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Editor's e-Note
Coding can be complicated. Throw in having to take into account risk factors and the task becomes even tougher.

This month’s E-News Exclusive, which offers pointers on how to best manage risk adjustment models, may be an ideal starting point for getting better acquainted with the nuances coders can encounter.

Lee DeOrio, editor
e-News Exclusive
Tips for Coding Under Risk Adjustment Models
By Deborah Marsh, JD, MA, CPC, CHONC

Risk adjustment is part of the move from fee-for-service payment to value-based payment for health care services. A basic concept behind risk adjustment payment models is that health status affects health care costs and quality. In other words, the sickest patients typically cost the most to treat and they may have worse outcomes than healthier patients for reasons outside of the provider’s control. ICD-10-CM codes, which represent a patient’s diagnoses, provide data about health status and, therefore, the expected outcomes and costs of care.

Below you’ll find pointers for proper ICD-10-CM coding, including examples with diagnoses that may affect payment under risk adjustment models.

Why it matters: In a risk adjustment model, a patient gets a risk score based on demographics, such as age and gender, as well as health status. Using the Hierarchical Condition Categories (HCCs) from the Centers for Medicare & Medicaid Services as an example, certain diagnosis codes on medical claims map to HCCs, identifying the severity of illness to assist with calculating risk. One aspect of risk adjustment is transferring funds from plans with lower-risk patients to plans that have a higher number of sicker-than-average patients, removing the incentive to insure only lower-risk patients. But risk adjustment also has a role in determining payments to facilities and, increasingly, to physicians. Payers may use the overall annual risk score from a group to calculate future contracted rates.

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DrChrono Announces New Mobile EHR Features
DrChronoInc has rolled all of the DrChrono features from iPad and iPad Pro into iPhone mobile EHR/practice management app. DrChrono EHR is fully compatible with the new iPad 7, iPhone 11, and iPhone 11 Pro. Using the new “Messages” icon on the DrChrono EHR on iPhone, physicians can get any information about their practice including incoming and outgoing faxes, lab results, prescription requests, referrals, and online appointments. Tasks are also now available on iPhone to allow staff and physicians to track complex patient workflows. Tasks features include task creation, custom statuses, categorization, filtering, searching, setting due dates, the ability to associate a task to inbox messages and/or patients, and task templates for common tasks. In addition, DrChrono launched the first Apple Pencil medical record experience, allowing providers to double tap on Apple Pencil while drawing on medical record images. Learn more »

Waystar Acquires Digitize.AI to Automate Prior Authorization
Waystar, a provider of revenue cycle technology, announces the acquisition of Digitize.AI, an artificial intelligence (AI) technology firm providing the health care industry with faster and smarter prior authorizations. Digitize.AI leverages the power of AI and machine learning to automate prior authorizations, resulting in faster authorizations, at less cost and with fewer denials. Digitize.AI automatically checks for new cases, submits them directly to payers via secure integrations, continually monitors payers for responses, and, once authorization is received, automatically submits to providers’ EHR systems. Digitize.AI’s platform includes real-time analytics and machine learning models that create valuable intelligence, allowing its customers to focus on patient care instead of administrative burdens. Learn more »

Cancer Center Enhances Patient Experience With New Technology
West Cancer Center & Research Institute has announced the completion of a new patient engagement program across its 13 regional locations. This platform from West’s new national partner, PatientPoint, offers an interactive way to share patient information through 3D diagrams, videos on diagnoses or procedures, and programs available at West with the ability to instantly send the information via e-mail or text. Features of this new PatientPoint program include interactive touch screens in every exam room, customized to include expert-reviewed information on the patient’s disease state, learning tools to better understand a diagnosis, and information about supportive resources available at West. The program also includes the installation of waiting room screens that rotate educational materials on diagnoses, procedures, and supportive resources. While in an exam or waiting room, patients and their families can view a video introduction of their provider, explore 3D anatomical models of the body, sign up for support groups, and inquire about programs such as financial aid, chaplain services, and nutrition counseling. Learn more »
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Industry Insight
Prader-Willi Syndrome Receives Specific ICD-10 Code

The National Center for Health Statistics has designated a specific ICD-10 code for Prader-Willi syndrome (PWS). Previously PWS was included as one of number of genetic disorders ICD-10-CM code Q87.1, which contains a large group of genetic disorders associated with short stature. However, the genetic causes, medical complications, and treatment of these disorders are very different.

As of October 1, PWS has a unique code. The new, dedicated ICD-10-CM code for PWS (Q87.11 Prader-Willi syndrome) will make it much easier to track medical care and outcomes in the PWS population. This designation will facilitate research studies aimed at understanding the true prevalence of PWS, the factors contributing to morbidity and mortality, and the outcomes of patient care and treatment.

“We’re thrilled to have this unique ICD-10 code for PWS, which will facilitate research studies and improve patient care,” says Theresa Strong, PhD, director of research programs at the Foundation for Prader-Willi Research. “The new ICD-10 code will allow scientists to conduct epidemiologic research on PWS, determine true mortality rates, recruit patients for clinical trials, track outcomes of clinical interventions, and develop protocols for standard of care,” Strong says.

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What is the diagnosis code for R Erosive Gastritis and modular GAVE?

Debera Lewis

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