Recently a faithful reader asked me to review the “Big 12,” that is the twelve diagnostic codes I always keep in mind whenever I see a Medicare Advantage patient.
Here they are with the documentation requirements to keep you out of trouble (and a couple of acute codes thrown in):
Atherosclerosis of the Aorta I70—need radiographic evidence.
Chronic Bronchitis J41.0—h/o smoking or other chronic irritants (dust from seed, occupational particulates) and two months of productive cough most mornings.
CHF I50.xx—including Class 1 diastolic dysfunction found on echo/
COPD J44.1—FEV1 <71% predicted.
Major Depressive Disorder F320.xxx—use DSM-V criteria, does not need medication only a treatment plan
Chronic Kidney Disease N18.xxx—two measurements of eGFR two months apart.
Obesity E66.0—documentation of BMI
Pathologic Fracture of Vertebrate M84.xx—radiographic evidence, can only be diagnosed once at the time of diagnosis
Substance abuse/dependence F12.XXXX—(esp. patients who use Cannabis to self-tx for anxiety or chronic pain)
Peripheral Neuropathy G60.xx—document testing wit9-gramam wire.
Diabetes E08.xx-E13.xxx—Hba1c >6.4, Abnormal Glucose Tolerance Test or Random Blood Sugar >200
Angina I20.9—Chronic or prn nitrate use.
Pneumonia J1x.xx-J4x.xx—Based on culture result
Bonus for institutionalized patients:
Fecal Impaction K56.41—no BM for three days and requiring medical treatment
As always, double-check the codes with your compliance folks before moving forward.
I use these as a checklist in my mind, going over each one of them every time
Does the patient have it?
Have I documented it?
Then, if needed I address it.
The supermajority of health systems and Medicare Advantage Organizations take a “strip mining” strategy to their Medicare Advantage contract.
They employ any number of data mining technology to identify risk codes—not uncommonly making the patient appear more ill than they actually are.
Then they rely on tried and true barriers to care to “control” costs; prior auths, percerts, limited networks.
The program was not designed to work this way.
It was designed to give the PCP real skin in the game, an incentive to develop a trusting relationship with their patient who in turn would allow their personal clinician to curate their care.
In this situation, all that’s needed to do very well is to keep in mind the low hanging “coding” fruit and take great care of the patient.
Data extraction tools are costly, time-consuming, and suck the clinician’s will to live.
And their return on investment depends on how much the Federal government pays and whether or not enforcement will continue to be lax.
Don’t take that route, it makes a lot of money upfront but is ultimately unsustainable and immensely risky.
Teach your clinicians how to approach their contract, share financial risk with them, and then leave them alone to practice with passion.
That way, everybody wins.