Oncology & Hematology Coding Alert

Capturing and coding patients' comorbidities affects reimbursement now, and later.

Until recently, diagnosis coding was good for one thing: it established and supported medical necessity. Linking a patient's diagnosis code and the corresponding CPT® code on claims ensured you got paid fairly for the procedures you performed. Now, diagnosis coding-and specifically, coding comorbidities-has become much more important thanks to the shift toward value-based reimbursement. It can even affect how your practice looks on the Physician Compare website!

Important: The ICD-10-CM codes you choose at each patient visit will have a lasting effect on your revenue.

As an oncology coder, you're probably shrewder about ICD-10-CM than coders in other specialties, and your diagnosis coding skills should help you adjust nicely during the shift to value-based reimbursement.

"Diagnosis coding is not going to be over and done within 30 days" when your claim gets paid, warns Matthew Menendez, an HIT expert at White Plume Technologies. In his recent webinar, Menendez detailed how diagnosis coding "is going to have a two-year tail on it." The usefulness of a diagnosis code doesn't end when the claim is closed out. It's also used to determine risk-adjusted payments and to establish providers' target scores for the resource use and quality categories in the Merit-based Incentive Payment System (MIPS) program.

MIPS is still in its infancy, and only a relatively small percentage of providers currently have risk-based payer contracts (you're more likely to have one if you're hospital-based or a member of an accountable care organization [ACO]). But that doesn't mean you can continue coding the same way you have been under fee-for-service.

"You have an opportunity to make a big impact in value-based reimbursement transparency by doing two things," says Kelly Loya, CPhT, CPC-I, CHC, CRMA, managing director at Pinnacle Enterprise Risk ConsultingServices. "First, you need to make sure your physicians are doing a good job of addressing and at the very least describing in their documentation the patient'scomorbid conditions, how they are treating them, and the effects the treatments are having," says Loya. "Even more importantly, you need to be consistently coding those comorbidities on your claims when they are documented."

Patients with cancer often have chronic conditions, diseases, or illnesses that affect your medical decision making, their treatment plan, and their outcomes. If you are not accurately reflecting the acuity-the "disease burden"-of your patients, you're not only risking your revenue now, you're also setting yourself up for future failure. Here's why:

1. Diagnosis codes are used to determine risk-adjusted payments.

Risk-adjusted payment models are now more frequently used in payer programs, both government and private. Simply put, risk adjustment is a way of accounting for the fact that some patients are sicker than others. There are sometimes conditions out of the physician's control that affect the cost of caring for these patients and the quality of their outcomes. Risk-adjusted models pay providers accordingly.

Example: You've been treating both Patient A and Patient B for prostate cancer. However, Patient B has a BMI >40-he is morbidly obese. He also has type 2 diabetes mellitus with hypoglycemia, and suffers from rheumatoid arthritis.

In a fee-for-service payment model, you'd get paid the same for each of these patients. Listing the prostate cancer diagnosis code on your claims in order to support the medical necessity of their treatment may be the only item of importance; however, capturing the additional considerations (comorbid conditions) results in a more in-depth picture of the severity of illness (SOI) and risk of your physician's treatment decisions.

In a risk-adjusted contract, payers determine your reimbursement based on the patient's expected healthcare costs. Therefore, reimbursement is determined based on the SOI in addition to what is being actively treated. To go back to the previous example, Patient B would yield higher reimbursement than Patient A because documentation shows that Patient B is sicker.

Capture the complete picture: In order to accurately predict those costs, you need to help payers understand how sick your patients really are.

"One of the frustrations when you talk to doctors about this is everybody thinks that their patients are sicker than everybody else's patients," says Menendez. And "everybody knows that their patients are sicker than what payers think their patients are." The comorbid conditions you are coding-or should be coding-account for the gap between these two viewpoints.

Warning: If you are not completely coding all of a patient's comorbid conditions, your patient will not appear as sick as they actually are. The payer will underestimate the patient's future healthcare costs, and you will be penalized with low reimbursements because a piece of the patient's condition "puzzle" is missing for the true picture.

2. Diagnosis codes affect your MIPS scores in Quality and Resource Use.

So what if you don't currently have any risk-adjusted contracts with your payers? That's not a reason to bury your head in the sand. The Quality and Resource Use (cost) categories of MIPS are equal to 60 percent of your MIPS score. You earn MIPS bonus payments by keeping quality high and costs low, as compared to your peers. "That's what the government is really after," says Menendez.

Let's go back to Patient A and Patient B. Patient B is much sicker than Patient A, so his care is likely to cost more, take more time, and have more complications. If you omit Patient B's comorbid conditions from your claims, it will appear that you have two average patients, one with an average cost of care and one with a very high cost of care. You'll be penalized, because it will look like Patient B's care costs more than Patient A's for no reason.

CMS needs to know that Patient B's cost of care is expected to be high due to his higher acuity, and you let CMS know that via the diagnosis codes for Patient B's comorbid conditions.

Top tip: Make sure that your claims are using codes to tell the whole story. For instance, if a patient is not being compliant, quality measures for that patient will be lower than they would be otherwise. Use codes for patient noncompliance so that you tell that part of the story, and so the patient's lower-quality outcome isn't attributed to your care.

And remember: You don't need to be perfect under MIPS. You just need to perform relatively better than your peers to receive MIPS bonuses and avoid the penalties. If you are consistently coding comorbid conditions on claims, that's an opportunity to get ahead of your peers by improving your Quality and Resource Use scores.

3. The Physician Compare website publishes your quality and cost data.

CMS' Physician Compare website is intended to help Medicare beneficiaries "make informed choices about the healthcare they receive through Medicare." The idea is to steer patients toward providers with higher quality ratings and lower cost ratings. Of course, it's not just your Medicare patients who can view the data-it's publicly available.

If you aren't coding a patient's comorbidities, your cost and quality data will be unfairly skewed. "Nobody wants to be low quality at high cost when that's not true," says Menendez. With each claim you file, "you are supplying payers with mounds of data, and they are analyzing that data," he continues. Make sure it's the right data. You need to be sure that you're accurately reporting how sick your patients actually are.