Ingenix InSite
Provider User Group
May 10, 2011
Approval Code: IN361
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.
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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 1-866818-7503 or client.support@ingenix.com.
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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
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InSite Operations Announcements
Presented By
Jerry Gauchat
InSite Operations Announcements –
Data Refresh Update

Data Refresh Update
–
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The May data refresh will include the shifting of years on the following reports:
• Prevalence
• Members with Declining RAF
• Patient Management
• PCP RAF
–
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Data refresh has been postponed for May
Next monthly data refresh is scheduled for June 6th
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.
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InSite Operations Announcements –
Q2 2011 Release
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Upcoming InSite Updates
•
New HEDIS/STARS PAF Versions
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No changes to PAF Management functionality
Summary of Accepted HCCs (SOAH)
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Modify query to access report more quickly
Upon export - HCC and description will match
•
Systematic User Entitlement
•
Learning & Resources Tab
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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
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
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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.
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Pam’s Tip #1
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
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CMS Payment Cycle
Walk Through Sweeps,
RAF & Payment
Presented By
Pam Holt
Sample CMS Payment Schedule
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CMS 2011 Payment Year Cycle
DOS
July – Dec
2009
Jan – June
2010
July – Dec
2010
CMS
Sweeps
Sept 2010
Sweep
March 2011
Sweep
Payment
Realized
Jan – June
2011
July – Dec
2011
Monthly payments
Monthly payments
Jan – Dec 2010
Data sent after March
2011 sweep
Jan 2012
Sweep
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
July – Dec 2011
Each patient’s RAF score
remains the same for this
6 month period
Each patient’s RAF score
remains the same for this
6 month period
Preliminary
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•Actual
•Adjusted
•Elimination of Lag
Final
Adjustment
Coding for TIAs,
CVAs and Late
Effect Conditions
Subacute stroke: Transcortical Aphasia
Colette Singleton, CPC
Sr. Provider Training & Development Consultant
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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.
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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.
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Documentation of Stroke
Simply Stated:
 When did the event occur?
 What deficits were left after the
event that are evident today?
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Stroke
 Stroke is often seen documented in the
generalized term: “CVA”
– Diagnostic statements need to be specific regarding
site or type of CVA.
– Concise documentation will lead to specified code
selection.
• Example:
 CVA due to cerebral embolism with infarction
 Hx of CVA with left-sided hemiparesis
 Cerebral artery occlusion
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Documentation of Stroke
When did the event occur?
 Document Acute Stroke on first admission to hospital only 434.91
 Document Residual Deficits of Stroke on office visits
following the acute incident – 438.XX
 Document History of CVA if there are no residual deficits
from a prior stroke code - V12.54
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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.
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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 category 438 has been expanded in this
way.
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Stroke: ICD-9-CM Coding Guidelines
Example:
Cerebrovascular accident two years ago with
Residual hemiplegia
Code: 438.20 “Index” - Late Effects,
Cerebrovascular Disease,
with Hemiplegia,
Unspecified Side
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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.
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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!!!
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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
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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.
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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.
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History
Coding History
 History ofThere are two types of history V 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.
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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.
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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
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Pam’s Tip #2
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
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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
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User Group Feedback Survey
 We want your feedback!
 Survey is to be sent immediately after this call
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Question and Answer
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