Changes to ICD-9-CM Coding Practices

The Centers for Medicare & Medicaid Services (CMS) is changing the way it handles ICD-9-CM diagnosis codes. Starting with 2008 payments, the only valid ICD-9-CM codes for the CMS-HCC, ESRD and RxHCC risk adjustment models will be those published by the National Center for Health Statistics (NCHS) and CMS for the three fiscal years prior to the payment year.

For example, codes used for 2008 dates of service must be from either the 2008, 2007 or 2006 code list. For 2009 dates of service, only codes from the 2009, 2008 and 2007 lists will be accepted.

Previously, CMS' Risk Adjustment System (RAS) accepted old ICD-9-CM codes that were technically invalid. These codes will no longer be accepted.

Having a standard set of codes for each year benefits not only CMS, but also physicians, health plans like Humana and members. The new approach will increase the accuracy of ICD-9-CM coding, which will improve communication between primary care physicians and specialists and allow Humana to process and pay claims correctly. The change will also support the goal of coding to the highest level of specificity, which allows CMS to capture disease conditions for specific populations and/or geographic locations and adjust fee schedules accordingly. Highly specific diagnosis coding will also allow Humana to identify members for enrollment in appropriate disease and case management programs and provide valuable data for utilization and quality management analyses.

Outdated ICD-9-CM codes will still be accepted for 2007 dates of service. The chart below summarizes the implementation schedule for this new rule.

The code lists are published each year at www.cdc.gov/nchs/icd9.htm. Annual changes to the list are based on recommendations from the ICD-9-CM Coordination and Maintenance Committee; all final decisions are made by the director of the NCHS and the administrator of CMS. More information on the process for updating ICD-9-CM codes can be found at www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/01_overview.asp#TopOfPage.

For more information, visit the CMS Web site at www.cms.gov.

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COPD Program Succeeding in Holistic Care

Humana launched a program for Medicare members with high-acuity chronic obstructive pulmonary disease (COPD) in the summer of 2006. As of October 15, 2007, more than 7,300 members are enrolled in the program.

The program offers ongoing telephonic support from a respiratory-care trained nurse, who updates the member's primary care physician on his or her progress. The service is available to members enrolled in Humana's Medicare plans, with the exception of the HMO plan in Florida.

"We try to work holistically with members, not just focus solely on the respiratory part of their care," explained Tina Gordon, a clinical coordinator with Humana's disease management department, who focuses on Medicare offerings. "The program has received a very positive response from members."

Humana offers the telephonic COPD program in cooperation with Alere® Medical. Nurses interact one on one with participants at least quarterly, and often more frequently. Members also can call with questions or concerns.

COPD nurses and personnel do all of the following:

• Address the participant's condition, symptoms and ways to maximize his or her health
• Work to increase adherence to medications and the physician's treatment plan
• Share educational modules that teach participants more about COPD
• Help the participant manage comorbid conditions, such as diabetes and heart disease
• Notify physicians when a patient enrolls in the program
• Send a previsit fax when a participant schedules a visit

COPD affects 12 million Americans and is the nation's fourth leading cause of death.

Typically, Humana's claims department or Medicare case managers identify candidates for the program. However, physicians also can refer a Humana member by calling (800) 655-LUNG (5864). A Humana case manager will confirm the member's eligibility and will contact him or her for enrollment.