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Resource Risk Adjustment Medical Record Reviewer Guidance

Hi Lori,
In risk adjustment, does Medicare accepts BMI code without obesity coded, but has a chronic diagnosis with it such as DM and Hypertension? I question this because of Humana MA policy under clinical significance ( see below).

I tried to search those information on all the links that you shared, but unable to find anything that pertains with this issue.

BMI codes are reported only as secondary diagnoses in association with a primary diagnosis for which the BMI has clinical significance and only when the BMI meets the definition of a reportable additional diagnosis (per ICD-10- CM Official Guidelines for Coding and Reporting).
 Principal or first-listed diagnoses are not limited to overweight, underweight or obesity-related conditions.
 A primary diagnosis for which BMI has clinical significance is any primary condition that can be
a) Improved if the patient loses weight or lowers his/her BMI; or
b) Worsened if the patient gains weight or increases his/her BMI.
Examples include but are not limited to: diabetes mellitus, hypertension, obstructive sleep apnea, hyperlipidemia.
 
I will let Alicia chime in as she is great with RA/HCC coding.

Medicare does not allow the billing of other services performed on the same day as an obesity counseling CPT CODE visit.

When a “Screening code is billed with a preventive medicine code” on the same date of service by the Same Specialty Physician or Other Health Care Professional, “only the preventive medicine code is reimbursed”.Obesity counseling is not separately payable with another encounter/visit on the same day. For services that contain HCPCS code G0447 CPT Code with another encounter/visit with the same date of service, the service line with HCPCS G0447 CPT Code will be denied.This intensive behavioral therapy service is considered to be included in the payment/allowance of other encounter services provided on the same date of service.

STATUS CODES THAT CONTRIBUTE TO RISK SCORES​


Z68.41​
BMI 40.0 – 44.9, adult​
Z68.42​
BMI 45.0 – 49.9, adult​
Z68.43​
BMI 50.0 – 59.9, adult​
Z68.44​
BMI 60.0 – 69.9, adult​
Z68.45​
BMI 70 or greater, adult​


Based upon authority to cover “additional preventive services” for Medicare beneficiaries if certain statutory requirements are met, the Centers for Medicare & Medicaid Services (CMS) initiated a new national coverage analysis on intensive behavioral therapy for obesity. Screening for obesity in adults is recommended with a grade of B

 
does Medicare accepts BMI code without obesity coded

For Risk Adjustment I can tell you that without the dx code of E66.01 you can not capture the BMI. Morbid Obesity has to be documented for the patient by the provider. That or Obeisty 1, 2 etc...

This is a major pain point for providers as patients do NOT like to see morbid obesity in their paperwork.
 
Lori/Alicia - I am reading the Dec. 2021 AAPC Healthcare Business Monthly and have a question. On page 38 under the FAQ No. 5, the statement, "The diagnosis does not need to be treated, managed or addressed; it merely has to be an ongoing chronic condition noted by the treating provider or part of MDM." I was in a webinar presented by a consulting team and they stated the mention of the disease and treatment/status must be documented in the HPI. If it is just in the assessment, the physician will not get credit as having addressed it at the visit and it can't be captured. Can you help clarify? Or am I misunderstanding altogether.
 
CMS has been publishing specific guidance on risk adjustment documentation and coding since 2003.

Here are some great resources:

A few links are included below:

2003 Regional Risk Adjustment Training for Medicare+Choice Organizations https://www.hhs.gov/.../2012213334-ky-slide...
2003 Regional Risk Adjustment Training for Medicare+Choice Organization Questions & Answers https://www.hhs.gov/.../2012215856-ml-final_june_qaht2...
2004 Regional Risk Adjustment Training for Medicare+Choice Organizations Participant Guide https://www.hhs.gov/.../2012183293-yv-partguide-revisions...
2005 RA Resource Guide https://www.hhs.gov/.../2012185381-jh-2005-riskadjust...
2006 Risk Adjustment Data Basic Training for MAOs Participant Guide https://www.hhs.gov/.../2012221210-js-raps-participant...
2008 Risk Adjustment Data Technical Assistance For Medicare Advantage Organizations Participant Guide https://www.hhs.gov/.../2012183293-yv-participant-guide...
2013 Risk Adjustment Participant Guide https://www.hhs.gov/.../2013_RA101ParticipantGuide_5CR...
2013 Risk Adjustment User Group https://www.hhs.gov/.../2012181486-wq...
 
Lori/Alicia - I am reading the Dec. 2021 AAPC Healthcare Business Monthly and have a question. On page 38 under the FAQ No. 5, the statement, "The diagnosis does not need to be treated, managed or addressed; it merely has to be an ongoing chronic condition noted by the treating provider or part of MDM." I was in a webinar presented by a consulting team and they stated the mention of the disease and treatment/status must be documented in the HPI. If it is just in the assessment, the physician will not get credit as having addressed it at the visit and it can't be captured. Can you help clarify? Or am I misunderstanding altogether.
I will have Alicia chime in.

Please see this thread for more info:

 
Pamela, if this is for Risk Adjustment to capture an HCC it only has to have MEAT. Now MEAT is usually obtained via the "treated, managed or addressed;". However, even if the provider does not address the chronic condition on that visit if there is a medication say, COPD and Albuteral then that is MEAT. If you can not draw the magic gold thread from the Dx to MEAT then it can not be captured.

This is different for ProFee. Some of the confusion comes from RA rules & ProFee coding rules.
 
That is what I thought. Thank you for the clarification. I think the consultant was incorrect by saying it must be in the HPI. Maybe they misspoke. I think the FAQ in the magazine is misleading or incorrect.
 
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