Coding Best Practices for Common Health Conditions: A Q&A With Dr. Victor Legner
On a recent episode of the miniVHAN podcast, host Mallory Yoder discussed best practices in risk-adjustment coding with Victor Legner, MD, a geriatrician with expertise in clinical documentation and coding integrity. Dr. Legner outlined some of the most common and complicated health conditions that benefit from risk-adjustment coding. In the following Q&A, Dr. Legner offers further insights on coding for depression, diabetes, obesity, heart failure as well as guidelines for better patient communication. To listen to the full episode, visit miniVHANPodcast.com.
The Centers for Medicare and Medicaid Services (CMS) uses a system called Hierarchical Condition Category (HCC) to predict future health care costs for Medicare Advantage patients. CMS recently updated this system to a new version (V28) to be more accurate. Why were these changes made?
CMS examined coding patterns between traditional fee-for-service and value-based practices to identify discrepancies. They discovered certain conditions were billed more frequently in value-based practices. Upon further investigation, they assessed the clinical relevance of these conditions. For instance, conditions like constitutional tall stature and toe amputations were previously risk-adjusted but didn’t predict higher patient risk. Consequently, CMS removed about 2,000 codes that no longer contribute to risk adjustment.
On top of that, CMS sought greater specificity in some codes, such as those for moderate depression. Overall, approximately 2,000 to 2,500 codes have been changed or removed, impacting 8-9% of diagnosis codes.
What can providers do to risk-adjust for depression?
To risk-adjust for a depression diagnosis, specificity is key. If a patient presents with depression, note the severity, whether mild, moderate or severe. Psychiatrists often view mild depression as not requiring treatment, while moderate depression usually involves antidepressants or counseling.
If a patient is experiencing depression for the first time, it’s coded as a single episode. If they’ve had depression before, it’s recurrent. It’s also important to consider whether the depression is in remission, partial remission or full remission based on clinical judgment. This level of specificity is necessary for accurate risk adjustment.
Why is risk-adjustment coding for diabetes so difficult?
Risk adjusting for diabetes requires time and attention to detail. Beyond diagnosing diabetes and noting insulin use, you must identify complications—whether ophthalmologic, neurologic or nephrologic. Many providers find this time-consuming and may resort to using a generic billing code, which doesn’t accurately represent the patient’s condition. Proper risk-adjustment coding is crucial for capturing the full scope of a patient’s health status.
How do you handle coding for obesity?
Obesity coding is challenging because patients see the coding on their chart, so sensitivity is important. Obesity must be coded along with the Body Mass Index (BMI) to risk-adjust. For instance, coding morbid obesity with a BMI of 41 is risk-adjusted. However, clinicians often hesitate because patients will see the code, so they might neglect to include the BMI.
What are tips for coding for heart failure?
Heart failure is another diagnosis that requires precise coding to include distinctions between chronic, acute, systolic and diastolic heart failure. That’s why it’s so important to code accurately. It’s possible that a patient could have chronic systolic and diastolic heart failure, for example. That’s why it’s so important to go through the codes and choose all the correct ones that apply to a patient’s health status.
Are there any other conditions that require risk-adjustment coding?
Chronic obstructive pulmonary disease (COPD) and chronic kidney disease (CKD) are important as well. One thing to remember is that if you have a patient’s labs and you see that their glomerular filtration rate (GFR) puts them in the range for CKD, you should code and document the health condition even though you might not be the one treating it. CKD affects medication choices and how the body handles other diseases, making it essential for a complete patient health profile.
What role does patient communication play in coding and documentation best practices?
Patients get incredibly confused and frustrated if we don’t communicate openly with them about their health status and any problem listed in their chart. Recently I had a new patient who told me they had prediabetes. However, when I looked at their chart, a note from a specialist noted type 2 diabetes. Unfortunately, the patient had no idea.
I explained the difference between diabetes and prediabetes to the patient, explaining that their issue was documented as “type 2 diabetes, diet controlled, not requiring medications.”
This is an example of why transparency and specificity in coding and patient communication are crucial for accurate patient records and effective risk adjustment.
For more information about coding for select conditions, download VHAN’s Medical Risk Adjustment Toolkit. Inside you’ll also find coding and documentation best practices, tips for coding annual wellness visits and much more.