoCal Market Consultation
CMS Announces New Codes for Model
 On October 1st each year, new ICD-9 codes are
 CMS evaluates which codes will be included in the
CMS-HCC and Rx Models
 CMS posted a new crosswalk including new codes
effective Oct 1st
 8 codes were added to the CMS-HCC model
 https://www.cms.gov/MedicareAdvtgSpecRateStats/06_
– Zip File Name: “2011 Model Diagnoses”
– File Name: “Risk Model Diagnoses for 2011.xls”
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Peripheral Vascular
(Arterial) Disease
Mary Jo Groome, CCS-P, CPC-H
Sr. Provider Training & Development Consultant
What is Peripheral Artery Disease (P.A.D.)?
 P.A.D. occurs when plaque builds up in the arteries that carry
blood to your head, organs, and limbs. Plaque is made up of a
fat, cholesterol, calcium, fibrous tissue and other substances in
the blood.
 When plaque builds up in the arteries, the condition is called
atherosclerosis. Over time, plaque can harden and narrow the
arteries. This limits the flow of oxygen-rich blood to the organs
and other parts of the body.
 P.A.D. usually affects the legs, but also can affect the arteries
that carry blood from the heart to the head, arms, kidneys and
 Today’s comments will focus on P.A.D. that affects blood flow to
the legs.
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Peripheral Arterial Disease (PAD)
Clinical description of PAD
 Present in approximately 8 to 12 million individuals in the
 Estimated to be present in 29% of those
– Age 70 or over; or
– Age 50 to 69 with a history of smoking 10 pack years or those
with diabetes.1
 History and physical examination may not be reliable for
the detection of lower extremity PAD8
– Presents with classic claudication 10% to 35% of cases
– Many individuals have no symptoms or non-classic
– Poor recognition (under-diagnosis) results in undertreatment (estimated only 25% of those with PAD are
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Peripheral Arterial Disease (PAD)
Clinical description of PAD
 Often caused by atherosclerosis
 Identifies risk for myocardial infarction
(also referred to as a heart attack) and
 Causes poor blood supply to
 Symptoms worsen when demand
increases (exercise)
 As disease progresses, less exercise
causes symptoms; if severe –
symptoms at rest (with no movement)
 May result in pain (disability), skin and
tissue damage (ulcers) and infection
 Can worsen diabetic complications
such as slow healing foot ulcers
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Peripheral Vascular (Arterial) Disease
PAD Facts:
 Most major cardiovascular events occur in those
without a prior diagnosis of vascular disease.
 Over 50% with PAD will not have previous vascular
symptoms; 40% have atypical symptoms.
 It is estimated that only 25% of afflicted individuals
receive care
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Peripheral Vascular (Arterial) Disease
 There are two types of PAD
– Arteriosclerotic: Involves medium to
large vessels and is amenable to
– Diabetic: Involves medium to small
vessels and is not typically helped
by bypass.
 Workup can be done by Ankle
Brachial Index (ABI)
– Can be used to diagnose PAD and can
be performed in any doctor’s office
– Reveals a comparison of the systolic blood pressure between the lower
and upper extremities and is measured using a Doppler.
– An ABI of less than or equal to 0.90 is abnormal and is considered
evidence of lower extremity PAD.
• Prompt investigation and risk-reducing treatments are then
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Documentation & Coding PAD / PVD
 Peripheral arterial disease, peripheral vascular
disease, and claudication are coded to 443.9
– It is important to note that this code excludes
atherosclerosis of the arteries of the extremities.
 Atherosclerosis of native arteries of the extremities,
Category 440, is further classified as such:
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With intermittent claudication 440.21
With rest pain 440.22
With ulceration 440.23 (see ulcer coding rules)
With gangrene 440.24 (see ulcer coding rules)
Unspecified 440.20
PAD Documentation & Coding
 Diagnostic statements that do not
impact severity adjustment as they
are coded to:
440.9: Generalized and unspecified atherosclerosis
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Arteriosclerotic (vascular) disease
Generalized arteriosclerosis
Arteriosclerotic endarteritis
Arteriosclerosis obliterans
Arteriosclerosis with calcification
Documentation & Coding PAD / PVD
Vascular diseases often occur as a manifestation
of diabetes:
 Diabetic Peripheral Circulatory Disorders
– If the PVD is due to diabetes mellitus, codes 250.7x and 443.81
would be assigned.
– The specificity of the PVD changes to 443.81, Peripheral
Angiopathy in diabetes mellitus.
– Code 443.81 provides a more comprehensive picture of the
patient’s PAD/PVD condition in regard to DM as an underlying
– Provide the appropriate linkage for the diabetes with Peripheral
Circulatory Manifestations (250.7x)
American Hospital Association, AHA Coding Clinic for ICD-9-CM. 3rd Qtr. 1991. p. 10
World Health Organization, 2009 Ingenix ICD-9-CM Professional for Physicians, Volumes 1&2. 6th ed. 2008. pp. 8&27
© Ingenix, Inc. 22
Underlying Disease – Diabetes Mellitus
 A patient with Type II controlled Diabetes that has treatment
for a manifestation of the disease should have both
conditions coded:
– PVD due to Diabetes Mellitus
• 250.70 Diabetes with peripheral circulatory disorder
• 443.81 Peripheral angiopathy in disease classified
 The underlying disease is coded first, followed by the
manifestation code.
 The linkage has been documented with “due to” and
the 4th digit is properly assigned on the 250.
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PAD Diagnosis Coding
Peripheral Vascular diseases as a result of
atherosclerosis of extremities:
 Atherosclerosis of Native arteries of the Extremities
(440.2 subcategory).
– For coding purposes, the physician must document that the PVD
is due to atherosclerosis (ASPVD) before a code from 440.2 may
be assigned.
– In fact, Coding Clinic advises to query the physician for further
specification if the physician documents vague diagnoses as
peripheral vascular disease or intermittent claudication.
American Hospital Association, AHA Coding Clinic for ICD-9-CM. 4th Qtr. 1992. p. 25
3M Health Information Systems (2008, April). Coding for peripheral vascular
In, For The Record, Vol. 20 No.8 P. 28. Retrieved March 10, 2009 from:
© Ingenix, Inc. 24
PAD Diagnosis Coding
Peripheral Vascular diseases as a result of
atherosclerosis of extremities
ICD-9-CM Coding:
 440.2 (Atherosclerosis of Native Arteries of the Extremities)
– 440.20 Atherosclerosis of extremities, unspecified
– 440.21 Atherosclerosis of extremities w/ intermittent claudication
– 440.22 Atherosclerosis of extremities w/ rest pain
– 440.23 Atherosclerosis of extremities w/ gangrene
– 440.24 Atherosclerosis of extremities w/ ulceration
 443 category (Other Peripheral Vascular Disease) - Without
additional documentation regarding the type or manifestation
of PVD/PAD, code 443.9 would be assigned.
– 443.9
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Peripheral Vascular Disease, unspecified
Rules of Coding PAD / PVD
When Assigning Atherosclerosis of Arteries of the
Extremities (440 Category)
 All patients documented as atherosclerosis with
gangrene are coded to 440.24
– If gangrene is documented without
mention of atherosclerosis, only code 785.4
 All patients documented as atherosclerosis without
gangrene, but with ulceration are coded to 440.23 *
– If ulceration is documented without
mention of atherosclerosis, only code 707.9
 Patients documented as atherosclerosis with neither
gangrene nor ulceration, but with rest pain are coded to 440.22
– If rest pain is documented without
mention of atherosclerosis, only code 729.5
 Patients documented as atherosclerosis with intermittent
claudication due to atherosclerosis are coded to 440.21
– If claudication is documented without mention
of atherosclerosis, only code 443.9
© Ingenix, Inc. 26
Ulcers: Codes from
707.1x (Ulcer of
lower limb) should
be assigned in
addition to 440.23
Rules of Coding PAD / PVD:
Ischemic Ulcers
 Subcategory 707.1x Ulcer of lower limbs, except
pressure ulcer
▪ First: Code
any underlying or causal condition
- 440.23 – Atherosclerosis of Extremities w/ Ulceration
- 250.8x – DM w/ Other Chronic Manifestations
▪ Second:
Code associative ulcers to the highest level of specificity
707.10 – Ulcer of lower limb, unspecified
707.11 – Ulcer of thigh
707.12 – Ulcer of calf
707.13 – Ulcer of ankle
707.14 – Ulcer of heel and midfoot
707.15 – Ulcer of other part of foot
707.19 – Ulcer of other part of lower limb
 Chronic ulcer of unspecified site – 707.9
 Varicose ulcer (lower extremity, any part) – 454.0
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Clinical Example
 Exam: S1S2 no murmur or gallop with regular rhythm.
Radial pulses 2+. Feet cool with left pedal faint and
absent rt pedal pulse. No edema. Hemosiderin stain of
both anterior LE.
 Dx: 443.9
 A/P Stable PVD.
 Comments: “Stable PVD.” represents a definitive
diagnosis. This is correct coding.
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Clinical Example
ankle fx 12/07, with small open area on medial aspect of
her ankle that heals over and then reopens.
VASCULAR: ULCER: Inner left malleolus has non-healing
wound. POSITIVE FOR: Ulcer
VASCULAR: 1+ pedal pulse on R. Foot warm w/sensation.
No reddened or open areas.
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Clinical Example
 Diagnosis : 440.23 - Atherosclerosis of native arteries
of the extremities with ulceration
– Treatment Plan : STATUS: Has open area on inner aspect of
left malleolus. very difficult to heal with probable osteomyelitis.
Will continue wound healing measures and conservative
interventions if wound worsens.
 Diagnosis : 707.13 - Ulcer of ankle
– Treatment Plan : STATUS: Chronic, PLAN: Had ankle
fracture 12'07. has had an open area on the medial aspect of
her left ankle that heals over, opens up, heals over, etc. 6'08
has open area 1 cm that has a pinpoint hole in the center. a
shiny metal piece is visible which is probably a plate or screw
that was used to fix the ankle fracture. xray ordered to r/o
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Clinical Example
 Comments:
 ROS documentation states:
VASCULAR: ULCER: Inner left malleolus has nonhealing wound. POSITIVE FOR: Ulcer
 Is this an ulcer or a non-healing surgical wound?
– The code for ulcer of the ankle is 707.13. It maps to HCC 149
with a RAF of 0.241.
– The code for non-healing surgical wound is 998.83. It does
not risk adjust.
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Clinical Example
 Atherosclerosis is never mentioned in the documentation.
In order to code 440.23 - Atherosclerosis of native
arteries of the extremities with ulceration, the
documentation must state atherosclerosis, ASPVD or
atherosclerotic PVD, etc.
– 440.23 maps to HCC 104 with a RAF of 0.482.
 An argument could be made that the documentation does
not support the codes reported.
 According to the documentation, the correct codes for this
scenario would be 998.83, and 443.9.
– 998.83 does not risk adjust.
– 443.9 maps to HCC 105 with a RAF of 0.165.
 Specific documentation can make a big difference!
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1 Hirsch, A.T., et al. Peripheral Artery Disease Detection , Awareness, and Treatment in
Primary Care. JAMA; Sept 19 2001; 286(11):1317-24
2 Bhatt DL, Steg PG, Ohman EM, Hirsch AT, Ikeda Y, Mas JL, Goto S, Liau CS, Richard AJ,
Rother J, Wilson PW; REACH Registry Investigators. International prevalence, recognition,
and treatment of cardiovascular risk factors in outpatients with atherothrombosis. JAMA.
3 Hirsch, A.T., et al. (October 2005). ACC/AHA Practice Guidelines. Journal of the American
College of Cardiology, 2006; 47; e1-e192, Retrieved February 12, 2009, from
4 Hiatt, WR. Medical Treatment of Peripheral Arterial Disease and Claudication. N Engl J Med
2001; 344:1608
5 McDermott, MM, Kerwin, DR, Liu, K, et al. Prevalence and significance of unrecognized
lower extremity peripheral arterial disease in general medical practice. J Gen Intern Med
2001; 16:384
6 Norgren, L, Hiatt, WR, Dormandy, JA, et al. Inter-Society Consensus for the Management of
Peripheral Arterial Disease (TASCII). J Vasc Surgery 2007; 45: Suppl S:S5
7 "Executive Summary: Standards of medical care in diabetes—2009". Diabetes Care 32: S6–
S12. 2009.
8 PAD Peripheral Arterial Disease. March 22, 2010. <www.padcoalition.org>.
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Future InSite Coding Topics:
◘ November -Diabetes, Linda Farrington, CPC, CPC-I
◘ December- Ulcers, Mary Jo Groome, CCS-P, CPC-H
© Ingenix, Inc. 34
User Group Feedback Survey
 We want your feedback!
 Survey is to be sent immediately after this call
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Question and Answer
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