Claim Coding Requirements - Provider Newsletter February 2024

BLUECONNECT

Providers

February 2024

In This Issue

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February news: Executive summary

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Arizona Priority Care to provide payment services

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History of vs acute condition: Claim coding requirements

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Annual update of AZ Blue fee schedules

Continuity of Care for Dignity Health patients

History of vs acute condition: Claim coding requirements

AZ Blue follows CMS risk adjustment coding guidelines for high-risk diagnoses. We’re reaching out to ensure your staff is aware of our coding requirements for patients with a history of a serious condition, such as a cerebral vascular accident (CVA).

As soon as a patient hospitalized for acute CVA is discharged, the condition is no longer acute and the diagnosis changes to history of CVA (with or without residual deficit). Claim coding must reflect a history of the condition, not a current acute condition.

Other examples of high-risk diagnoses for acute conditions

The same type of diagnosis coding applies when patients have been hospitalized or treated for conditions such as acute myocardial infarction and acute or chronic embolism. Once the acute episode has been addressed (or the chronic condition treated), subsequent follow-up care falls under the “history of” category and must be coded with that diagnosis.

Why it matters

CVA is the number one misdiagnosed condition in post-acute settings. When a patient’s condition is misrepresented through an inaccurate diagnosis code, the data can result in an inflation of risk scores. In addition, auditors will be expecting to see inpatient claims, tests, surgeries, and/or prescribed medications to support the acute condition coding.

High-risk diagnoses for active conditions

Other high-risk diagnoses include major depressive disorder and cancer. These diagnoses require a current assessment to validate that the condition is active.

Note: Active cancer diagnoses are appropriate when the patient is newly diagnosed, is waiting to begin treatment, is currently receiving treatment, is being watched without treatment, or has declined treatment.

Coding guidelines

Please see our Post CVA ICD-10 CM diagnosis and coding guide for some great tips and a comprehensive list of sequelae categories with ICD-10-CM codes and descriptions. This document and others like it are available via our Standards for Quality Care page in the “Quality coding captures quality care” menu.

More information

Please share this information with your coding and billing teams. To learn more about CMS guidelines, see the ICD-10-CM Official Guidelines for Coding and Reporting. If you have questions about our coding requirements, please reach out to Irene Garcia at Irene.Garcia@azblue.com.