Number 45 RAPS RECAP How to Address Pending Diagnoses on the Attestation So, what exactly does Pend or Pending diagnoses mean on the Attestation sheet? Pending means the diagnosis is suspected and awaiting provider action by marking: Agree: if the diagnosis is current, clinically significant and affecting patient care, treatment, and management on that DOS.  The provider must then address the diagnosis in a face-to-face visit with the patient and document an appropriate plan of care in the progress note. Disagree: if diagnosis does not exist for the patient or it is not clinically significant. Resolved: if the diagnosis was current but is now resolved.  If the provider marks Disagree or Resolved, no supporting documentation is necessary. Example: Diagnosis pending from the prior year, found on chart review, or requiring clarification from the PCP. These could originate from the PCP, a specialist, or a facility record. Review the information provided under “Location” and “Reason” to determine the appropriate action to be taken. Example: Diagnoses pending from eDataMining are possible diagnoses based on diagnostic tests, vitals, or from other data sources and will list eDataMining as the “Location.” Review the information provided under “Reason” to determine the basis for this diagnosis pending. 4) 440.0 ATHEROSCLEROSIS OF AORTA  Agree  Disagree  Re solved 6) 585.5 CHR KIDNEY DISEASE STAGE V  Agree  Disagree  Re solved Location: Radiology abdomen Location: eDataMining Action: Pending Ref. Date: 5/31/2012 Reason: Please clarify – This is listed as an impression on a Radiology report. If agree, please address with the pt and document an assessment & treatment plan. The provider needs to determine if the diagnosis is appropriate and/or still current for that patient. If so, mark “Agree” on the Attestation and address as indicated above. Example: Diagnoses pending from CMS Encounter Data are probable diagnoses based on claims data submitted for that patient to CMS by various inpatient (can include rule-out diagnoses) and outpatient sources then reported to us as HCC history. 1-5 of the most common diagnoses per HCC category are listed for the provider to review. 4) HCC 80: Congestive Heart Failure 1) 425.4 PRIM CARDIOMYOPATHY NEC  Agree  Disagree  Re solved Action: Pending Ref. Date: 1/1/2013 2) 428.0 CHF NOS  Agree  Disagree  Re solved Action: Pending Ref. Date: 1/1/2013 The provider needs to determine if any of the diagnoses listed currently apply to the patient. If so, mark “Agree” on the Attestation for the diagnosis that applies and address as indicated above. If none apply but another diagnosis from the same category applies, mark “Disagree” and submit the documentation addressing the applicable diagnosis for that patient. Action: Pending Ref. Date: 10/24/2013 Reason: Suspect CKD Stage 5 (585.5) due to eGFR of 14.0 on 26-Mar-2013 and eGFR of 18.0 on 20-Jun-2011. eGFR is a calculation that varies by race. The provider needs to determine if the diagnosis is applicable for that patient based on his/her clinical judgment. If the diagnosis applies and is current, mark “Agree” on the Attestation and address as indicated above. Example: Diagnosis pending as Insufficient means the provider attempted to address the diagnosis; however, some element is missing so the diagnosis could not be validated. This could be administrative data (name, DOS, signature/credential, etc.), missing/insufficient or unclear clinical information to support the diagnosis. Review the feedback provided under “Reason” to determine what the discrepancy is and how to correct it. 3) 174.9 MALIGNANT NEOPLASM OF BREAST UNSPECIFIED SITE Location: Action: Insufficient Ref. Date: 6/13/2013 Reason: Pls clarify if this diagnosis is current/ being actively treated? If so, please address with a POC at next visit. If not, please resolve to Hx of. The provider will need to correct, clarify, or provide the missing/insufficient information. While administrative data can usually be corrected and returned, discrepant clinical information will usually require another face-toface visit to address. Please address all RAPS RECAP subject matter questions to Mary Wilson, CPC, Medical Coding Advisor Email: [email protected], Telephone: 407-645-7929 x5663 WellMed Medical Management. "RAPS Comprehensive Presentation." DataRAP. San Antonio, TX: 2013. Print. Slides 25-28 Created November 2013