Success Codes— For Taking Care of Your Disadvantaged Patients

This week finally solves the mystery as to why I developed “Success Codes.”



It’s joy.



I experienced so much joy in caring for patients from disadvantaged populations.




Intellectual challenge, resource management, and personal gratitude were only a few of the benefits.




When it came time to build rapport, I usually found they had led pretty damned interesting lives.




Anyone can successfully manage CHF in an affluent, socially stable patient. Keeping a disadvantaged person out of the hospital requires significant leveling.




However, with their much higher rates of chronic disease, taking care of such patients under a fee-for-service system is a certain financial loser—and will be much more so under data-based fee-for-service hybrids such as MACRA.




Their disease burdens, their socio-economic disruption and their lack of resources require high-intensity management (most of which will be performed out of the office and hence uncompensated) with little likelihood of meeting the metrics upon which your payments are dependent.



Even if you have a “care team.” you’re still the one who is going to end up “coordinating” the care—all on uncompensated time of course.




You can be certain that the cherry-picking of patients required to be successful under MACRA will leave these disadvantaged folks with less access to care.




It doesn’t have to be that way.




How was I able to take care of so many disadvantaged patients in private practice and still be (extremely) financially successful?




Medicare Advantage.




I was able to generate revenue based on the intensity of their disease burden—revenue that not only made caring for them financially sustainable but also allowed me to innovated systems to promote their wellbeing.




As a clinician, the fulfillment was wonderful.




And that’s the reason for the “Success Codes” series.








The joy of practicing medicine—something that’s in short supply these days.




In the coming years, these patients are going to be in desperately need of your help. And you in desperate need of the rewards.




Understanding the “Success Codes” is the key to meeting both needs.




Use them—and help each other thrive.




Time for the final edition of my wildly popular “Success Codes” series. If you haven’t already, you may want to review my world-class, yet humbly simple (yes, really) explanation of RAF scoring—it’ll help you understand some of the shorthand terminologies below. It’s the only one on the web written by a PCP who’s been in the trenches blocking and tackling since Medicare Advantage first arrived on the scene 20+ years ago—and done so with incredible results.



That’s probably why it’s so good—and so good for you!



Now let’s get started.




Over the past months, I’ve shown you how to use about 100 “Success Codes.”




What are “Success Codes?”




These the codes associated with increased capitation under Medicare Advantage that you must know to be successful. In short, they’re common, they’re lucrative and pretty much won’t be coded correctly (or at all) unless you do it yourself.




Now, 100 is a lot. But it’s much better than the more than 10,000 risk-based codes that are out there—most of which you’ll never see. And with common use, I guarantee that you’ll memorize them quickly,  Coming soon will be some additional tools to help.




When taking care of disadvantaged populations, however, there are a few codes that really stand out.


  • Simple Chronic Bronchitis
  • Substance Dependence, Abuse, or Intoxication
  • Hepatitis C
  • Sickle Cell Trait
  • Obesity


Every time you walk into an exam room of a disadvantaged patient with Medicare Advantage, you should get in the habit of mentally checking off this list. Chances are you won’t see them very often and this could be your only chance this calendar year of catching these diagnoses.






  • Simple chronic bronchitis (smoker’s cough) J41.0 RAF 0.3
    • Screen all your smokers by asking them about productive coughs!
    • All you have to document “productive cough, most mornings for past 2 continuous months” and you’re good.


  • Substance Dependence
    • Similar codes along similar pattern with the same RAF adjustment for amphetamines, cocaine, hallucinogens and inhalants.
    • For prescription medications such as opioids and amphetamines, the clinician submitting the diagnoses CANNOT be the clinician who’s prescribing them—unless the patient is not taking them as prescribed. If you can document that the patient is not taking them as prescribed, then code away!


  • Alcohol
    • uncomplicated F10.20
    • in remission F10.21
    • with intoxication F10.220
    • with withdrawal F10.23
  • Opioid
    • uncomplicated F11.20
    • in remission F11.21
    • with intoxication F11.220
    • with withdrawal F11.23
  • Cannabis
    • uncomplicated F12.10
    • in remission F12.21
    • with intoxication F12.220
    • no withdrawal code for Cannabis


  • Hepatitis C (B18.2  RAF 0.2)
    • Only code with a corresponding blood test.
    • These patients often drop out of treatment—especially in disadvantaged communities.
    • If you can’t convince them to get treated, at least capture the code routinely so you have the resources available to address their complications.


  • Sickle Cell Trait ICD-10 D57.3 RAF 1.3-4.0!!!!
    • This is one case where systematic screening might be indicated
    • If present address it every year
    • Don’t neglect the biracial population
    • Often buried in the medical record
      • Well worth your time to review


  • Diabetes type 2 with complications ICD-10 multiple. RAF 0.3
    • Diabetes with complication codes have more the twice the RAF as diabetes without complication


  • Obesity
    • Z 68.41 BMI 40-44.9
    • z68.42 BMI 45-49.9
    • Z68.43 BMI 50-59.9
    • Z68.44 BMI 60-609.9
    • Z68.45 BMI >70


  • If BMI>40
    • Documentation of BMI is all that’s needed
  • If BMI 35-39.9     Z 68.35
    • Must Document BMI AND associated 2 co-morbidities
      • Explicitly tie them to Obesity
      • Must document and submit codes for associated co-morbidities
        • Can include
          • HTN
          • OSA
          • Dyslipidemia
          • CAD
          • COPD
        • Example documentation:
          • “Assessment: BMI 36.7 complicating benign HTN and OSA”
        • If BMI less than 35
          • Look for co-morbid protein-calorie malnutrition—very common



Look for more “Success Codes” tools coming soon—all to help you take the best care of your patients without spending your life at the keyboard—or in an audit.








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