Code Spotlight — ICD-10 Code I16
Welter Healthcare Partners is excited to present our monthly Code Spotlight! Each month, Welter Healthcare Partners will spotlight a unique CPT or ICD-10 code to profile and discuss practice applications of the code, as well as pertinent guideline reminders.nnICD-10 Code I16 – Hypertensive Crisis
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- I16.0 — Hypertensive Urgency, which should be reported when a patient has a systolic blood pressure equal to or greater than 180 or a diastolic pressure greater than 110 in the absence of associated organ damage or dysfunction, he or she is said to be in hypertensive urgency. Immediate blood pressure reduction is often not necessary and acute complications are unlikely, but the patient will need his or her medication adjusted and blood pressure monitored more closely to ensure it continues to stay at a suitable level.
- I16.1— Hypertensive emergency, which should be reported when a patient is experiencing a hypertensive emergency when blood pressure levels exceed 180 systolic over 120 diastolic and organ damage is present. The organ systems typically affected include cardiac, renal, and neurologic, manifested as coronary ischemia, disturbed cerebral function, renal failure, cerebrovascular events, and pulmonary edema. These cases require intensive care hospital admission for immediate but controlled blood pressure reduction via IV medications. Complete work-up and evaluation should be completed to determine the underlying cause or trigger of the hypertensive emergency.
- I16.9 — Hypertensive crisis NOS, which should be reported when there is a life-threatening rapid increase in a patient’s blood pressure. The presence or absence of associated organ damage further classifies the type of hypertensive crisis as urgent or emergent.
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nnAs a group, doctors are ill-prepared to meet the requirements of a law that will change the way they are paid, shows a survey of a thousand physicians by the American Medical Association and Big Four auditing firm KPMG.nnThat lack of preparedness could hit them in the pocketbook, even amid new flexibility shown by CMS in last week’s proposed changes that would delay mandatory reporting data for another year and reduced reporting burdens for small physician practices.nnPhysicians must choose one of two reimbursement tracks under the Medicare Access and CHIP Reauthorization Act (MACRA). One, known as the Merit-based Incentive Payment System, is where most physicians will start, but some will participate in approved Advanced Payment Models (APMs) that will reward physicians with as much as 5% annual payment bonuses in return for taking more upside and downside risk based on value measures.nnIn either scenario, physicians rate themselves as less prepared than they should be, with half calling MACRA requirements “very” burdensome, according to the survey.nnMore than 56% of those surveyed still planned to participate in the MIPS program in 2017, while 18% are expected to quality for higher and more stable payment as an APM participant.n
nnAs part of the new coding format for our newsletter, Welter Healthcare Partners is excited to offer you a new surgery coding series in which we want to help you! The 2nd week of every month we will highlight a complicated surgical case. This week we are highlighting a general surgery case. We want to hear from you! If you have a complicated surgery case and need help with coding, please upload the operative note by clicking on the link below. Remember to remove ALL patient protected health information and organization identifiers. Welter Healthcare Partners will not use any medical records submitted in which PHI is not removed and protected. 
nnCheck out this article about a half-dozen changes to the adjudication of Medicare claims-denial appeals that are designed to ease a backlog of cases.nnThe new rules for Medicare claim-denial appeals feature several changes crafted to ease administrative burdens and speed reductions in a backlog nearing 1 million cases. The new rules went into effect March 20. “This final rule streamlines administrative appeal processes, increases consistency in decision making across appeal levels, and improves efficiency for both appellants and adjudicators,” a Department of Health and Human Services fact sheet on the new rules says.nnThursday afternoon, three officials at the Office of Medicare Hearings and Appeals (OMHA) led a presentation to walk healthcare providers through more than a dozen significant changes in the new rules. OMHA reports directly to Health & Human Services Secretary Tom Price, MD.nnDisputed Medicare claims of more than $160 can be appealed to Administrative Law Judges (ALJs) and attorney adjudicators for reviews that can include a hearing. The last stop before federal court is the Medicare Appeals Council.nnThursday’s Medicare Learning Network (MLN) presentation featured a half-dozen changes to the claims-denials appeals process at the ALJ-level that are designed to either quicken or streamline adjudication:n
Medicare Advantage: You have probably heard some industry buzz about the recent investigations (and settlements) into risk adjustment fraud with several of the major insurers. United Health Group along with others, are accused of manipulating diagnosis codes to make patients appear to be sicker to achieve higher reimbursement outcomes via the Medicare Advantage program. Medicare Advantage allows providers to participate in a reimbursement model based on risk adjustment factor. Risk adjustment factor is determined by diagnosis complexity and specificity. Providers who treat patients that are sicker or have more chronic conditions are reimbursed at a higher rate per patient, regardless of actual health outcomes. This all relates back to the importance of understanding the False Claims Act and maintaining an ongoing internal compliance program. If you are still in the mindset of thinking accuracy with regards to reporting diagnosis codes is meaningless – Think Again!n
nnSmall practices could add points to their total performance scores in the merit-based incentive payment system and may qualify for an exemption from EHR requirements.nnMore small practices may qualify for exclusions from the Quality Payment Program (QPP), claim hardship exceptions from electronic health record (EHR) requirements, and earn automatic bonus points if the proposed QPP rule released June 20 is finalized.nnThe Centers for Medicare & Medicaid Services has proposed increasing two low-volume thresholds that would grant additional exclusions in 2018:n