Chronic Diseases Creating Coding and CDI Implications

These conditions should be on the radar for coding and clinical documentation integrity.

There has been much discussion about healthcare expenses in recent months. The Centers for Medicare & Medicaid Services (CMS) is focusing on value-based purchasing (VBP), and payors are focused on reducing costs through Hierarchical Condition Categories (HCCs) and preventative care.

I was interested in what were considered the top chronic diseases and how health information management (HIM) coders could impact reimbursement related to these conditions.

HealthPayerIntelligence in July 2017 published a list of the top 10 most expensive chronic diseases for healthcare payors. I did an analysis of these diseases, which include cardiovascular diseases, smoking-related health issues, alcohol-related health issues, diabetes, Alzheimer’s disease, cancer, obesity, arthritis, asthma, and stroke. More specifically:

1. Cardiovascular diseases include hypertension, coronary artery disease (CAD), angina, cardiac arrhythmias, myocarditis, and heart failure. These diseases are also on the HCC list, as they are chronic and demand long-term treatment. The key to the documentation is specificity with regards to type, stage, and acuity.
2. Smoking-related health issues: CMS and other healthcare organizations have been working on decreasing the number of smokers nationwide, as these patients tend to develop other chronic conditions. The issue with coding for smoking is the code Z72.0, which is nicotine use. This code is not well-defined in ICD-10-CM. It is suggested that each facility develop its own internal coding guideline as to how this code will be utilized. If the patient is a smoker, then the case would be coded as F17.2-. ICD-10-CM does provide the ability to code people who are affected by secondhand smoke, using the code F77.22. Smoking does not qualify as a HCC, but should be listed for statistical purposes, as well as for predicting healthcare issues for a patient.

3. Alcohol-related health issues: the coding for this condition falls in category F10. There are many clinical documentation issues with regards to specificity (use, abuse, dependence) as well as the manifestation of the alcohol disease. In order to capture HCCs for this condition, specificity is the key.
4. Diabetes: it was amazing to discover that all diabetes codes (E08 – E13) are considered an HCC. As clinical documentation improvement professionals (CDIPs) know, there are many options for specificity regarding diabetes, including the type (1, 2, drug-induced, underlying condition, other secondary diabetes) as well as the manifestations. Hyperosmolarity, hyperglycemia, hypoglycemia, and ketoacidosis are the conditions that create major complication/comorbidity status for the Medicare-Severity Diagnosis Related Groups (MS-DRGs).
5. Alzheimer’s disease: this condition is a chronic condition that is easily coded from the G30 category. The CDI opportunity is in identifying the type as well as the presence of behavior disturbance (F02.80 vs. F02.82). It was interesting to see that Alzheimer’s disease is not an HCC, but the behavior disturbance did qualify as an HCC.
6. Cancer: this condition is a large grouping of various types and the codes range from C00-D49. If you remember cancer and death, you will remember the beginning letter of the ICD-10-CM codes. From a documentation standpoint, the neoplasm type or morphology, behavior, secondary versus primary, anatomic location, and manifestations are key in clear documentation of the disease. From an HCC perspective, most of the skin cancers are excluded from HCCs, as well as cancer in situ, benign neoplasms, and neoplasms of uncertain behavior.
7. Obesity: obesity codes fall between E66.01-E66.9, with the body mass index (BMI) captured in category Z68. Obesity does not impact MS-DRGs, except for E66.2 (morbid obesity with alveolar hypoventilation), which is a CC. Only morbid obesity (E66.01 or E66.2) is considered an HCC. The BMI should be coded with obesity. It is important that a facility document the “source of truth” when coding the BMI. The Official Coding Guidelines say that the BMI does not have to be documented by the provider, but what documentation in your electronic health record should be utilized to code? For consistency, it is important that the same documentation is utilized for coding as well as auditing. The BMI can be a CC and an HCC.
8. Arthritis has many variations and can be identified using ICD-10-CM categories M00-M02, M05-M06, M08-M13, M15, and M19. The type, anatomical site(s), laterality (when applicable), bacteria involved (when appropriate), and associated conditions and manifestations should be clearly documented to provide a picture of the patient’s condition. Bacterial arthritis, rheumatoid arthritis, Felty’s syndrome, and juvenile arthritis are the only conditions that are considered HCCs. None of the arthritis codes are MCCs, but the bacterial arthritis codes are CCs and could impact reimbursement.
9. Asthma: this condition has been a longstanding issue for clinical documentation integrity under ICD-10-CM. The type (intermittent versus persistent) and the severity (mild, moderate, or severe) are needed to specify asthma. The condition is coded from category J45. Asthma is captured with chronic obstructive pulmonary disease (COPD) using J44.9 and an asthma code. Asthma does not determine HCC status. The chronic condition associated with asthma (such as COPD) will classify the patient with an HCC.
10. Stroke is coded in the category range of I60-I63. The coder can also capture if the condition occurs intraoperatively or postoperatively using codes from the range of I97.810-I97.821. The clinical documentation should specify the type of stroke, involved vessels, dominance, and associated manifestations. HCCs include the acute stroke as well as past strokes with residuals.

As healthcare moves toward reimbursement being based on chronic diseases, it is important to have specificity regarding these conditions. The specificity could impact acute care reimbursement as well as managed care reimbursement. These conditions should be on the radar for coding and clinical documentation improvement/integrity.

Program Note:
Listen to Laurie Johnson live today on Talk Ten Tuesday, 10-10:30 a.m. EST.

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