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ICD-10-CM Changes for 2025

Changes to the International Classification of Diseases, 10th Edition, Clinical Modification (ICD-10-CM) occur every year, and for 2025, the update includes 252 new codes, 36 code deletions and 13 code revisions.5  The fact that these codes are for 2025 can be misleading because their implementation occurs on October 1, 2024; there is no grace period, and claims will reject for incorrect coding.

This year’s changes are overwhelmingly of clarification:  adding/modifying exclusions and synonyms, and adding/changing coding instructions.  Exclusions, as you may recall, come in two varieties:  Excludes1 are mutually exclusive codes; this means that the selected code cannot be coded with another containing an Excludes1.  Examples of Excludes1 are E10.- Type 1 diabetes mellitus and O24.2- Gestational diabetes.  The patient can have one or the other, but not both.  Excludes2 notations represent conditions that may be coded together.   Examples of Excludes2 are I12- Hypertensive chronic kidney disease and N17.- Acute kidney failure. 

Given the proliferation of online sources for ICD-10 codes, all coding staff are reminded to use the ICD-10-CM index, tabular and other books, freely available from CMS.  They contain all the exclusions and coding notations.  Googling a code only scratches the surface in the world of coding and most online sources will not provide coding guidelines.

The chapters identified below contain code additions.2

Chapter 2: Lymphoma codes now have the fifth character A, denoting remission.  See C81 Hodgkin lymphoma; C82 Follicular lymphoma; C83 Non-follicular lymphoma (these include B-cell & mantle-cell); C84 Mature T/NK-cell lymphomas; and C85 Other specified and unspecified types of non-Hodgkin lymphoma (this includes non-Hodgkin lymphoma).

Other lymphoma codes now distinguish between not having achieved remission and in remission.  Those are: C86 Other specified types of T/NK-cell lymphoma, and C88 Malignant immunoproliferative diseases and certain other B-cell lymphomas.

Chapter 3: The only new code in this chapter is under aplastic anemia: D61.03 Fanconi anemia.

Chapter 4:  This section saw some interesting changes, with two new codes for less common conditions (E74.82- and E88.82).  However, big changes occurred in the following areas:

E10.A Type 1 diabetes mellitus, presymptomatic, which has additional definition as to stage 1, stage 2 or unspecified stage. An article in the October 1, 2015 issue of Diabetes Care defines this condition as, “an immune-mediated loss of functional pancreatic β-cell mass, leading to symptomatic diabetes and lifelong insulin dependence.”  In short, a patient may have antibodies that herald the onset of T1D but may be asymptomatic and still producing insulin. Read more about the stages here.3

For any codes that refer to hypoglycemia (e.g., E10.64 Type 1 diabetes mellitus with hypoglycemia, etc.), a level is required, as applicable.  Use E16.A Hypoglycemia level:  E16.A1 for Level 1 (generally defined as a glucose level between <70 mg/dl and ≥54 mg/dl), E16.A2 for Level 2 (generally defined as a glucose level <54 mg/dl), E16.A3 for Level 3 (generally defined as a severe event characterized by altered mental and/or physical status requiring assistance.). 4

Obesity codes (E66.8) will require additional coding for class: E66.811 for Class 1 (generally defined as BMI 30-34.9%), E66.812 for Class 2 (generally defined as BMI 35-39.9%), and E66.813 for Class 3 [severe] (generally defined as BMI 40+)1.  It’s important to note that, heretofore, a BMI of 40+ (or 35+ with specific comorbidities) has been characterized as E66.01 Morbid obesity.  E66.01 continues to be a risk adjusted code, while E66.813 is not in the CMS-HCC model as of this writing. Coders are advised to code based on the clinician’s documentation and to educate providers on the distinctions between E66.813 and E66.01, which should contain additional documentation beyond the BMI to support morbid obesity.

Chapter 5: Eating disorders saw great expansion with severity qualifiers such as mild, moderate, severe, in remission and unspecified [severity] for F50.0 Anorexia nervosa, F50.2 Bulimia nervosa, F50.8 Other eating disorders, including binge eating. Pica and rumination in adults have now have specific codes.

Chapter 6: G40.8 Other epilepsy and recurrent seizures expanded to include a few codes for G40.84 KCNQ2-related epilepsy.  Other disorders of the nervous system (G89-G99) grew to include specific codes for Serotonin syndrome (G90.81) and other disorders of the autonomic nervous system (G90.89) as well as a new code for developmental and epileptic encephalopathy (G93.45).

Chapter 9: Surprisingly little coding growth occurred in the diseases of the circulatory system with only five new codes added to I26.0 for greater definition of pulmonary emboli.

Chapter 10: J34.8 Other specified disorders of nose and nasal sinuses grew to include new codes for different types of nasal valve collapse.

Chapter 11: Several new codes were added to K60.3 Anal fistula, K60.4 Rectal fistula and K60.5 Anorectal fistula to further characterize their status:  simple or complex; initial, persistent or recurrent; and unspecified.

Chapter 12: This chapter welcomed a few new codes, expanding pruritus (L29) and qualifying cicatricial alopecia (L66).

Chapter 13: M51 added codes allowing for greater characterization of pain with disc degeneration: with back pain only, with lower extremity pain only, with back & LE pain and without mention of back or LE pain.  Synovitis and tenosynovitis (M65.9) added codes for specific location and laterality.

Chapter 17: Definitions of congenital aortic and mitral valve malformations (Q23.8-) are new this year, as is the code for Kleefstra syndrome (Q87.86).

Chapter 18: Anosognosia is a new code (R41.85) in this chapter.

Chapter 19: Two coding categories underwent changes, specifically: T45.A Poisoning by, adverse effect of and underdosing of immune checkpoint inhibitors and immunostimulant drugs and T81.32 Disruption of internal operation (surgical) wound, not elsewhere classified.

Chapter 21: Z15 Genetic susceptibility to disease added specific codes for susceptibility to epilepsy and neurodevelopmental disorders (Z15.1) and obesity (Z15.2). The category for Estrogen, and other hormones and factors receptor status (Z17) grew to include codes for specific hormones. New codes now exist for Encounter for sepsis aftercare (Z51.A); for social determinants of health related to insufficient insurance coverage (Z59.71) and welfare support (Z59.72); and pediatric BMI (Z68.5-).

Z86.010 Personal history of colon polyps was expanded to reflect the types of polyps, and Z92.2 Personal history of drug therapy was divided into history of monoclonal drug therapy and immune checkpoint inhibitor therapy.

In summary, given that the majority of our firm’s clients are primary care providers, the scope of the 2025 changes is relatively small, but the new endocrine codes are certainly worth noting.  Finally, since new codes go into effect on October 1, 2024, medical practices should ensure their coding and provider staff are educated on them and that the EMR will automatically load new codes on time to prevent rejected claims or encounters.

Sources:

  • Centers for Disease Control & Prevention1                             
  • Centers for Medicare & Medicaid Services2
  • Diabetes Care Journal, Volume 38, Issue 103
  • Clinical Diabetes Journal, Volume 35, Issue 24
  • American Academy of Professional Coders (AAPC)5

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What We’re Reading: When is a Mid-Level Manager Personally Liable for Wage Violations?

Wage and hour issues can become serious violations, as an Alabama hotel manager recently learned when he was held personally liable for violations to the Fair Labor Standards Act (FLSA).  Here’s a quick summary of the backstory: Manager is the hotel owner’s son, with no ownership in the employer’s business; the hotel clerk worked the night shift and was compensated with an hourly wage plus onsite lodging; after a falling out, the worker sued. And the 11th Circuit Court of Appeals decided in favor of the worker, per a recent Fisher & Phillips article.

You might be – rightfully – wondering why we’d post an article about a hotel…two reasons: the personal liability for the manager and the definition of an employer, both of which healthcare businesses, and their managers, should note. 

Federal wage law defines an employer quite broadly as, “any person acting directly or indirectly in the interest of an employer in relation to an employee.” This leads me to believe you’re an employer, I’m an employer, we’re all employers, even if we’re just managers or directors.  F&S writes that someone with supervisory responsibility or control over significant aspects of the company’s day-to-day functions may be considered an employer. In times past, personal liability was reserved for those in executive positions, but this case brings it very close to home.

F&S offers some good, actionable advice:

  • Educate managers on wage & hour compliance and the risk of personal liability.  Managers, make sure you know all the ins and outs of these important wage laws and that you’re closely supervising this aspect of your department or team. 
  • Encourage timely reporting of errors and look for potential wage & hour issues before they become a problem.
  • Review your company’s pay practices regularly by: assessing timekeeping processes and employee compliance; reviewing non-exempt classifications, especially in light of recent worker-favorable changes in this area; proactively escalate any issues you believe could become problematic for the company; and consider discussing any questions with an attorney who specializes in human resources.  Our company has worked with F&S since 2009 and can honestly say that the peace of mind is well worth any fees.

As a refresher, here is a link to the first in a series of blogs on wage & hour issues.

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2024 ICD-10-CM Changes Are Weeks Away

Every year, CMS issues clarifications, additions and deletions to diagnosis codes that become effective on October 1st.  For 2024, CMS announced 395 new diagnosis codes, 25 deletions and 13 revisions. Although there are many changes in wording, synonyms and instructional notations, below are the most salient code changes, but please note that this is not an exhaustive list.  Do check CMS directly for a list of ICD-10-CM codes in effect for 2024 as all providers are responsible for reporting accurate codes on their effective dates. Our focus, as always, is adult primary care and codes that are, or could be, risk adjusted.

Chapter 2: The code category of Neoplasms of uncertain behavior of connective and other soft tissue grew to accommodate new codes for Desmoid tumors (D48.11-) of various locations.

Chapter 3: Sickle-cell thalassemia (D57.4) expanded to include other complications, and there was a small code expansion for aplastic anemia. Codes were created for the association of COVID to certain coagulopathies (D68).

Chapter 4: Hypoparathyroidism (E20.8) grew to include other specific types, such as autoimmune, secondary, etc. Metabolic disorders in E88 saw several new codes, and cachexia (R64) now has a counterpart (E88.A) called Wasting disease (syndrome) due to underlying condition, with an Excludes1 notation.

Chapter 6: Parkinson’s disease (G20) split into codes reflecting the disease with (G20.A) or without (G20.B) dyskinesia. Parkinsonism, unspecified will be coded G20.C. Similarly, epilepsy received new codes for Lafora progressive myoclonus epilepsy (G40.C). Chronic migraine with aura (G43.1) also saw additional codes, as did Other & unspecified encephalopathy (G93.4).

Chapter 7: Retinal disorders (H36) spawned new codes for two types of sickle-cell retinopathy (in H36.8), and mechanical strabismus (H50.6) expanded to include various codes for specific muscle entrapments. Lastly, a new code for Foreign body sensation eye (ocular) was created (H57.8).

Chapter 9: A new code for resistant hypertension (I1A.0) was created and other forms of angina (I20.8) was divided slightly into two codes. The distinction of microvascular disease was added to acute MI and chronic ischemic heart disease, creating a few new codes. Supraventricular tachycardia (I47.1) was further divided to reflect greater diagnostic specificity, and various new notations were added to this important chapter.

Chapter 10: Bronchiolitis obliterans was added to other COPD (J44.8) and for Emphysema (J43), the Excludes1 became an Excludes2.

Chapter 11: No big changes in this chapter except a few Excludes1s becoming Excludes2s and the addition of Short bowel syndrome (K90.82) and Intestinal failure (K90.83).

Chapter 13:  Osteoporosis with pathological fracture (M80.0 and M80.8) has new codes for laterality.

Chapter 14: Code category Glomerular diseases birthed new codes for recurrent and persistent hematuria (N02), nephrotic syndrome (N04) and a type of isolated proteinuria (N06).

Chapter 17: This section has some changes in coding congenital conditions, including new codes for liver malformations and craniosynostosis. 

Chapter 18: A new code for Foreign body sensation of the circulatory and respiratory system (R09.A) was created and several new codes representing Mammographic density found on imaging of breast (R92.3) will be in use next year.

Chapter 19: Toxic effect of gadolinium (T56.82) was created within several contexts.

Chapter 20:  As we’ve seen, new foreign body codes were created for the eyes, circulatory and respiratory system. This chapter includes several more under the heading Foreign body entering into or through a natural orifice (W44) for items such as batteries, plastic, glass and other objects.

Chapter 21: Be sure to carefully check this section entitled Factors influencing health status and contact with health services for many new codes and notations. The most notable are the expansion of Family history of adenomatous and serrated polyps (Z83.71), Personal history of military service (Z91.85), expansion in caregiver noncompliance codes (Z91.A) and the creation of codes for carriers of certain conditions.

Chapter 22: This chapter is for special uses and so far, only contains codes for vaping and COVID. The latter saw an important “use additional code” notation for associated conditions.

For any coding questions, please feel free to contact our office.

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Knowledge is Power: the AHCA Survey

In this series, we’ve been discussing the major steps in launching your long-term care business in Florida.  The first step was looking at the business types and environmental factors (here & here) in favor of this type of venture.  We’ve reviewed the licensure application, financial projections and policies & procedures.  All of these steps lead up to the licensure survey conducted by the Agency of Heath Care administration (AHCA). 

The AHCA surveyor’s job is to make sure you (as an owner or administrator) have the knowledge and framework to operate a successful LTC business that meets all state regulations, statutes and rules. So where do you start?  By reading the regulations.  There is a lot of transparency in AHCA licensure so make sure to download the statutes and know the rules your business will need to follow.  AHCA also publishes a surveyor regulation set; download and study that one too.  And finally, read and know your policy manual. Consider the licensure survey to be an open-book test, and you have the books!

For sure, people are fallible, and AHCA surveyors are people too 😊  Our company’s meticulous survey preparation paid off for a client recently when the surveyor inquired about regulations to which her agency was not subject.  By knowing the regs and her policy manual, our client was able to manage the surveyor’s questions and pass her survey with no deficiencies. 

Let’s face it….. when you’ve invested your nest egg to start the business of your dreams and you’ve reached the last milestone in the licensure process, you’re excited and nervous.  We’ve attended surveys where the client became a deer in the headlights when asked about policies and regulations.

This is why it’s critical for you to take the time not to have a superficial understanding, but a true, deep knowledge of the statutes and rules, as well as the interconnectedness of the processes. Surveyors aren’t there for a “gotcha;” they have a job to do and they want you to pass your survey.

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Just Following Orders isn’t a Defense to Fraud

A case from North Carolina highlights what we see too often:  healthcare entrepreneurs and providers committing fraud, paying monetary penalties and even facing incarceration. But rarely do we see the penalties travel down the ladder to a company’s employees. A pharmacy owner was sentenced to 24 months this month for conspiracy to commit fraud.  Apparently, the pharmacy owner ran a scheme for 11 years, billing Medicare, Medicaid and private insurers for prescription drugs that were never dispensed. Sadly, if you read enough of these OIG reports, billing for services that were not rendered is not new, and sooner or later, the authorities catch up to these criminals.

The interesting twist is that one of the pharmacist’s former employees was also sentenced to 24 months’ imprisonment, followed by three years of supervised release, in connection with the same scheme. It was uncovered that the pharmacy owner trained the employee and other workers on how to bill insurance plans for drugs that were not authorized, how to falsely reauthorize a previously existing prescription from a licensed medical professional, and how to falsely bill health care benefit programs as though a drug had been dispensed. The OIG’s press release summed the case up by reporting that the employee began independently running the pharmacy while the owner knowingly profited from the fraudulent billing practices! 

The takeaway for employees from this case is, Just following orders isn’t a defense.  Anyone working in healthcare for even a day should have the basic understanding that billing for a product or service that was not provided is against the law, as well as a personal line in the sand which she will not cross.  What went through that employee’s mind the first time someone trained her to bill a false claim or resurrect an old prescription? In that split second, with the alarm bell subtly ringing in her mind, she made a choice. In this case, it was the wrong one.

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Knowledge is Power: Policies & Procedures

We’ve been reviewing various steps along the process to get your long-term care business up and running [catch up by clicking here] and this installment concerns your comprehensive policies & procedures, or P&P. P&P are a big, tangible step toward your licensure survey, where the surveyor will ensure you have the minimum framework to operate your LTC business within the confines of state and other regulations.  Although your survey is a blip in time where P&P will be reviewed, don’t underestimate your P&Ps’ true value in the soundness of your operation after the survey.

P&P cover two important bases – first, is the “what” of the business:  what are you required to do, such as the rules and guidelines under which you will work.  Your policy & procedure manual is not merely a formality, like checking a box on a list of preparatory tasks.  It’s (supposed to be) a living, breathing blueprint for how you operate within the framework of state, and in other cases, federal and accreditation requirements. This is the “how” aspect of your business.

To be sure, regulators want to know that you know the rules, but they also want to know that you know how you will make sure to follow those rules.  Good policies & procedures don’t just regurgitate the what, but they establish the how in enough detail to make them a guide for your company managers.  P&P should also include checks & balances for you as an agency owner or administrator to keep your business in compliance with all the rules.  For example, AHCA doesn’t require audits, but we all know that as companies grow and add staff, it’s not enough to train people on the rules and hope they follow them. 

Every manager must “Trust, but verify.”  And the verification happens with documented spot-checks (more intimidatingly referred to as audits) so you can re-train personnel and tighten your processes as needed.  And so, while establishing one of these in-demand healthcare businesses seems straightforward – and it is – don’t underestimate the need to have robust P&P so you can be fully conversant in all aspects of the rules and your operations prior to the survey.

As the title conveys, knowledge is power, so know the rules and just as importantly, know how your agency will demonstrate it can comply with them.  To learn more about the AHCA licensure survey, read the next installment in this series.

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What We’re Reading: The CY 2024 Physician Fee Schedule Proposed Reg: The Good, the Bad and the Ugly

We’re always curious about reactions to CMS announcements and recently read a comprehensive blog post by McDermott+Consulting, a subsidiary of McDermott Will & Emery (MWE).  Their analysis ranges from good to bad to ugly, based on CMS policies being delayed, rescinded or enacted. Below is a summary of the main points; to read MWE’s complete blog, click here.

The ugly news first:

In 2021 CMS created an add-on complexity code (G2211) for office and outpatient E/M codes but delayed its implementation until January 1, 2024. The reason, in a nutshell, is that CMS – in its quest toward budget neutrality in new payment policies – over-shot its expectation of this code’s use, and has since revised it down considerably.  This results in a more muted negative payment effect, but MWE estimates that the use of G2211 will reduce physician payments by 2%, especially those whose practice doesn’t allow for additional coding for complexity.

Next, the bad:

CMS’s Quality Payment Model has two tracks: the Merit-based Incentive Payment System (MIPS) and the Advanced Alternate Payment Model (APM) with the goal of transitioning providers from MIPS to APMs. 2024 will make MIPS incentives more challenging and also lessen the incentives to move to APMs – sounds like a rock & a hard place.  The performance threshold that determines whether clinicians will receive a bonus or penalty has been 75 points and will move to 82 points next year, with no exemptions. Two other policies will also take effect: increasing the data completeness criteria threshold to 80% for 2027/2029 and lengthening the interoperability performance period from 90 to 18- days. 

Advancing to APMs hasn’t been an option for the majority of specialists because the advancement criteria were based on the entity itself and not the individual clinician; this will change for 2024.  MWE writes that this change would make it “exceedingly hard” for many clinicians, especially specialists, to meet the thresholds.  

And now for the good news:

CMS will delay four policies that could have had great impact on providers: 1) Indefinite delay to the Appropriate Use Criteria Program, requiring practitioners to use a qualified clinical decision support mechanism before ordering advanced diagnostic imaging.  2) Determining the substantive portion in a split/shared service will continue as-is for 2024. 3) Revisions to the Medicare Economic Index are delayed, so RVU weights remain unchanged, for now. 4) Delaying yet again the imposition of financial penalties to providers who do not electronically order at least 70% of eligible controlled substance prescriptions.

Three more “goodish” policies include CMS proposals: 1) for new codes and payment for community health/social determinants of health and expanding access to behavioral health with new codes and an expanded list of eligible clinicians. 2) to simplify the process for adding new codes to the telehealth list, either permanently or temporarily. 3) to allow a higher non-facility payment rate for telehealth for services performed in the patient’s home and a lower rate for services provided to patients not located in their home. 4) and continuing the suspension of frequency limitations for certain subsequent inpatient & SNF visits provided by telehealth.

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Knowledge is Power: The AHCA Licensure Application

This short blog series is intended to help new entrepreneurs understand a little more about the licensure process with the Agency for Healthcare Administration (AHCA) in establishing your Florida long-term care business.  We started by discussing why long-term care can be a new career for you. If you missed the initial blog, feel free to catch up by clicking here. The process encompasses many steps, which we’ll review briefly in this series. 

The first rung on the licensing ladder is the application, which at first glance, seems straight-forward – after all, what’s so difficult about filling in your name, address, etc.? True enough but after 22 years completing AHCA and CMS applications, we can tell you they’re not cut & dried. 

  • Information must be 100% accurate and complete. 
  • Filling out the information isn’t the difficult part – it’s compiling all the supporting documentation, assuring that it matches application sections and addresses AHCA’s requirements.
  • Financial schedules are part of the application process.  For more information on this step, click here.
  • Errors will cost you time and possibly money.  AHCA will review your application and cite any omissions (including errors) in a separate document. You have one chance and a relatively short window of time to correct the issues and submit revised materials. If your “re-do” doesn’t pass, your application will be denied, you forfeit the licensure application fee paid and must start the process again.

Although our company’s turnkey, start-up process includes the application and all the steps through to final licensure and beyond, we’ve had clients attempt it themselves.  Some are successful and others end up asking us to take over the process after some mis-steps.  Making your future business a reality is what we do and we hope this short blog series helps in your decision. 

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A Moment of Silence for the Sunsetting MRA Program – Part 3

This has been a difficult series of articles for our company, summarizing the 2024 changes to the CMS-HCC risk adjustment model.  And we imagine our clients are speechless when considering the financial ramifications to their businesses. If you’ve missed any of the installments, click here for Part 1, which links you to each subsequent article. However, remember that the changes will be phased in over time. This means that for the rest of 2023, you will be paid at 100% for the conditions currently in the model and slightly less next year.  MRA payments lag the reporting year so the payment impact will be delayed 12 to 18 months.

We strongly suggest:

  • Embarking on a most comprehensive campaign of retrospective chart reviews to uncover any “hidden” conditions in your members’ charts. These are diagnoses currently in the model which you may not have been reporting and/or about which you may have been uninformed. Consider engaging a third-party organization to assist with retrospective reviews and to evaluate your medical coding and documentation and confirm its robustness to withstand regulatory scrutiny.
  • Ensure that you have solid evidence – filed in the chart and documented on the progress note – for every single risk adjusted condition you’ve reported AND that your provider’s documented assessment meets M-E-A-T criteria. Remember, risk adjustment is not about getting paid because patients have certain conditions but because you have demonstrated how those conditions are doing and how you’re managing them.
  • Assure you have an airtight system for making sure all of your Medicare Advantage members are being seen in your office at least once in each six-month period and that all risk adjusted conditions are being properly assessed and reported.  While telehealth is still allowed by CMS, conduct audio/video visits if patients won’t or can’t come to the office, and perhaps consider a program of house (or ALF) calls by your non-physician practitioners so no one falls through the cracks.  Housecall companies external to your practice can be a great tool for the arsenal although the comprehensiveness and quality of those assessments and documentation may vary considerably.
  • The Office of Inspector General (OIG) is actively auditing health plans and citing them for provider coding and documentation irregularities.  Similarly, many plans are conducting provider audits and finding misdiagnosed or unsupported conditions.  Not only does this open your practice up to funding recoupments, but also to penalties and damages for false claims by the OIG. So, step up your practice compliance activities to make sure you’re reporting only legitimate, properly assessed conditions for which there is evidence in the chart.

While the sky may indeed be falling when considering the magnitude of the impending MRA changes, there is a great deal you can do today to position your practice to successful navigate these waters into the next iteration of risk adjustment.

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A Moment of Silence for the Sunsetting MRA Program – Part 2

By now, you may have come to terms that MRA, as we know it, is on its way out. If you’re not informed about the changes for 2024, we urge you to read the first installment of this article series.  In this article, we’ll cover the commonly coded conditions in primary care that are slated for removal from the CMS-HCC model. The list below does not reflect all of the codes being removed from the current model.   For a complete list of the 2024 CMS-HCC model, including tabs for the removed and added codes, please click here.

Hematological

  • Anemias due to enzyme deficiencies
  • Hemolytic & aplastic anemias
  • Alpha and other thalassemias
  • Sickle cell trait
  • Coagulation defects
  • “Penias” such as thrombocytopenia, neutropenia, pancytopenia
  • Immunodeficiencies
  • Purpuras

Endocrine

  • Drug or chemical induced diabetes mellitus (with all manifestations)
  • Glandular conditions, such as those affecting the parathyroid, pituitary and thymus
  • Malnutrition
  • Metabolic disorders such as carnitine deficiencies, homocystinuria

Substance Use Disorders

  • Alcohol & cannabis use and abuse with intoxication (with/without other complications)

Psychiatric

  • Bipolar disorder in remission
  • Major depressive disorder, single and recurrent episodes, mild
  • Major depressive disorder, single and recurrent episodes, in remission

Neurological

  • Degenerative diseases of the nervous system (including cerebral atrophy)
  • Polyneuropathies, including inflammatory, radiation-induced and those in diseases classified elsewhere
  • Guillain-Barre syndrome

Cardiac

  • Anginas (except unstable)
  • Supraventricular tachycardia
  • All ASHDs with angina (except unstable)
  • Atherosclerosis of aorta
  • Atherosclerosis of renal artery
  • All atheroscleroses of the lower extremity (except with rest pain or ulcer)
  • All unruptured aneurysms
  • Peripheral vascular disease
  • Other arterial conditions, such as tortuous, ectatic, dissection of arteries, including intestinal

Rheumatological

  • Most Sjogren’s syndrome (except with lung involvement)
  • Polymyalgia rheumatica
  • Connective tissue diseases
  • Spinal enthesopathy
  • Sacroiliitis
  • Infective & inflammatory spondylopathies

Renal

  • Acute kidney failure
  • Hyperparathyroidism of renal origin

Other

  • Toe amputations
  • Dependence on renal dialysis

As a company in the risk adjustment space since 2003, this list leaves us speechless, but honestly, we’ve seen some of these removals coming.  Regardless of the tenuous connection to future medical costs and the fact that many of these conditions are reported by some providers without foundation, the losses in funding will be huge.  If you’re reaching for whiskey or Häagen-Dazs®, take heart.  First, some interesting codes were added to the CMS-HCC model: benign carcinoid tumors, retinal vein occlusions, severe asthma, phemigoids and malignant ascites. And second, read on for some things you can do right now to soften the landing for your practice.

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