August 2, 2011 CBCC Conference Call

Community-Based Collaborative Care Working Group Meeting

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Attendees

• Kathleen Connor
• Jon Farmer
• Delane Heldt
• Milan Petkovic
• Pat Pyette
• Richard Thoreson CBCC Co-chair
• Ioana Singureanu
• Serafina Versaggi scribe

Agenda

1. (5 min) Roll Call & Accept Agenda
2. (25 min) SHIPPS Domain Analysis Model discussion
   • eMeasure implementation approach
   • Rule-out; history of; family history diagnoses: how are these distinguished from actual diagnoses in claims data?
   • Difference in how diagnosis codes are captured depending on "encounter type" (“inpatient” versus outpatient/non-inpatient)
     • Outpatient/Non-inpatient encounters (encounters that do not fall into the categories of acute care, short term, long term care and psychiatric hospitals; home health agencies; rehab facilities; nursing homes, etc): Coding guidelines for inconclusive diagnoses (probable, suspected, rule out, etc.) developed for inpatient reporting and do not apply to outpatients.
     • Inpatient: rule-out coding "permitted", but appropriate coding should be used (V codes; signs & symptoms).
       • • CMS Evaluation and Management Services Guide, Dec. 2010
         • ICD9 Coding for Diagnostic Tests
         • California Society of Pathologists newsletter Oct 2007
         • Diagnosis Coding for Physician Billing
   • Vocabulary binding and eMeasure value sets
3. (30 min) HL7Confidentiality Code Project

Minutes

Rule-out (uncertain diagnosis); personal history of; family history of diagnoses

• Issue: Inaccurate coding of uncertain diagnoses may cause erroneous diagnoses to be attributed to patients, especially if the source is claims data
• How are these distinguished from actual diagnoses in claims data?
• What are the issues related to the ways in which each of these diagnosis "types" are coded?
• Definition – Uncertain Diagnosis: a diagnosis that is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out”, or other similar terms indicating uncertainty.
• Definition – Inpatient encounter:
• Definition – Outpatient encounter:

1. Inappropriate use of ICD-9 diagnosis codes for ordering diagnostic services may claims skew data
   • When clinicians create requisitions for diagnostic tests (lab tests, radiologic studies, etc.), they are required to supply “reason for test”.
   • Clinicians are not are not trained in the subtleties of proper coding practice, and therefore may use an unconfirmed diagnosis rather than the presenting signs and symptoms during the encounter as the reason for test
     • This results in ICD-9 codes for unconfirmed diagnoses appearing in claims data rather than appropriate codes as billable services are associated with the encounter which generated the order
   • Symptoms, Signs, and Ill-defined conditions are coded from Section 780.0 - 799.9
   • When diagnostic testing yields abnormal results but they are not definitive for a specific condition or disease, and the patient does not have clinical signs or symptoms, codes from categories 790 – 796 (Nonspecific Abnormal Findings) should be used to indicate non-specific abnormal findings. These codes support the medical necessity for follow up encounters or additional testing to confirm or rule out a condition
   • The V-code category – Supplementary classification of factors influencing health status and contact with health services (V01-V89) deals with occasions when circumstances other than a disease or injury classifiable to categories 001-999 (the main part of ICD) are recorded as "diagnoses" or "problems." This can arise mainly in three ways:
     • a) When a person who is not currently sick encounters the health services for some specific purpose, such as to act as a donor of an organ or tissue, to receive prophylactic vaccination, or to discuss a problem which is in itself not a disease or injury. This will be a fairly rare occurrence among hospital inpatients, but will be relatively more common among hospital outpatients and patients of family practitioners, health clinics, etc.
     • b) When a person with a known disease or injury, whether it is current or resolving, encounters the health care system for a specific treatment of that disease or injury (e.g., dialysis for renal disease; chemotherapy for malignancy; cast change).
     • c) When some circumstance or problem is present which influences the person's health status but is not in itself a current illness or injury. Such factors may be elicited during population surveys, when the person may or may not be currently sick, or be recorded as an additional factor to be borne in mind when the person is receiving care for some current illness or injury classifiable to categories 001-999. In this circumstance, the V code should be used only as a supplementary code and should not be the one selected for use in primary, single cause tabulations. Examples of these circumstances are a personal history of certain diseases, or a person with an artificial heart valve in situ.
2. Inpatient versus Outpatient coding
   • There are differences in the way uncertain diagnoses are coded depending on whether it was documented during an “inpatient” encounter or an “outpatient” encounter. So even if coding is done correctly, following all guidelines, it may be difficult to tease out unconfirmed instances of a diagnosis from an actual instance especially from inpatient encounters due to the coding guidelines.
     • It is likely there are a number of codes in claims data that are mis-coded because they were used in lieu of the appropriate unconfirmed/rule-out, family history of, or personal history of diagnosis codes.
     • Inpatient encounters: If the diagnosis documented at the time of discharge is qualified as an uncertain diagnosis, code the condition as if it existed or was established (actual diagnosis, not signs, symptoms and ill-defined conditions (780 - 799). The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis. Note: This guideline is applicable only to short-term, acute, long-term care and psychiatric hospitals (inpatient encounters)
     • Outpatient encounters: Uncertain Diagnosis - may not be included in outpatient encounter claims; however, the sign, symptom or condition that instigated the encounter should be coded.
3. ICD-9-CM Limitations
   • Each unique ICD-9-CM diagnosis code may be reported only once for an encounter. This applies to bilateral conditions or two different conditions classified to the same ICD-9-CM diagnosis code.

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