by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
July 5th, 2022
Sometimes it’s the little coding conundrums that make us bite our nails and overthink our coding processes. Should we have added modifier 25 to that E/M or not? When do I report a Z68.- code for BMI? Should I report depression unspecified or major depressive disorder? If only there was an indexed version of a universal coding conundrum workbook to reference when these concerns arise.
Given the complexities of the medical coding process, the question of whether something was coded correctly always seems to be a looming concern. Unfortunately, even small errors can, and often do, lead to claim denials or delays in payment, and in the case of risk adjustment payments to payers, these demands for repayment can be near devastating. A quick look at how one of these coding conundrums resulted in an audit finding and subsequent disagreement is enlightening and may help resolve questions you face daily about the same thing.
In May of 2021, the Office of Inspector General (OIG) published a report titled, “Medicare Advantage Compliance Audit of Specified Diagnosis Codes that Anthem Community Insurance Company, Inc., (Contract H3566) Submitted to CMS.”
In this report, the OIG’s independent auditors claimed the payer submitted HCCs for major depressive disorder, but the medical record did not support major depressive disorder and the corresponding HCC resulted in a refund demand. At this point, the report reflects that Anthem audited the OIG’s independent review contractor’s findings and performed a comprehensive review of the medical record, resulting in the submission of additional supporting documentation indicating the HCC should be acceptable. This is Anthem’s response to the OIG:
|“OIG’s independent medical review contractor has misinterpreted the medical record. The provider documented “mild depression,” and in the context of the entire medical record and consistent with clinical diagnostic standards, the term “mild” should be read to modify major depressive disorder. The most widely accepted definitions of mental health conditions can be found in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders V (“DSM-V”). The DSM-V states that major depressive disorder can be either mild, moderate, or severe—there is no separate diagnosis in the DSM-V for “mild depression.”|
Anthem clarified to the OIG that the medical record also showed the patient suffered from depressed mood, difficulty sleeping, and fatigue; and that these symptoms were affecting the patient’s daily functioning, as the provider documented a recommendation to “resume social interaction.” It should be noted that while the ICD-10-CM code descriptions for major depressive disorder include three levels of severity (mild, moderate, severe), there are no other depressive disorders described in ICD-10 with a severity rating that can be explained by the symptoms of major depressive disorder.
|F32.0||Major depressive disorder, single episode, mild||CMS-59/HHS-0|
|F32.1||Major depressive disorder, single episode, moderate||CMS-59/HHS-0|
|F32.2||Major depressive disorder, single episode, severe without psychotic features||CMS-59/HHS-88|
Of note, when these types of codes are being reviewed by the OIG to determine whether the documentation supports a specific HCC code assignment, it is because there is a dollar value assigned to the HCC code. According to the above table F32.A does not have a CMS or HHS HCC value but does have one for prescriptions written for the condition. ICD-10 codes F32.0-F32.2 have CMS HCC risk model values assigned to them. CMS requires adequate documentation to support the assignment of codes for major depressive disorder over an unspecified type of depression. While this may at times seem like a simple coding conundrum, when incorrectly reported, it can quickly become a larger issue.
For additional information on some of the many coding conundrums we face on a daily basis and how to ensure we are coding them correctly, join us for our next webinar, "Sometimes it's the Little Coding Conundrums That Keep Us Concerned" scheduled for Thursday, July 7, 2022 @ 10:15 AM PT, 11:15 AM MT, 12:15 PM CT, 1:15 PM ET. Click HERE to register for this FREE webinar.
Disclaimer: The above article is the opinion of the author(s) and should not be interpreted by providers/payers as official guidance. For any questions about the content of this article, please contact the author(s).
About the Author: Aimee L. Wilcox is a medical coding, billing, and auditing consultant, author, and educator with more than 30 years of clinical and administrative experience in healthcare, coding, billing, and auditing. Medicine, including coding and billing, is a constantly changing field full of challenges and learning and she loves both. Aimee believes there are talented medical professionals who, with proper training and excellent information, can continue to practice the art of healing while feeling secure in their billing and reimbursement for such care.