May 10, 2011 Approval Code: IN361

1. Ingenix InSite Provider User Group May 10, 2011 Approval Code: IN361

2. Ingenix InSite User Group: Welcome Administrative Reminders: • This call is hosted in a listen only mode for participants until our Q&A segment. • Questions you may want to ask prior to the Q&A segment can be typed in our chat panel for the host to address • Please keep your phones on mute during Q&A. • The webex login password for this call is ‘insite’. • When logging into the webex please enter in your first and last name. • The user group presentation materials will be sent with the meeting minutes. • Ingenix InSite User Group Questions or Product Enhancement requests? Email ingenix.insite@ingenix.com. • Ingenix InSite Website Questions? Call or email the Ingenix Helpdesk 1-866-818-7503 or client.support@ingenix.com.

3. Ingenix InSite User Group: Agenda • 10:00 AM Welcome • 10:03 AM InSite Operations Announcements • 10:10 AM CMS Payment Cycle: Walk through Sweeps, RAF and Payment • 10:25 AM Documentation and Coding Focus On: Understanding the Coding for TIAs, CVAs, and Late Effect Conditions • 10:45 AM Q & A

4. InSite Operations Announcements Presented By Jerry Gauchat

5. InSite Operations Announcements – Data Refresh Update • Data Refresh Update • Data refresh has been postponed for May • Next monthly data refresh is scheduled for June 6th • The May data refresh will include the shifting of years on the following reports: • Prevalence • Members with Declining RAF • Patient Management • PCP RAF • HCC RAF Detail Report • New value for FFS Normalization will appear in 2012 PY Column • Reports shifting years in InSite • In January and April data, the new 2012 payment year or 2011 Dates of Service (DOS) will begin to be reported and InSite drops the oldest year of data. • Reports shift years on reports depending on which time period is the most actionable for the specific report.

6. InSite Operations Announcements –Q2 2011 Release • Upcoming InSite Updates • New HEDIS/STARS PAF Versions • No changes to PAF Management functionality • Summary of Accepted HCCs (SOAH) • Modify query to access report more quickly • Upon export - HCC and description will match • Systematic User Entitlement • Learning & Resources Tab • Adding April, May & June 2011 Ingenix Insiders • Removing all 2010 Ingenix Insiders • Removing 2010 ICD-9 Brochure • Further docs to be added as they are approved

7. InSite Operations Announcements – How to Access Reports After Completing Validation/Attestation • When in as Validation Approver, validate providers by accessing the Provider Validation tab • When validation is completed and you want to access reports: Select another role (not Validation Approver) re-select your group, click Apply

8. InSite Operations Announcements – Users with Access to Only One Role • If you only have access to one role, you will not have access to a role drop-down. The role you have access to will be automatically displayed.

9. Pam’s Tip #1

10. Export Reports Prior to Years Shifting • Consider exporting the following reports this week • prior to the data refresh which will switch years • dropping off the oldest year • Prevalence • Members with Declining RAF • Patient Management • PCP RAF

11. CMS Payment CycleWalk Through Sweeps, RAF & Payment Presented By Pam Holt

12. Sample CMS Payment Schedule

13. CMS 2011 Payment Year Cycle March 2011 Sweep Sept 2010 Sweep July – Dec 2009 Jan – June 2010 July – Dec 2010 Jan – Dec 2010 Data sent after March 2011 sweep DOS CMS Sweeps Jan 2012 Sweep Payment Realized Jan – June 2011 Monthly payments July – Dec 2011 Monthly payments August 2012 Final payment Lump sum + Retroactive "true-up" adjustment of Jan - Jun 2011 payment based on difference between Prelim & Actual RAF/Payment.  Can result in payment or adjustment; if payment, is paid in lump sum in July RAF Scores Change Jan – June 2011 Each patient’s RAF score remains the same for this 6 month period July – Dec 2011 Each patient’s RAF score remains the same for this 6 month period • Actual • Adjusted • Elimination of Lag Final Adjustment Preliminary

14. Coding for TIAs, CVAs and Late Effect Conditions Subacute stroke: Transcortical Aphasia Colette Singleton, CPC Sr. Provider Training & Development Consultant

15. TIA vs. CVA Difference between TIA & Stroke • A transient ischemic attach (TIA) has stroke-like symptoms that completely resolve within 24 hours. • A cerebral infarct that lasts longer than 24 hours but fewer than 72 hours is termed a reversible ischemic neurologic deficit or RIND. • A cerebrovascular accident (CVA) has persistent symptoms that last greater than 72 hours. National Stroke Association. Web. 25 Apr. 2011. <http://www.stroke.org/site/ PageServer?pagename=TIA>.

16. Coding Tips: TIA • If the documentation states that the patient had a TIA, code 435.9 should be assigned. • Impending CVA and intermittent cerebral ischemia should also be assigned code 435.9. • Code V12.54 is reserved for patients who have a personal history of TIA.

17. Documentation of Stroke Simply Stated: • When did the event occur? • What deficits were left after theevent that are evident today?

18. Stroke • Stroke is often seen documented in the generalized term:“CVA” • Diagnosticstatements need to be specificregardingsite or type of CVA. • Concise documentationwill lead to specified code selection. • Example: • CVA due to cerebral embolism with infarction • Hx of CVA with left-sided hemiparesis • Cerebral artery occlusion

19. Documentation of Stroke When did the event occur? • DocumentAcute Strokeon first admission to hospital only -434.91 • DocumentResidual Deficits of Strokeon office visits following the acute incident –438.XX • DocumentHistory of CVAif there are no residual deficits from a prior stroke code -V12.54

20. Stroke: ICD-9-CM Coding Guidelines The Coding of “Late Effects” • A “late effect” is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. • The “late effects” are in the past tense. • The “residual condition” would be sequenced first – there is no time limit for the reporting of a residual. • The “late effect” or resolved condition is indexed through the words “late effect” and then by the condition. • Normally, this is a a two code scenario • Stroke can be the exception.

21. Stroke: Rules of Coding Stroke is an exception to the typical coding of “Late Effects” When the late effect code has been expanded at the 4th and 5th digit level to include the residual conditions, only the cause of the late effect is assigned. At present, only category438has been expanded in this way.

22. Stroke: ICD-9-CM Coding Guidelines Example: Cerebrovascular accident two years ago withResidual hemiplegia Code:438.20“Index” - Late Effects, Cerebrovascular Disease, with Hemiplegia, Unspecified Side

23. Stroke: ICD-9-CM Coding Guidelines Example: Cerebrovascular accident five years ago with residual dysphagia Code:438.82“Index” - Late Effects, Cerebrovascular Disease, with, Dysphagia Note: Use additional code to identify the type of dysphagia, if known (787.20-787.29) In this case we will use 787.20, Dysphagia, unspecified.

24. Documentation makes the difference How the information is documented will affect how its coded. Example: Patient continues with left-sided weakness due to CVA 4 months ago  438.89 Patient continues with left-sided hemiparesis due to CVA 4 months ago  438.20 Documentation is key!!!

25. Coding Tips: Acute CVA • Codes from category 434, Occlusion of cerebral arteries, are used on the admission to the hospital for the acute event: • 434.01 Cerebral thrombosis with cerebral infarction • 434.11 Cerebral embolism with cerebral infarction • 434.91 Cerebral artery occlusion, unspecified with cerebral infarction

26. Acute but ill-defined, cerebrovascular disease • Code 436, Acute but ill-defined, cerebrovascular disease, should not be used when the documentation states stroke or CVA. • Code 436 is no longer used for acute stroke and is now reserved for conditions such as apoplexy or cerebral seizures.

27. Coding Tips: History & Late Effects • Code V12.54 is reserved for patients who have a personal history cerebral infarction without residual deficits. • If a provider documents “History of CVA,” there is an assumption that there are no neurologic deficits and V12.54 is assigned. • If a patient has a history of CVA with residuals, it is important for the provider to document the residuals (e.g. history of CVA with resultant dysphagia). • The residuals of stroke are coded to the Late Effects category 438 – Late effects of cerebrovascular disease.

28. History Coding History • History of- There are two types of historyV Code, personal and family. Personal history codes explain a patient’s past medical condition that no longer exists and is not receiving any treatment, but that has the potential of recurrence, and therefore may require continued monitoring. 2011 Ingenix Professional ICD-9-CM for Physicians. 6th ed. 2 vols. Chicago, IL: Ingenix, 2010. Print.

29. Case Sample • Chief Complaints/ Concerns Old CVA, Occasional HA, still takes a few sec’s at times in order to initiate speech. Sometimes has trouble coming up with a right words every since her stroke. • Problem List Detail RHEUMATOID ARTHRITIS Seeing Dr. last week. Had testing done and reportedly was ok. Pt report increased MCP pain. Essential Hypertension Unsp Patient reports the pressure has been under good control. Has not had high blood pressure nor orthostatic symptoms at home. Major dep recurrent moderate History of depression doing well and is not currently on medication.

30. Case Sample • Major dep recurrent moderate (ICD-9 Code: 296.32) Depression under control. Continue to monitor. No medication needed at this time.In remission? 296.35 • Accident, cerebrovascular (ICD-9 Code: 434.91)NO CVA was in September 2009. (DOS 10/12/10) She still continues to have some mild aphasia and difficulty with words as well as word salads. Continue with Plavix 75 mg p.o. q.d. He did take Nexium 12 hours from last Plavix dose to help minimize interaction.438.11

31. Pam’s Tip #2

32. Audit Code: 436 • ICD-9 code 436, when used to code the condition of stroke is inaccurate • Prior to 10/1/2004 it was the default code for stroke • It was simple to remember, and unfortunately, some physicians still use it when coding a patient who had a previous stroke • Recommendation: • Run a report of patients coded with 436 & include provider name • Audit the charts and educate any providers still using 436 to code for stroke • Re-audit 6 – 9 months later

33. Upcoming Documentation & Coding Topics June 2011 – Skin Ulcers July 2011 – VTE - Venous Thromboembolism Aug 2011 – Major Depression Sept 2011 – Peripheral Arterial Disease (National Vascular Disease Awareness Month) Oct 2011 – Cirrhosis (Liver Awareness Month) Nov 2011 – Dementia (National Alzheimer’s Disease Awareness Month) Dec 2011 – COPD

34. User Group Feedback Survey • We want your feedback! • Survey is to be sent immediately after this call

35. Question and Answer