PHYSICIAN ALLIANCE OF THE ROCKIES
191452536195000RAF Coding Guidance for Appropriate DocumentationDiabetes: Approach adult diabetic patients with an expectation of having some chronic diabetic complication. Usual suspects are: retinopathy, microalbuminuria, peripheral neuropathy, PAD, and dyslipidemia. Peripheral arterial disease (PAD)/peripheral vascular disease (PVD) warrants mention as it is both a diabetic complication (code diabetes with peripheral circulatory dysfunction with or without gangrene) and it risk adjusts as a separate vascular code. Additionally, proliferative diabetic retinopathy risk adjusts beyond standard chronic diabetic complications. Diabetic dyslipidemia can commonly be coded if no other complications are present and the patient has any of: elevated LDL, high TG, or low HDL and requires statin. Secondary hyperaldosteronism (E26.1): This is appropriate to code for patients with a volume overload state related (secondary) to decompensation of cirrhosis, heart failure, and rarely chronic kidney disease. A cirrhotic or CHF patient that requires daily diuretics also DOES meet criteria for this code even if well compensated from a volume standpoint. Resistant hypertension that requires daily spironolactone, eplerenone, or amiloride also meets criteria. Code both the resistant hypertension and secondary hyperaldosteronism.Malnutrition: Mild (albumin < 3.5), Moderate (albumin < 3.0), Severe (albumin < 2.5) associated with an acute or chronic condition that impairs proper nutrition. For chronic conditions BMI is < 19.Morbid Obesity: BMI > 40, or > 35 with at least one comorbidity (DM, HTN, lipids, OSA, depression, etc). No rounding allowed.Secondary hypercoagulable state (D68.69): Any AFIb patient with CHADS2VASC score of 1 or higher (clearly any patient on anticoagulants) meets criteria.Chronic angina (I20.9): Symptomatic ongoing angina OR use of daily anti angina meds (imdur, ranolazine).Secondary hyperparathyroidism (N25.81): Check PTH, vitamin D, and phosphorus yearly in all patients with CKD 3 or higher to capture this code (and manage it).Peripheral neuropathy: This code confuses many—idiopathic PN, neuropathy due to nerve compression (lumbar issues), and diabetic PN due not map to this HCC. If neuropathy is caused by another condition (prediabetes, B12 deficiency, chemo or other drugs, hypothyroid, or alcohol) then it adds an additional RAF. You must document Neuropathy due to medical condition (G63 code) PLUS the condition that is causing the neuropathy and “link” them together. Alcoholic neuropathy (G62.1) and chemotherapy induced neuropathy (G62.0) have their own ICD-10 codes.Purpura senilis (D69.2): Old and fragile skin that bruises spontaneously or with minimal trauma, regardless of anticoagulant or antiplatelet use.Chronic hypoxic respiratory failure (J96): Patients that require 24/7 oxygen supplementation to manage hypoxia (not due to acute CHF) OR live with O2 sats of 88% or less should also have this code.Chronic major depressive disorders: Frequently miscoded as simple depression, depression with anxiety, or just left off the assessment/plan. For RAF capture, a chronic major depression code (mild, mod, or severe) is needed. Code F32.9 does NOT risk adjust. Stable patients (on or off meds) can be coded with F32.5-Major depression in remission which DOES risk adjust.Sick sinus syndrome (I49.5)/3rd degree AVB (I44.2): Patients who have required a pacemaker for these conditions should continue to have these codes documented along with the pacemaker status. SSS was not cured by the pacer, it is just being managed by it. ................
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