AFFILIATED NETWORKS ADVENTHEALTH - 2022 PROVIDER INFORMATION BOOKLET - ADVENTHEALTH PROVIDER NETWORK
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AdventHealth Affiliated Networks 2022 Provider Information Booklet AdventHealth Employee Plan (AHEP) AdventHealth Commercial Individual/Group (AHAP) AdventHealth Medicare Advantage (AHAP MA) Florida Hospital Healthcare System (FHHS)
Table of Contents 1-1
1-2
Network Services
Health Management
1-3 Provider Operations and Engagement
1-3 FHHS Augmentation
2-1 AdventHealth Employee Plans (AHEP)
and AdventHealth Advantage Plans (AHAP)
2-2 Glossary
2-3 Contact Quick Reference Guide
2-4 Plan Participation and ID Cards
2-6 CaféWell Overview
2-8 Colorectal Cancer Screening
2-9 Medication Adherence Guide
2-13 Provider Portal AHAP
2-14 Authorizations
2-15 Claim Submission
2-16 Claim Disputes and Corrected Claims
3-1 Clinical Documentation Integrity
and Risk Adjustment for AHAP MA
3-2 Introduction
3-3 AdventHealth Advantage Plans Medicare Advantage
3-4 Diabetes Mellitus
3-5 Cancer
3-6 Pulmonary
3-7 Congestive Heart Failure
3-8 Rheumatoid Arthritis and Infectious
Connective Tissue Disease
3-9 Morbid Obesity
3-10 Mental Health
3-11 Heart Arrhythmia
3-12 Vascular Diseases
3-13 Chronic Kidney Disease
3-14 Risk Adjustment Factor Tip Sheet
Section One:
Network Services
1-2 Health Management
1-3 Provider Operations and Engagement
1-3 FHHS Augmentation
Back to Contents
1-1
Health Management
Health Management is a no-cost program designed to
assist your value-based contract lives who have ongoing
medical needs related to chronic illness. Our team of
skilled professionals includes registered nurse health
advisors, LPN health coordinators and social workers
who work together to support patients with education in
managing chronic illness and assistance in coordinating
care between visits.
Physician Benefits
• Increased patient compliance with physician orders Health Management Works.
• Reduced costs due to prevention of avoidable visits “Nurse health advisors have been effective in helping my most
• Improved continuity of care challenging patients stay compliant with their medications and
• Increased patient satisfaction more. Nurses have the time to connect and follow up with the
patients. It’s resulted in fewer visits to the emergency rooms.
• Customized patient care plan
Health Management is a valuable service for me and my patients.”
Referral Process Robert Rodgers, MD
Central Florida Division
health.management@adventhealth.com
FAX: 407-776-7980
West Florida Division
Health Management
wfd.health.management@adventhealth.com
FAX: 813-929-5912
Gets Results.
Patients who participate in Health Management are more
likely to close care gaps and experience lower cost-of-care.
88% 88% 36%
of Participants Decrease in Reduction
Have A1c
Provider Operations FHHS Augmentation
and Engagement Several Florida Hospital Healthcare System (FHHS) providers have
been invited to participate in one or more AdventHealth Physician
The Provider Operations and Engagement team supports Network clinically integrated network products (i.e. Allegiance/Disney,
network physicians by working to enhance the physician Oscar, Bright Health Commercial/ Bright Medicare, Roundstone,
experience with the network, with the goal of improving patient etc.). The invitation to participate in these exclusive narrow network
outcomes, quality and reducing the overall cost of health care. programs is not meant for all providers but is primarily based on
network adequacy and the State of Florida regulatory requirements.
The team is dedicated to assisting with removing barriers to If you have questions, please email the respective team.
patient care through education, implementation, and support
of Population Health technologies.
Population Management Advisor
Your Population Management Advisor (PMA) is available to
assist your practice as needed with contracting, credentialing
and claims questions which may arise from FHHS-contracted
payors. Your PMA can provide quality measure and care-gap
information specific to your attributed members. PMAs can also
engage coding experts and other resources to assist as needed
to achieve high performance for population health programs.
Some of the services offered are:
For general questions about Augmentation:
• Understanding specific population health payer/plan
physician requirements FHHS/PHSO Provider Outreach Team
PHSO.Provider.Outreach@adventhealth.com
• Educating and supporting physicians and office staff to
improve performance on specific quality measures and
reduce care gaps for attributed members For Augmented Providers with questions regarding
a specific network:
• Implementing and optimizing population health technology
solutions Central Florida Provider Relations Team
• Assisting providers with contracting, credentialing and AHPN.CF@adventhealth.com
recredentialing West Florida Provider Relations Team
• Working with providers to resolve claim issues for payors pn.wfd.networkdevelopment@adventhealth.com
affiliated with FHHS
Back to Contents
Section One: 2022 Network Services 1-3
Section Two:
AdventHealth
Employee Plans
and AdventHealth
Advantage Plans
2-2 Glossary
2-3 Contact Quick Reference Guide
2-4 Plan Participation and ID Cards
2-6 CaféWell Overview
2-8 Colorectal Cancer Screening
2-9 Medication Adherence Guide
2-13 Provider Portal AHAP
2-14 Authorizations
2-15 Claim Submission
2-16 Claim Disputes and Corrected Claims
Back to Contents
2-1
Glossary AdventHealth Employee Plan (AHEP) The benefit plan
name for AdventHealth employees and their dependents is an
AdventHealth Advantage Plans product and is administered by
Health First Health Plans. The participating counties are in Central
AdventHealth Hospital system with more than 50 hospital
and West Florida.
facilities in nine states. In Florida, AdventHealth includes over
30 hospitals and emergency rooms, 40 Central Care urgent
care locations and numerous imaging, sports rehab and other Aetna health care company will be the Third-Party Administrator
outpatient facilities. for the population AdventHealth Employee Plan (AHEP) as of
Jan. 1, 2022. This includes processing and paying claims, customer
service for patients and providers, care management and more.
AdventHealth Advantage Plans (AHAP) The brand name of a
health insurance created in partnership between AdventHealth
and Health First Health Plans (HFHP) and supported by the Clinical Documentation Integrity Program This program
Florida Hospital Healthcare System (FHHS) networks. AHAP compensates physicians for providing and documenting appropriate
covers Medicare Advantage and Commercial (Group and treatment and coordinating care for Medicare Advantage patients.
Individual) members. Providers can earn over $200 per member per year by participating
in the AdventHealth Advantage Plans CDI Program.
AdventHealth Advantage Plans Commercial Plans Includes
Individual plans for individuals and families as well as Group plans Florida Hospital Healthcare System (FHHS) A provider network
for small (
Contact Quick Reference Guide
AdventHealth Advantage Plans
AdventHealth Employee Plan Medicare Advantage & Commercial
Authorizations Aetna Behavioral Health Availity.com Optum Health ProviderExpress.com
Behavioral Health Phone: 888-632-3862 Fax: 888-463-1309 Phone: 800-888-2988
Aetna AHAP/HFHP myAHplan.com/4providers
Authorizations Medical
Phone: 855-600-0032 Fax: 833-596-0039 Phone: 844-522-5278 Fax: 833-554-9046
RX Plus Pharmacy CVS
Authorizations Pharmacy
Phone: 855-600-0032 Fax: 833-596-0039 Phone: 855-344-0903 Fax: 855-633-7673
Central Florida Division
Email: .health.mangement@adventhealth.com Fax: 407-303-8026
Care Management
West Division
Email.: wfd.health.mangement@adventhealth.com Fax: 813-605-4699
Customer Service Services: Aetna AHAP/HFHP Contact Us Form
claims, benefits, and eligibility Phone: 888-632-3862 Phone: 844-522-5282
TrueHearing
Hearing Only through the VSP Vision plan.
Phone: 855-687-9718
Aetna – Claims Payer ID: 60065 AHAP/HFHP – Claims Payer ID: RP039
Change Healthcare Availity, Eligible or Change Healthcare
SUBMISSIONS SUBMISSIONS
Phone: 888-632-3862 Mail: PO Box 981106 Mail: PO Box 66490
Provider Claims Fax: 859-455-8650 El Paso, TX 79998-1106 Phone: 844-522-5282 Phoenix, AZ 85082-6490
DISPUTE DISPUTE
Fax: 859-425-3379 Mail: PO Box 14463 Submit the Dispute Resolution Form
Attn: CRTM Lexington, KY 40512 Phone: 844-522-5278 Fax: 888-977-2062
Aetna Portal Aetna.com AHAP Portal myAHplan.com/4providers
Provider Portal
Help Line: 888-632-3862 Help Line: 844-522-5282
VSP Davis Vision
Vision
Phone: 800-877-7195 Phone: 800-77-DAVIS
Back to Contents
2-3 Section Two: 2022 AdventHealth Employee Plans (AHEP) and AdventHealth Advantage Plans (AHAP)
Plan Participation and ID Cards
How do you recognize an AdventHealth Advantage Plans member?
FHHS providers are contracted to accept all AdventHealth Advantage Plans and HFHP products, including Medicare Advantage,
Individual and Group plans, and Self-Funded plans such as AdventHealth and Health First employees. All FHHS providers accept these
contracts unless expressly excluded from your FHHS contract.
AdventHealth Employee Plan (AHEP)
HDHP Traditional
Back to Contents
Section Two: 2022 AdventHealth Employee Plans (AHEP) and AdventHealth Advantage Plans (AHAP) 2-4
AdventHealth Advantage Plans (AHAP) Health First Health Plans ID Cards
CMS requires the MA card to have the HFHP logo. Members of Health First Health Plans (HFHP) are covered
as part of your FHHS provider contract.
Medicare Advantage (SunSaver Plan) HFHP Medicare Advantage
Commercial: Individual and Group HFHP Individual and Family Plans
Back to Contents
2-5 Section Two: 2022 AdventHealth Employee Plans (AHEP) and AdventHealth Advantage Plans (AHAP)CaféWell Overview
What is CaféWell?
CaféWell® is a personalized wellness and health maintenance program that allows your patients to get rewards when they focus on a
healthier lifestyle. While members only earn rewards for select preventive screenings, they have access to many other programs that
will provide additional self-paced education. Members also have the option to complete a Health Risk Assessment (HRA) questionnaire.
Based on the information submitted, members will see specific programs that will help them to improve their wellness and health.
Members can also print a HRA summary and bring it with them to their next visit with you, or any other healthcare provider.
Activity Medicare 2021 Commercial 2021 Reward Age Frequency
CHA N/A $50 No age Annually
HRA N/A $25 No Age Annually
Annual Physical N/A $25 18 and older Annually
Flu Shot $5 18 and older Annually
Diabetic Eye Exam $10 18 and older (if eligible) Annually
Diabetic A1C $10 18 and older (if eligible) Annually
Diabetic Nephropathy $10 18 and older (if eligible) Annually
Diabetic Bundle $20 18 and older (if eligible) Annually
Mammogram $10 35 and older Annually
Colon Ca Screening $10 50 and older Varies
ICP $10 18 and older (if eligible) Annually
Diabetic Education $10 18 and older (if eligible) Varies
*The flu shot is the only self-reported activity, all others are claims based
**Medicare members can earn up to $100 annually and Commercial members can earn up to $75 annually
Exclusions: CaféWell is not currently available to AdventHealth Employee Health Plans, Rosen TPA or Brevard County ASO members.
Back to Contents
Section Two: 2022 AdventHealth Employee Plans (AHEP) and AdventHealth Advantage Plans (AHAP) 2-6CaféWell FAQ
When can members redeem their rewards?
Once the health plan has received the claim for the
completed screenings, the member's account will be
credited with the appropriate reward amount. Typically,
claims take 6 to 8 weeks to arrive.
How can members redeem
their rewards and view progress?
1. Log into their member portal, enter the CaféWell site,
and choose a gift card under the rewards section.
Health First Health Plans Member Portal
myHFHP.org/welcome
AdventHealth Advantage Plans Member Portal
myAHplan.com/welcome
2. Call Customer Service who will redeem a gift card
on the member’s behalf.
As a provider, what can you do?
• Discuss preventive screenings as normal to help members
close their care gaps.
• Bill the appropriate screening to ensure proper credit
for completion.
• Be aware that rewards are not instantly received after
the appointment has been complete.
• Remind members that they must redeem their gift card
as they are no longer automatically sent to the member.
• Connect members with Customer Service if the member
has any questions or concerns.
Back to Contents
2-7 Section Two: 2022 AdventHealth Employee Plans (AHEP) and AdventHealth Advantage Plans (AHAP)Colorectal Cancer (CRC) Screening Using
DNA Analysis (Cologuard™)
Background Order
To meet the Healthcare Effectiveness Data and Information Set (HEDIS) For oncology colorectal screening, quantitative real-time
Quality of Care measures, members between 50 and 75 years of age target and signal amplification of 10 DNA markers (KRAS
are required to have a documented screening colonoscopy or flexible mutations, promoter methylation of NDRG4 and BMP3) and
sigmoidoscopy. A screening colonoscopy meets HEDIS measures for a fecal hemoglobin, utilizing stool, algorithm reported as a
period of 10 years, while a flexible sigmoidoscopy meets the measure positive or negative result use CPT 81528. (Ref. HCPCS Code
for five years. In the event a member does not want to have a screening and CPT © Codes)
colonoscopy, colorectal cancer screening can be achieved by stool
DNA analysis (Cologuard™). While a colonoscopy is considered the “gold Prior Authorization
standard” for screening, DNA analysis (Cologuard™) would meet HEDIS
criteria for a period of three years. The member should be counseled that Effective Sep. 1, 2018, this service no longer requires prior
if the results are positive, a diagnostic colonoscopy should be performed authorization if criteria above is met.
as follow-up visit. Effective Sep. 1, 2018, this screening no longer requires
Note: Fecal Occult Blood Test (FOBT): Guaiac (gFOBT) or immunochemical
prior authorization. (FIT) are also options for annual screenings; however, screening
colonoscopy is preferred.
Criteria
• Covered once every three years.
• Age 50 to 85 years and has not had the test within the past three years.
• Is asymptomatic (no signs or symptoms of colorectal disease, including,
but not limited to, lower gastrointestinal pain, blood in stool, positive
guaiac fecal occult blood test or fecal immunochemical test).
• At average risk of developing CRC; no personal history of adenomatous
polyps, CRC or inflammatory bowel disease, including Crohn’s disease
and ulcerative colitis; no family history of CRC or adenomatous polyps,
familial adenomatous polyposis or hereditary nonpolyposis CRC.
Back to Contents
Section Two: 2022 AdventHealth Employee Plans (AHEP) and AdventHealth Advantage Plans (AHAP) 2-82022 Medication Adherence Guide
Cholesterol Management, Diabetes and Blood Pressure Management
Health First Health First 30 day supply: Rx cost 90 day supply: Rx cost
"Formulation
Health Health Plan Health Plan contribution toward contribution toward
Drug Covered
Brand Name Generic Name First Medicare Tier Medicare Medicare entering the coverage entering the coverage
Class *If on
Formulary Advantage Plan Advantage Plan gap (donut hole) gap (donut hole)
Formulary*"
30 day Copay 90 day Copay beginning at $4,130 beginning at $4,130
CHOLESTEROL MANAGEMENT
Y
$ $
Altoprev lovastatin Generic Tier 1 $0 $0
Y
$ $
Zocor simvastatin Generic Tier 1 $0 $0
Y
$ $
Pravachol pravastatin Generic Tier 1 $0 $0
Y
$ $$$$
Statins Lescol XL fluvastatin Generic Tier 1 $0 $0
Y
$ $$
Crestor rosuvastatin Generic Tier 1 $0 $0
Y
$ $
Lipitor atorvastatin Generic Tier 1 $0 $0
Y
$$$$ $$$$$$
Livalo pitavastatin Generic Tier 1 Up to $90 Up to $270
Y
$$ $$$$
Caduet amlodipine-atorvastatin Generic Tier 1 $0 $0
Statin Combo
Vytorin ezetimibe-simvastatin Y Generic Tier 1 $0 $0 $$ $$$$
DIABETES
Y
$ $
Glucophage metformin Generic Tier 1 $0 $0
Y
$ $
Glucophage XR metformin ER Generic Tier 1 $0 $0
Biguanides
N
$$$$ $$$$$$
Fortamet metformin ER (Osm) Non-Formulary Non-Formulary Non-Formulary Non-Formulary
N
$$$$$$ $$$$$$
Glumetza metformin ER (MOD) Non-Formulary Non-Formulary Non-Formulary Non-Formulary
Y
$$ $$$
Actos pioglitazone Generic Tier 1 $0 $0
Thiazolidinediones
N
$$$ $$$$
Avandia rosiglitazone Non-Formulary Non-Formulary Non-Formulary Non-Formulary
N
$$$$$ $$$$$$
Onglyza saxagliptin Non-Formulary Non-Formulary Non-Formulary Non-Formulary
Y
$$$$$ $$$$$$
Tradjenta linagliptin Brand Tier 3 up to $45 up to $135
DPP-4
Inhibitors
Y
$$$$$ $$$$$$
Januvia sitagliptin Brand Tier 3 up to $45 up to $135
N
$$$$ $$$$$$
Nesina alogliptin Non-Formulary Non-Formulary Non-Formulary Non-Formulary
Y
$$$$$ $$$$$$
Farxiga dapagliflozin Brand Tier 3 up to $45 up to $135
N
$$$$$ $$$$$$
Invokana canagliflozin Non-Formulary Non-Formulary Non-Formulary Non-Formulary
SGLT2
Y
$$$$$ $$$$$$
Jardiance empagliflozin Brand Tier 3 up to $45 up to $135
N
$$$$ $$$$$$
Steglatro ertugliflozin Non-Formulary Non-Formulary Non-Formulary Non-Formulary
Continued on next page.
Back to Contents
2-9 Section Two: 2022 AdventHealth Employee Plans (AHEP) and AdventHealth Advantage Plans (AHAP)Continued: 2022 Medication Adherence Guide Cholesterol Management, Diabetes and Blood Pressure Management
Health First Health First 30 day supply: Rx cost 90 day supply: Rx cost
"Formulation
Health Health Plan Health Plan contribution toward contribution toward
Drug Covered
Brand Name Generic Name First Medicare Tier Medicare Medicare entering the coverage entering the coverage
Class *If on
Formulary Advantage Plan Advantage Plan gap (donut hole) gap (donut hole)
Formulary*"
30 day Copay 90 day Copay beginning at $4,130 beginning at $4,130
DIABETES (continued)
Y
$ $$
Starlix nateglinide Generic Tier 1 $0 $0
Y
$$$ $$$$
Victoza liraglutide Brand Tier 3 up to $45 up to $135
Y
$$ $$$
Prandin [DSC] repaglinide Generic Tier 1 $0 $0
N
$$$$$ $$$$$$
Adlyxin lixisenatide Non-Formulary Non-Formulary Non-Formulary Non-Formulary
GLP-1
Y
$$$$$ $$$$$$
Ozempic semaglutide Brand Tier 3 up to $45 up to $135
Y
$$$$$ $$$$$$
Rybelsus semaglutide Brand Tier 3 up to $45 up to $135
Bydureon/
Y
$$$$$ $$$$$$
exenatide Brand Tier 3 up to $45 up to $135
Byetta
N
$$$$$ $$$$$$
Trulicity dulaglutide Brand Tier 3 Up to $45 up to $135
Alpha Glucosidase Precose
Y
$ $
acarbose Generic Tier 2 up to $15 up to $45
Inhibitor
D2 Receptor Cycloset bromocripitine N Non-Formulary Non-Formulary Non-Formulary Non-Formulary
$$ $$$
Agonist
Y
$ $
Glucotrol glipizide-metformin Generic Tier 1 $0 $0
Y
$ $
Glucotrol XR glipizide er Generic Tier 1 $0 $0
Sulfonylureas
N
$ $
Glynase glyburide Non-Formulary Non-Formulary Non-Formulary Non-Formulary
Y
$ $
Amaryl glimepiride Generic Tier 1 $0 $0
Y
$ $
glipizide-metformin Generic Tier 1 $0 $0
Glucovance
N
$ $
glyburide-metformin Non-Formulary Non-Formulary Non-Formulary Non-Formulary
[DSC]
N
$$ $$$$
Kazano alogliptin-metformin Non-Formulary Non-Formulary Non-Formulary Non-Formulary
N
$$ $$$
Actoplus Met pioglitazone-metformin Non-Formulary Non-Formulary Non-Formulary Non-Formulary
N
$$$ $$$$$
Segluromet ertugliflozin-metformin Non-Formulary Non-Formulary Non-Formulary Non-Formulary
N
$$$ $$$$$
repaglinide-metformin Non-Formulary Non-Formulary Non-Formulary Non-Formulary
Y
$$$ $$$$$
Combos Jentadueto lingaliptin-metformin Brand Tier 3 up to $45 up to $135
Y
$$$ $$$$$
Jentadueto XR lingaliptin-metformin XR Brand Tier 3 up to $45 up to $135
Y
$$$ $$$$$
Janumet sitagliptin-metformin Brand Tier 3 up to $45 up to $135
Y
$$$ $$$$$
Janumet XR sitagliptin-metformin XR Brand Tier 3 up to $45 up to $135
N
$$$$ $$$$$
Invokamet canagliflozin-metformin Non-Formulary Non-Formulary Non-Formulary Non-Formulary
canagliflozin-metformin
N
$$$$ $$$$$
Invokamet XR Non-Formulary Non-Formulary Non-Formulary Non-Formulary
XR
Y
$$$$ $$$$$
Synjardy empagliflozin-metformin Brand Tier 3 up to $45 up to $135
Continued on next page.
Back to Contents
Section Two: 2022 AdventHealth Employee Plans (AHEP) and AdventHealth Advantage Plans (AHAP) 2-10Continued: 2022 Medication Adherence Guide Cholesterol Management, Diabetes and Blood Pressure Management
Health First Health First 30 day supply: Rx cost 90 day supply: Rx cost
"Formulation
Health Health Plan Health Plan contribution toward contribution toward
Drug Covered
Brand Name Generic Name First Medicare Tier Medicare Medicare entering the coverage entering the coverage
Class *If on
Formulary Advantage Plan Advantage Plan gap (donut hole) gap (donut hole)
Formulary*"
30 day Copay 90 day Copay beginning at $4,130 beginning at $4,130
DIABETES (continued)
Y
$$$$$ $$$$$$
Xigduo XR dapagliflozin-metformin Brand Tier 3 up to $45 up to $135
N
$$$$$ $$$$$$
Duetact pioglitazone-glimepiride Non-Formulary Non-Formulary Non-Formulary Non-Formulary
empagliflozin-linagliptin
Y
$$$$$ $$$$$$
Trijardy Brand Tier 3 up to $45 up to $135
Combos and metformin
(continued)
empagliflozin and
Y
$$$$$ $$$$$$
Glxyambi Brand Tier 3 up to $45 up to $135
linagliptin
empagliflozin-metformin
Y
$$$$$ $$$$$$
Synjardy XR Brand Tier 3 up to $45 up to $135
XR
BLOOD PRESSURE MANAGEMENT
Y
$ $
Accupril quinapril Generic Tier 1 $0 $0
Y
$ $
benazepril Generic Tier 1 $0 $0
Y
$ $
fosinopril Generic Tier 1 $0 $0
Y
$ $
trandolapril Generic Tier 1 $0 $0
Y
$ $$
moexipril Generic Tier 1 $0 $0
ACE
Y
$ $
Prinivil, Zestril lisinopril Generic Tier 1 $0 $0
Y
$ $
Altace ramipril Generic Tier 1 $0 $0
Y
$ $
enalapril Generic Tier 1 $0 $0
Y
$ $$
perindopril Generic Tier 1 $0 $0
Y
$ $
captopril Generic Tier 1 $0 $0
Y
$$ $$$
candesartan Generic Tier 1 $0 $0
Y
$ $
Cozaar losartan Generic Tier 1 $0 $0
N
$$ $$$$
eprosartan Non-Formulary Non-Formulary Non-Formulary Non-Formulary
Y
$ $$
irbesartan Generic Tier 1 $0 $0
ARB
Y
$ $$
Micardis telmisartan Generic Tier 1 $0 $0
Y
$ $$
Diovan valsartan Generic Tier 1 $0 $0
Y
$$$ $$$$$
Edarbi azilsartan Brand Tier 4 up to $90 up to $270
Y
$ $$
Benicar olmesartan Generic Tier 1 $0 $0
Direct Renin aliskiren Y Generic Tier 2 up to $15 up to $45
$$$ $$$$$
Inhibitor
Continued on next page.
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2-11 Section Two: 2022 AdventHealth Employee Plans (AHEP) and AdventHealth Advantage Plans (AHAP)Continued: 2022 Medication Adherence Guide Cholesterol Management, Diabetes and Blood Pressure Management
Health First Health First 30 day supply: Rx cost 90 day supply: Rx cost
"Formulation
Health Health Plan Health Plan contribution toward contribution toward
Drug Covered
Brand Name Generic Name First Medicare Tier Medicare Medicare entering the coverage entering the coverage
Class *If on
Formulary Advantage Plan Advantage Plan gap (donut hole) gap (donut hole)
Formulary*"
30 day Copay 90 day Copay beginning at $4,130 beginning at $4,130
BLOOD PRESSURE MANAGEMENT (continued)
enalapril-
Y
$ $$
Generic Tier 1 $0 $0
hydrochlorothiazide
quinapril-
Y
$ $$
Accuretic Generic Tier 1 $0 $0
hydrochlorothiazide
lisinopril-
Y
$ $$
Zestoretic Generic Tier 1 $0 $0
hydrochlorothiazde
Y
$ $$
amlodipine-benazepril Generic Tier 1 $0 $0
benazepril-
Y
$ $$
Lotensin HCT Generic Tier 1 $0 $0
hydrochlorothiazide
fosinopril-
Y
$ $$
Generic Tier 1 $0 $0
hydrochlorothiazide
losartan-
Y
$ $$
Hyzaar Generic Tier 1 $0 $0
hydrochlorothiazide
irbesartan-
Y
$ $$
Avalide Generic Tier 1 $0 $0
hydrochlorothiazide
captopril-
Y
$$ $$$
Generic Tier 1 $0 $0
hydrochlorothiazide
candesartan-
Y
$$ $$$
Atacand HCT Generic Tier 1 $0 $0
hydrochlorothiazide
N
$$ $$$$
Tarka trandolapril-verapamil Non-Formulary Non-Formulary Non-Formulary Non-Formulary
Combos
telmisartan-
Y
$$ $$$$
Micardis HCT Generic Tier 1 $0 $0
hydrochlorothiazide
Y
$$ $$$$
Twynsta telmisartan-amlodipine Generic Tier 1 $0 $0
valsartan-
Y
$$ $$$
Diovan HCT Generic Tier 1 $0 $0
hydrochlorothiazide
Y
$ $$
Exforge amlodipine-valsartan Generic Tier 1 $0 $0
Y
$$$ $$$$$
Edarbyclor azilsartan-chlorthalidone Brand Tier 4 up to $90 Up to $270
olmesartan-
Y
$ $$
Benicar HCT Generic Tier 1 $0 $0
hydrochlorothiazde
amlodipine-valsartan-
Y
$$ $$$
Exforge HCT Generic Tier 1 $0 $0
hydrochlorothiazide
Y
$$ $$$
Azor amlodipine-olmesartan Generic Tier 1 $0 $0
omesartan-amlodipine-
Y
$$ $$$
Tribenzor Generic Tier 1 $0 $0
hydrochlorothiazide
aliskiren-
N
$$$$ $$$$$$
Tekturna HCT Non-Formulary Non-Formulary Non-Formulary Non-Formulary
hydrochlorothiazide
Y
$$$$$ $$$$$$
Entresto sacubitril/valsartan Brand Tier 3 up to $45 up to $135
COST $ = $20-50 $$ = $51-150 $$$ = $151-300 $$$$ = $301-500 $$$$$ = $501-1,000 $$$$$$ = +$1,000
Back to Contents
Section Two: 2022 AdventHealth Employee Plans (AHEP) and AdventHealth Advantage Plans (AHAP) 2-12Provider Portal
AdventHealth Advantage Plans (AHAP) Benefits of having your own access to the
AHAP Provider Portal
The new provider portal myAHplan.com/4providers is administered by • Check member eligibility.
Oscar. The 2021 HealthTrio provider portal myAHplan.com will still be • Check status of claims.
accessible for historical data referencing regarding any claims on or
before Dec. 31, 2021. • Submit prior Authorizations electronically.
• Sign up for electronic payments.
The Provider Portal will help you find in-network experts, lab facilities,
and more by searching the provider directory. Additionally, get easy • Review members’ clinical information.
access to Provider Manuals for all markets, policies for clinical guidelines, • Connect your staff to your organization (practice) account
reimbursement policies and required forms. and grant permission to complete tasks in the Portal.
Create your AHAP Provider Account
As of Nov. 1, 2021 you may create your Provider Portal account. Please Note: Account sharing is
not permitted and the first associate to register will be established as the practice’s “Organization
Manager”. The Organization Manager will have the ability to approve access for all others within
the practice.
1. Go to myAHplan.com/4providers
2. Click Log-in at the top right of screen. A pop-up will appear (as pictured on the right). On
the bottom of that pop-up, click "Create an account."
3. Select verification method, Instant Access or Skip Now for manual verification.
• Instant access is only available if you have at least two claims on file in the last 90 days.
You will need claim ID, paid date of claim, amount paid and check number.
• Manual verification involves receiving a call within 3-5 business days to verify information.
4. Verify email once you receive an email and click the link to verify. Use dropdown on
top right side to invite staff. The staff will receive an email inviting them to create a
password to login.
Need a Tour? Check out the Portal Tutorials and How-To Guides once you are completed.
Back to Contents
2-13 Section Two: 2022 AdventHealth Employee Plans (AHEP) and AdventHealth Advantage Plans (AHAP)Submit a Medical Outpatient Authorization Request
AdventHealth Advantage Plans (AHAP) When to use the Authorization Form:
• Pre-service, in-network medical authorizations that are
To submit a Medical Outpatient Authorization request, log in to reviewed by Oscar (not partner) staff.
the provider portal at myAHplan.com/4providers. You can begin to
• Concurrent or post-service auth for ER to inpatient admission.
process Prior Authorizations as of Dec. 15, 2021 for dates of service
(DOS) on or after Jan. 1, 2022.
When not to use the Authorization Form:
• Click on Providers tab > Provider Resources > select Florida >
click on Forms (on left side). Out of network physician or facility request.
• Complete the Authorization Request Form. Authorizations for services that are reviewed by a partner
or to determine authorization requirements.
• Fax this form to 833-554-9046.
To find an in-network provider or facility.
For these requests, please call 844-522-5278 or visit
myAHplan.com/4providers.
Back to Contents
Section Two: 2022 AdventHealth Employee Plans (AHEP) and AdventHealth Advantage Plans (AHAP) 2-14Claim Submission
AdventHealth Advantage Plans (AHAP)
AHAP Medical Services Payor ID: RP039
Optum Behavioral Health Services Payor ID: 87726
Electronic Claims
Oscar highly recommends submitting electronic claims by using
Availity, Eligible or Change Healthcare.
For any issues setting up the ability to submit claims
electronically, please contact the billing vendor to ensure that
they have the new AHAP payor ID in their system.
If unlisted or miscellaneous codes are used, notes and/or a
Paper Claims
description of the services rendered must accompany the claim.
If a claim cannot be submitted electronically, a paper UB-04 Using unlisted or miscellaneous codes will delay claims payment.
or CMS 1500 form should be submitted to: Claims received with unlisted or miscellaneous codes that have
Health First Health Plans no supporting documentation may be denied, and the member
P.O. Box 66490 may not be held liable for payment.
Phoenix, AZ 85082-6490
Timely Processing of Claims
CMS 1500 Form: Required for all physician services claims, Oscar and its delegated provider organizations and hospitals
including internal medicine, gynecology, and psychiatry. The are required to meet the claims timeliness standards established
International Classification of Diseases (ICD-10) diagnosis codes by state law. Oscar will abide by the guidelines of the Florida
and HCPCS/CPT procedure codes must be used. All field Office of Insurance Regulation (FLOIR), which stipulate that all
information is required unless otherwise noted. undisputed claims requiring no additional information must
be processed and paid or denied within 20 calendar days if
UB-04 Form: Required for all institutional services claims. All field submitted electronically and 40 calendar days if submitted by
information is required unless otherwise noted. paper, unless otherwise set forth in the provider contract.
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2-15 Section Two: 2022 AdventHealth Employee Plans (AHEP) and AdventHealth Advantage Plans (AHAP)Submitting Claims
Disputes
AdventHealth Advantage Plans (AHAP)
Provider disputes are preferred to be submitted
electronically through our online provider web
portal. The portal is available 24 hours a day,
seven days a week.
By Electronic Submission (preferred):
1. Log in to the provider portal at myAHplan.
com/4providers.
2. Click on For Brokers & Providers tab >
Provider Resources > select Florida >
click on Forms (on left side).
3. Complete the Provider Dispute Resolution Form.
By Mail:
Health First Health Plans
P.O. Box 66490
Phoenix, AZ 85082-6490
For questions about the dispute process, please review
the Provider Manual, talk to your provider network
representative or contact our Customer Service
Department at: 844-522-5278.
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Section Two: 2022 AdventHealth Employee Plans (AHEP) and AdventHealth Advantage Plans (AHAP) 2-16Provider Disputes and Corrected Claims
AdventHealth Advantage Plans (AHAP) At any time during the Dispute Resolution Process, either party may
request to meet and confer by telephone. If the meet and confer
process does not resolve the dispute, either party may submit the
Disputes dispute to binding arbitration, in accordance with the terms of the
provider’s contract.
Providers can submit disputes through myAHplan.com/4providers
or on paper to:
Appeals Process
Health First Health Plans
P.O. Box 66490 In cases where an authorization request is denied, the enrollee or
Phoenix, AZ 85082-6490 the enrollee's authorized representative will have an opportunity
to appeal the decision. The appeal will be handled through a
Phone: 844-522-5278 structured appeals process and a licensed physician not involved in
Fax: 888-977-2062 the initial coverage decision will review the appeal. Upon resolution
of every appeal, a resolution letter is sent to the member, which,
Providers who would like to make an inquiry may contact Oscar via
in the case of an adverse determination, will include information
phone, web, email, fax, or letter sent to the address specified on the
regarding any additional appeal rights the member might have and
EOP. Inquiries leading to the submission of adjusted claims or late
instructions on how to dispute the determination. A copy of this
submissions will be reviewed according to the timelines set forth in
letter will also be faxed to the provider and the member’s authorized
the Claims Submission section.
representative, if applicable.
A provider wishing to submit a payment dispute may do so using
Any appeal of a denied utilization review (UR) decision, in which the
the Dispute Resolution Form or other written format submitted by
services were determined not to be medically necessary, should be
mail, through Oscar’s electronic provider portal, or via fax within 90
filed within 180 days of the provider’s receipt of the denial (adverse
calendar days of a claim processing decision. A copy of the Dispute
determination). In order to file an appeal, the provider should specify
Resolution Form can be found in the appendix of this manual and
they are seeking to file an appeal of a denied UR decision with the
on Oscar’s website. This submission will trigger Oscar’s Dispute
Clinical Review team, whether the appeal is submitted via telephone
Resolution Process. Once the Dispute Resolution Form is received,
or in writing. The provider may submit a one-page Appeal Form,
Oscar will send an acknowledgment letter to the provider. Oscar will
along with additional clinical information in order to file an appeal.
resolve or seek additional information needed to resolve disputes
within 60 calendar days. If Oscar requests additional information In Florida, members or their authorized representatives may request
to resolve a dispute, the provider has 30 calendar days to respond. an Independent Medical Review of disputed health care services if
Upon receipt of all requested information, Oscar will then seek to they believe that health care services have been improperly denied,
resolve the dispute within 60 calendar days. modified, or delayed by Oscar or one of its contracting practitioners.
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2-17 Section Two: 2022 AdventHealth Employee Plans (AHEP) and AdventHealth Advantage Plans (AHAP)Corrected Claims Guidelines for Additional Information
Providers who believe they have submitted an incorrect or The following content guidelines for medical records and itemized bills
incomplete claim may submit an updated claim within 180 will ensure timely processing of claims requiring additional information.
calendar days of the last date of service (the same timely All requested documents must be legible and must present the
filing limit established in the “Timely Filing of Claims” section information in a way that can be reasonably interpreted. Medical Record
above). Providers must submit a corrected claim when Content Complete medical records requested for the purpose of claim
previously submitted claim information has changed (e.g. payment must include the content outlined below only for the requested
procedure codes, diagnosis codes, dates of service, etc.). dates of service. The content is as follows, but is not limited to:
When a claim is submitted as a correction or replacement,
• Member demographics
the entire claim must be submitted.
• Biographical information
Electronic Corrected Claims • Consultation reports including specialist consultations
• History & physical examination
Electronic corrected claims must be submitted with
frequency code 7 in Element CLM05-3 (Claim Frequency • Daily clinician notes
Type Code). Updated claim submissions that do not have • Laboratory reports
these codes may be denied as duplicate submissions. • Vitals
• Medication list
Paper Corrected Claims
• Imaging results, if applicable
Paper CMS 1500 corrected claim submissions must use • Diagnostic tests
frequency code 7 under Item 22 (Resubmission Code) and
• Preventative health records including immunizations
the corresponding original reference code field must list the
original payor claim ID. Paper UB-04 corrected claims must • Operative notes, if applicable
be submitted with Claim Frequency Type 7 as the third digit • Inpatient/ER discharge summary reports, if applicable
under Type of Bill (Form Locator 04). • Progress or office visit notes, if applicable
Providers should refer to their respective contracts for timelines when
Requests for Additional Information
submitting requested additional information for claims. Unless a different
During the claims adjudication process, Oscar may request timeline is specified in the contract, providers must submit the requested
additional information—such as medical records, acquisition information to Oscar, along with the associated Explanation of Payment
invoices, or itemized bills— from the provider in order to (EOP) and/or a copy of the information request letter, within 35 calendar
better ascertain financial liability and whether or not the days of the initial request. If all requested documentation is not received
services on the claim should be reimbursed. Oscar will make within this timeframe, Oscar will deny the claim. The member cannot be
any requests for more information within timelines set by held financially responsible for claims denied due to the provider’s failure
state regulation or the provider’s contract with Oscar. to submit requested documentation.
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Section Two: 2022 AdventHealth Employee Plans (AHEP) and AdventHealth Advantage Plans (AHAP) 2-18Section Three:
Clinical Documentation
Integrity and
Risk Adjustment
3-2 Introduction
3-3 AdventHealth Advantage Plans
Medicare Advantage
3-4 Diabetes Mellitus
3-5 Cancer
3-6 Pulmonary
3-7 Congestive Heart Failure
3-8 Rheumatoid Arthritis and Infectious
Connective Tissue Disease
3-9 Morbid Obesity
3-10 Mental Health
3-11 Heart Arrhythmia
3-12 Vascular Diseases
3-13 Chronic Kidney Disease
3-14 Risk Adjustment Factor Tip Sheet
Back to Contents
3-1Introduction
Evolution to Value
Why is clinical documentation integrity (CDI) needed?
As we continue to move toward a value-based and patient-
centered health care environment, diagnosis coding is becoming • Ensure that patients are treated at least once a year for all
vital to physicians, health care professionals and payers to chronic conditions.
establish the complexity of the patient’s health status, medical • Improve coordination of care by making sure all conditions
decision-making and ultimately reimbursement. are tracked by the primary care physician and treated by the
appropriate specialist.
Accurately capturing each patient’s health status by coding to the
• Ensure complete and accurate registries to be used in case
highest level of specificity for their active conditions supports the
management programs for Population Health improve the
quality and optimization of patient care. The following sections
accuracy of value-based payments to providers by appropriately
provide example assessments/plans, documentation requirements
capturing disease burden of populations.
and ICD-10 diagnosis coding tips for some of the most commonly
reported chronic conditions.
Why is documenting conditions every year necessary?
Why focus on documentation and coding integrity? A patient’s risk adjustment factor (RAF) is based on the health
conditions they have, as well as demographic factors. An accurate
• Support and meet clinical quality measurement initiatives
RAF score and expected level of risk depend on complete
and requirements.
documentation and correct coding of the patient’s medical record.
• Improve the overall health status and continuity of care for patients.
The Centers for Medicare & Medicaid Services (CMS) requires
• Optimize a healthy revenue cycle and claims processing.
that health care providers identify all conditions the patient may
• If it hasn’t been documented, it hasn’t been done. have (specifically, those that may fall within a hierarchical condition
• Just because it’s documented, doesn’t mean it’s supported. category [HCC]) at least once per calendar year to support an
Codes without support are non-compliant. accurate RAF score for the patient.
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Section Three: 2022 Clinical Documentation Integrity and Risk Adjustment 3-2AdventHealth Advantage Plans Medicare Advantage
Medicare Advantage (MA) is one of the available plans under
AdventHealth Advantage Plans. As an FHHS provider, you accept
this plan unless it was specifically omitted from your FHHS
contract. Occasionally, CMS conducts audits of participating
physicians; therefore, it is important that you tell your patients that
you accept AdventHealth Advantage Plans MA products.
Clinical Documentation Integrity (CDI) Program
AdventHealth Advantage Plans providers who see more than one
Medicare Advantage patient have an opportunity to participate in
the Clinical Documentation Integrity (CDI) program. This program
compensates physicians for providing and documenting appropriate
treatment and coordinating care for Medicare Advantage patients.
Providers can earn over $200 per member per year by participating
in the AdventHealth Advantage Plans CDI Program.
Participation in the program is simple. There are four components:
The Comprehensive Health Assessment (CHA) referral, completion
of the Documentation Recapture Opportunity CDI form, quality
(HEDIS) care gaps and pharmacy (STARS) care gaps. Providers can Plans. Payments will be mailed quarterly to the group under your
start earning compensation at any time by referring your patients Employer Tax ID Number. For providers new to the program, some
for a CHA using the dedicated referral line with the AdventHealth initial training is required.
Advantage Plans CHA vendor. AdventHealth Advantage Plans CDI
If you have questions about the CDI program or
program providers will receive forms for each MA patient where
would like to participate, please contact the Provider
there are open care gaps. These forms will be available via paper
Experience Center by calling 877-850-5438 or via
or access through a web-based tool. To receive compensation,
email at ahs.experiencecenter@adventhealth.com.
after patients are seen in the office and appropriate information is
gathered at the point of care, CDI forms will need to be completed * The total compensation opportunity will vary based on the number of measures
in the web-based tool or returned to AdventHealth Advantage for which a patient is eligible.
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3-3 Section Three: 2022 Clinical Documentation Integrity and Risk AdjustmentDiabetes Mellitus
Consider the following common, risk-adjusted • Provider must specify hyper/hypoglycemia.
ICD-10 diagnoses for Medicare patients. • Z79.4 – code to indicate patient uses insulin. Note: if patient has
• Diabetes Mellitus Type II, unspecified (E11.9_)DMII with renal type 1 diabetes, do not use Z79.4 as insulin use is presumed.
complications (E11.2_) • All diabetic complications are weighted with a roughly three
• DMII with ophthalmic complications (E11.3_)DMII with neurologic times greater RAF score than diabetes without complications. To
complications (E11.4_) code conditions as being diabetic complications/manifestations,
the medical record documentation must present a specific
• DMII with periph. circulatory complications (E11.5_)
causal relationship between the two conditions. Examples of
• DMII with other specified complications (E11.6_) such a causal relationship include: with, in relation to, related
with, diabetic, due to, etc.
Example | Diabetes with Hyperglycemia • There are exceptions to the causal relationship rule. Please refer
Assessment & Plan to the ICD-10 code book for guidelines.
Diabetes is not controlled, and the patient is unable to keep blood
Note this list is not all-inclusive. Please refer to the ICD-10-CM
sugar (BS) low enough. Will adjust insulin and see the patient for
codebook for the complete list. Diabetes, diabetic (mellitus)
follow up in two weeks. Asked patient to keep a log of daily BS
(sugar) – E11 with:
during this time.
• Amyotrophy – E11.44 • Glomerulonephrosis,
ICD-10 CM Codes Arthropathy – NEC E11.618 intracapillary – E11.21
• E11.65 – Type 2 diabetes mellitus with hyperglycemia
• Autonomic (poly) neuropathy • Gomerulosclerosis,
• Z79.4 – Long-term (current) use of insulin – E11.43Cataract – E11.36 intercapillary – E11.21
• Charcot’s joints – E11.610 • Hyperglycemia – E11.65
• Chronic kidney disease (Coma – E11.641)
Documentation & Coding Tips
(CKD) – E11.22Circulatory • Hyperosmolarity – E11.00
• E11 (type 2 diabetes mellitus) – if the type of diabetes is not complication – NEC E11.59 (Coma – E11.01)
documented or documentation states patient uses insulin. Dermatitis – E11.620 • Kidney complications – NEC
• Hyperglycemia – poorly controlled diabetes; patient with • Foot ulcer – E11.621Gangrene E11.29
elevated BS or elevated A1c should be coded type2 diabetes – E11.52 • Kimmelsteil-Wilson disease –
with hyperglycemia, E11.65. • Gastroparesis – E11.43 E11.21
Back to Contents
Section Three: 2022 Clinical Documentation Integrity and Risk Adjustment 3-4Cancer
Consider the following common, risk-adjusted Example | Secondary Malignant Neoplasm of Bone
ICD-10 diagnoses for Medicare patients. Assessment & Plan
• Secondary malignant neoplasm of brain (C79.31) Metastatic bone cancer originating from breast cancer. Breast
• Acute myeloblastic leukemia, not having cancer was eradicated four years ago. The patient is doing well
achieved remission (C92.00) with the current pain management regimen. A follow up with the
patient will be scheduled for after the next round of radiation.
• Acute promyelocytic leukemia, not having
achieved remission (C92.40)
• Acute myelomonocytic leukemia, not having ICD-10 CM Codes
achieved remission (C92.50) • C79.51 – Secondary malignant neoplasm of bone
• Secondary malignant neoplasm of bone (C79.51) • Z85.3 – Personal history of malignant neoplasm of breast
• Secondary malignant neoplasm of bone marrow (C79.52)
• Malignant neoplasm of unspecified part
Documentation & Coding Tips
of bronchus or lung (C34.9)*
• Multiple myeloma not having achieved remission (C90.00) • When a secondary cancer is coded and the primary cancer is
still present, the primary cancer should be coded as well; if the
• Other specified types of non-Hodgkin lymphoma,
primary cancer has been completely eradicated, it should not be
lymph nodes of multiple sites (C85.88)
coded as active. A history code should be considered.
• Other specified types of non-Hodgkin
• Cancer (except those coded to categories [C80-C95] for which
lymphoma, unspecified site (C85.80)
treatment is no longer received) would be coded with a Z code
• Malignant neoplasm of colon, unspecified (C18.9) for history of malignant neoplasm. Likewise, any cancer stated to
• Malignant neoplasm of bladder, unspecified (C67.9) have been completely eradicated would be coded to a Z code.
• Malignant neoplasm of rectum (C20)
• Malignant neoplasm of unspecified site
of female breast (C50.9)*
• Malignant neoplasm of prostate (C61)
• Malignant neoplasm of thyroid gland (C73)
* Documentation should reflect site or body part as well as laterality.
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3-5 Section Three: 2022 Clinical Documentation Integrity and Risk AdjustmentPulmonary
Consider the following common, risk-adjusted Documentation & Coding Tips
ICD-10 diagnoses for Medicare patients. Four codes are required for the below scenarios.
• COPD, unspecified (J44.9)
1. COPD with acute exacerbation
• COPD with acute lower respiratory infection (J44.0)
• COPD with acute exacerbation (J44.1) 2. COPD with acute bronchitis
• Emphysema, unspecified (J43.9) 3. Acute bronchitis
• Unspecified chronic bronchitis (J42) • J20.9 and J44.0 – are necessary to correctly code acute
bronchitis with COPD
Example | COPD With Acute Exacerbation
• J44.0 – note: use additional code to identify the infection
Assessment & Plan • J20.9 – added to identify the infection, acute
Patient has acute exacerbation of COPD with acute bronchitis • J44.1 – additional code to identify the COPD exacerbation
due to patient smoking. Advised on smoking cessation. Increased
prednisone, prescribed antibiotic and increased nebulizer 4. A cause-and-effect relationship must be documented to
treatments to every two to four hours. Follow up in five days or assign code F17.218. If a cause-and-effect relationship is
sooner if symptoms worsen. not documented, use code F17.210 (nicotine dependence,
unspecified, uncomplicated).
ICD-10 CM Codes If the causative organism is known and documented, use code
specified organism code under J20, acute bronchitis.
• J44.0 – COPD with acute lower respiratory infection J44.1 –
COPD with (acute) exacerbation
• J20.9 – Acute bronchitis, unspecified
• F17.218 – Nicotine dependence, cigarettes, with other
nicotine induced disorders
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Section Three: 2022 Clinical Documentation Integrity and Risk Adjustment 3-6Congestive Heart Failure
Consider the following common, risk-adjusted Documentation & Coding Tips
ICD-10 diagnoses for Medicare patients. First code whether heart failure is due to an underlying
• Heart failure, unspecified (I50.9) condition such as:
• Other restrictive cardiomyopathy (I42.5) • Hypertension
• Primary pulmonary hypertension (I27.0) • Hypertension with chronic kidney disease
• Other secondary pulmonary hypertension (I27.2) • Rheumatic heart failure
• Other specified pulmonary heart diseases (I27.89) • Heart failure following surgery
• Complication abortion or ectopic or molar pregnancy
Example | Congestive Heart Failure
• Obstetric surgery and procedures
Assessment & Plan
The primary care physician can code for CHF if care is coordinated Link heart failure to its underlying condition – Link heart failure to
with the cardiologist. The assessment and plan can be related to the underlying hypertensive chronic kidney disease with stage 1
care coordination. through 4 CKD or unspecified CKD. The medical record should
notate a causal relationship between these conditions.
ICD-10 CM Codes The type of heart failure should be documented as:
• I50 – Heart failure • Diastolic
• I50.1 – Left ventricular failure • Systolic
• I50.2 – Systolic (congestive) heart failure I50.3 – Diastolic • Combined/mixed diastolic/systolic
(congestive) heart failure
• Left ventricular
• I50.4 – Combined systolic and diastolic heart failure I50.9
– Heart failure, unspecified
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3-7 Section Three: 2022 Clinical Documentation Integrity and Risk AdjustmentRheumatoid Arthritis and
Infectious Connective Tissue Disease
Consider the following common, risk-adjusted
ICD-10 diagnoses for Medicare patients. ICD-10 CM Codes
• M05._ Code Category – Rheumatoid arthritis with
• Rheumatoid arthritis, unspecified (M06.9) rheumatoid factor M06._ Code Category – Other
• Inflammatory polyarthropathy (M06.4) rheumatoid arthritis
• Sacroiliitis, not elsewhere classified (M46.1) • M07 – Enteropathic Arthropathies
• Sicca syndrome, unspecified (M35.00)
• Sicca syndrome with keratoconjunctivitis (M35.01) Documentation & Coding Tips
• Polymyalgia rheumatica (M35.3)
Over 400 ICD-10 Codes that allow for greater detail including:
• Progressive systemic sclerosis (M34.0)
• CR(E)ST syndrome (M34.1) • Type: RA with rheumatoid factor, other rheumatoid arthritis,
• Systemic sclerosis, unspecified (M34.9) enteropathic, arthropathies.
• Other psoriatic arthropathy (L40.59) • Subtype: Felty’s syndrome, rheumatoid lung disease, vasculitis,
heart disease, myopathy, polyneuropathy, other organs, etc.
• Systemic lupus erythematosus, organ or system involvement
unspecified (M32.10) • Anatomic location: Shoulder, elbow, wrist, hand, hip, etc.
• Polymyositis, organ involvement unspecified (M33.20) • Laterality: Right, left, unspecified.
Example | Rheumatoid Arthritis
Assessment & Plan
Patient presents with pain, swelling and stiffness of joints in the
hand which is found to be a flare of their rheumatoid arthritis.
Reviewed patient’s Disease-Modifying Antirheumatic Drug
(DMARDs) medication routine and sending patient for Disease
Activity Score 28 (DAS28).
Back to Contents
Section Three: 2022 Clinical Documentation Integrity and Risk Adjustment 3-8Morbid Obesity
Consider the following common, risk-adjusted Documentation & Coding Tips
ICD-10 diagnoses for Medicare patients. • Any clinician can document BMI in the patient’s medical record.
• Morbid (severe) obesity due to excess calories (BMI greater • Physicians, and other health care professionals, must document
than or equal to symbol 40.2) (E66.01). Please specify in the condition and its medical significance (i.e., overweight/
documentation that the patient has obesity due to excess morbid obesity).
calories.
• Two codes should be reported for conditions coded to E66. _,
• BMI Ranges (Z68.41 - Z68.45) overweight and obesity along with code for documented BMI.
• Morbid (severe) obesity with alveolar hypoventilation (E66.2)
Example | Body Mass Index (BMI)
Assessment & Plan
Morbid obesity recorded BMI ≥ 40.2, and the patient admits to
overeating. Discussed dietary changes and reduced caloric intake
at length. Will schedule consult appointment with our registered
dietitian. Type 2 diabetes without complications and A1c is within
normal limits. Patient to continue current medication.
ICD-10 CM Codes
• E66.01 – Morbid (severe) obesity due to excess calories
Z68.41 – BMI 40.0 - 44.9, adult
• E11.9 – Type 2 diabetes mellitus without complications
Z71.3 – Dietary counseling and surveillance
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3-9 Section Three: 2022 Clinical Documentation Integrity and Risk AdjustmentMental Health
F32.9 Major depressive disorder, F33.4 Major depressive disorder,
Consider the following common, risk-adjusted single episode, unspecified recurrent, in remission
ICD-10 diagnoses for Medicare patients. F33.0 Major depressive disorder,
recurrent, mild
F33.40 Major depressive disorder,
recurrent, in remission, unspecified
• Bipolar disorder, unspecified (F31.9) F33.1 Major depressive disorder,
F33.41 Major depressive disorder,
recurrent, in partial remission
recurrent, moderate
• Major depressive disorder, single episode, unspecified F33.42 Major depressive disorder,
F33.2 Major depressive disorder,
(PHQ-9: 10 - 27) (F32.9) recurrent severe without
recurrent, in full remission
psychotic features F33.8 Other recurrent depressive disorders
• Major depressive disorder, recurrent, unspecified
F33.3 Major depressive disorder, F33.9 Major depressive disorder,
(PHQ-9: 10 - 27) (F33.9) recurrent, severe with recurrent, unspecified
psychotic symptoms
Example | Major Depression
Documentation & Coding Tips
Assessment & Plan
• Major depression can be coded when a patient scores between
A comprehensive medication reconciliation, including
a 10 and 27 on the PHQ-9 Tool.
documentation of each medication: indication, length of treatment,
benefits, side effects and plan for continued treatment is sufficient • Per DSM-5 guidelines, to document major depression, the
documentation of TAMPER (treat, assessment, monitor/medicate, medical record must show that the patient has suffered loss of
plan, evaluate, referral) to support coding it on a claim. function for a minimum of two weeks. At least five symptoms
need to be present during the same two-week period to
diagnose major depression. List all signs of depressed mood and
ICD-10 CM Codes notate how long these symptoms have been present, document
• F32._ – Major depressive disorder, single episode severity and episode.
• F33._ – Major depressive disorder, recurrent • Depression and anxiety do not risk adjust, but major depression
does, even a single episode.
• Documentation for depression must include:
Major Depression ICD-10 Codes: – Episode (single or recurrent)
F32.0 Major depressive disorder, F32.3 Major depressive disorder,
single episode, mild single episode, severe with – Severity (mild, moderate, severe)
psychotic features
F32.1 Major depressive disorder, – Presence of any associated symptoms (with or without
single episode, moderate F32.4 Major depressive disorder,
single episode, in partial psychotic features)
F32.2 Major depressive disorder, remission
single episode, severe without – Clinical status of current episode (in partial or full remission)
psychotic features F32.5 Major depressive disorder,
single episode, in full remission
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