Success Codes-Pulmonary Medicine Edition


Time for another 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.


There are many, many pulmonary codes associated with increased capitation for your Medicare Advantage patients.


Fortunately, you only need to know four.


But you have to know them well.


Here they are:

  • 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.
  • COPD J44.9 RAF 0.3
    • It’s a functional diagnosis—never diagnose from chest X-ray alone.
    • Want to make yourself “clawback proof?
      • Document FeV1/FVC <70% while patient is in a “stable state”.
  • Emphysema J43.
    • Radiographic diagnosis.
    • Review all chest x-ray reports for this finding.
    • Explicitly address during a face-to-face visit or as an addendum to the visit where the x-ray was ordered
  • Bronchiectasis J43.xx RAF 0.3
    • Surprisingly common incidental finding on CT chest.
    • Explicitly address during a face-to-face visit or as an addendum to the visit where the x-ray was ordered.


Important time saver!!!!

  • All four map to the same HCC group
    • Any one of them will give you the 30% bump in your capitation.
    • They’re not additive—only one will count toward your capitation.
      • Don’t waste your time hunting for all of them—capture one code and concentrate on treating the patient.


Keep these four codes in mind for all your patient’s pulmonary problems and don’t go hunting for all the rest.


That’s the success tactic with there greatest return on your time!







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