3m health information systems, inc. 3m provides these slides to better understand 3m's software...

3M Health Information Systems, Inc.

3M provides these slides to better understand 3M's software and/or services. These slides contain 3M confidential information and are for customer’s internal review only.

InnovatingHealth

Languageof

theInnovating

HealthLanguage

of

the

Advocate CondellSurgery Trauma Neurosurgery Orthopedics v 2

Thomas C Kravis MD

© 3M 2015 - 3M Confidential - For Customer's Internal Review Only.explaiFurther use or disclosure requiresexplain apr and inpatint prior approval from 3M.

2

3M Health Information Systems

© 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M.

3



Clinical Documentation Improvement Goals and Objectives

Clear concise accurate documentation

Across the continuum of care: inpatient and outpatient

Capture the severity of illness (SOI) and the Risk of Mortality (ROM)

Support hospital and physician reimbursement

Improve quality report cards and clinical outcomes

Reduce denials and queries

Prepare for ICD-10

4



Value of Accurate and Complete Documentation MD and Hospital Quality Reports

Care Coordination

Team Medical Necessity

Value Base

Purchasing

PSIs

Core Measures

ComplianceFraud Abuse

RAC

2 MIDNIGHTRULE

E&M Pro feesDenial related

claims

ICD-9-CMICD-10

POAHACs

Preventable ReadmissionComplications

5



Impact of DocumentationMS-DRG 330 2.4981

Bowel Procedurewith CC

PDx: Colon cancer

SDx:

Dehydration

Post-op ileus(codes to 997.4 + 560.1)

“Ulcer/Wound” noted by RN

PPx: Left hemicolectomy

MS-DRG 329 5.1396

Bowel Procedurewith MCC

PDx: Colon cancer

SDx:

Acute Renal Failure – ATN

Expected ileus(560.1)

Pressure Ulcer, site unspecific


APR DRG: 221SOI Level: 2APR Weight: 1.7681ROM Level: 1Peer Group 0.0%


Highest MS-DRG paymentHighest MS-

DRG payment

MS-DRG 329 5.1396

Bowel Procedurewith MCC

PDx: Colon cancer

SDx:

Acute Renal Failure – ATN

Expected ileus(560.1)

Pressure Ulcer Stage IV on Sacrum



6



© 3M 2011. All Rights Reserved.Copy Right 3M 2013 All Rights Reserved

7



California Statewide Health Planning and Development

Copy Right 3M 2015 All Rights Reserved

8



General guidelines for Documentation Document all diagnoses and procedures Licensed hands-on treating practitioner in the body of the EMR

and discharge summary All medications, treatments and diagnostic studies and the

corresponding medical diagnoses for each and the clinical significance

Conditions cannot be coded from lab, x-ray, other diagnostic test results or symbols (↑, ↓) without practitioner documentation.

‘Cut and pasted’ documentation must accurately reflect the clinical condition of the patient at the time of the documentation

9



When should I document a condition?

To assign an appropriate code and capture the severity of illness and risk of mortality in the inpatient setting a condition must meet at least one of the following criteria:

Clinical evaluation Therapeutic treatment Diagnostic procedures Extended length of hospital stay Increased nursing care and/or monitoring

10



Documentation & Coding Issues at Advocate

Physician Document in

CLINICAL terms

Documentation for coding, profiling &

compliance requires specificity in

DIAGNOSIS terms

This gap will be increased with ICD-10This gap will be increased with ICD-10

Two separate languages

Documentation Improvement can help bridge the gap

Documentation Improvement can help bridge the gap

11



Liver failure, renal failure, resp failure

Respiratory failure : acute, acute on chronic

Hypotension, shock-cardiogenic/septic

Dehydration, hypovolemia

Simple UTI

Hypokalemia

Pneumonia Left Lower Lobe

Acute/Chronic Blood Loss Anemia

Coma, Encephalopathy

Protein Calorie Malnutrition

Able to CodeUnable to Code

Multi-system organ failure

Severe respiratory distress

Hemodynamically unstable

Will rehydrate

“Urosepsis”

↓ K = 2.0, will give KCL

Chest X infiltrate

↓ HgB 5.2, Transfuse

Altered Mental Status

Emaciated,Total Protein/Albumin Low

Clinical Diagnostic

12



Unknown Dx and if evaluated treated : “Probable”

“Possible”

“Suspected”

Coded as if condition exists until condition has been excluded

The Key Elements : Chief Complaint History Examination Medical Decision Making

Chief Complaint: Symptom, problem, condition,

diagnosis

Physician Inpatient E&M DRG Assurance

Two Midnight RuleSigns Symptoms Expectation of 2 Midnight

Risk of Adverse Event Exception INPATIENT ONLY

13



ICD-10 Consists of 2 Components

12ICD-10-PCS Procedure Classification

System for Inpatient Hospital Use

ICD-10-CM Diagnosis Classification System

14



ICD-9 vs. ICD-10 Structural Changes

ICD-9 (Diagnoses)

3-7 charactersaa ## a/#a/# a/#a/# a/#a/#

Category etiology, site,manifestation

extension

a/#a/# a/#a/#

ICD-10 (Diagnoses)

## ## ## ## ##

CategoryCategory etiology, site,manifestationetiology, site,manifestation

3-5 characters3-5 characters

Encounter

15



ICD-10-CM requirements

Laterality Neoplasm e.g malignant neoplasm of upper lobe of right lungInjuries e.g laceration of left subclavian veinBody Part - e.g. DVT of left iliac vein

Acuity:AcuteChronicAcute on Chronic

Etiology or Cause Encounter ( treatment status) Specificity:

Initial- patient receiving active treatment for a condition e.g. injuries,Subsequent- patient has received active treatment and is receiving routine care

during the recovery period Sequela-recovered

Note: “visit” in CPT = patient type (new or established).

16



ICD-10 Diagnosis Code example Fracture Femur

SS 77 22 00 44 22 KK

Fracture of the femur

Fracture of the femur

Head &Neck

Head &Neck

Base ofNeck

Base ofNeck

Displacedfracture leftDisplaced

fracture leftSubsequent encounter for

closed fx with nonunionSubsequent encounter for

closed fx with nonunion

17



Physician role Clinical Documentation

Focus remains on patient care Real time 3M 360 :Natural Language Processing Respond to query and document in the EMR Do not need to learn coding Minimal impact on day-to-day routine Clinical Documentation Specialists – a resource to

the physician

18



Concurrent Query Process

Doc. Spec. Identifies

Query Opportunity

Query Posed to Physician

Physician Agrees?

Yes

Write Diagnosis inProgress Note

No No Response

Write “NO” on the Query Form

360

19



Impact of Responding to Query

Impact w/ Response to Query RW = 2.9797 GLOS = 8.98 SOI = 3 Major ROM = 2 Moderate

Impact w/o Response to Query RW = 2.9797 GLOS = 8.98 SOI = 2 Moderate ROM = 2 Moderate

Query: “The magnesium level is 1.6 and the patient is receiving magnesium sulfate” “Please provide a corresponding diagnosis ” Physician documents: “hypomagnesemia”

Cardiac Procedure

20



Probable, Possible, Suspected Diagnosis Uncertain Diagnosis

Inpatient application only: These conditions may be coded as though they exist Applies to hospital setting only If condition is ruled out, it may not be coded

Outpatient application:Must code signs/symptoms, not the suspected conditionSupports appropriate E&M professional component

21



Clinical example

66 year old male admitted with nausea, abdominal and chest pain and “AMS” altered mental status; history of elevated triglycerides

and daily alcohol use.

22



Possible probable suspected alternatives

Cardiac CathMS-DRGs 286/287

RW = 1.9634

23



Abdominal Pain ICD-10

What Stays the Same?― Specifies abdominal pain,

tenderness and rigidtiy by anatomic locations :• All four quadrants• Epigastric• Periumbilical• Generalized

What’s New?― rebound tenderness

24



Hemorrhoids Document the degree/grade/stage of hemorrhoids:

• First degreeo Hemorrhoids (bleeding) without prolapse outside of anal canal

• Second degreeo Hemorrhoids (bleeding) that prolapse with straining, but retract spontaneously

• Third degreeo Hemorrhoids (bleeding) that prolapse with straining and require manual replacement

back inside anal canal• Fourth degreeo Hemorrhoids (bleeding) with prolapsed tissue that cannot be manually replaced

Document presence of any associated complications:• Prolapsed• Strangulated• Thrombosed• Ulcerated

25



Documentation of Pancreatitis

Lab: Elevated bilirubin lipase and amylase

Treatment: IVF, NPO, pain control, electrolyte correction.

Final Diagnosis: Acute pancreatitis due to alcohol dependence

Current Documentation Improved Documentation

Final Diagnosis: Pancreatitis, alcohol abuse

26



Barrett’s Esophagus & Barrett’s Ulcer Barrett’s esophagus,

disease, syndrome― Document presence of

dysplasia• High grade dysplasia• Low grade dysplasia

Barrett’s ulcer― Document presence of

bleeding

27



Respiratory Failure Acute/chronic/acute on chronic

Cause or etiology (pneumonia,COPD,drug,trauma;

If following surgery was it POA ( PSI) or due to underlying pulmonary condition, failure to wean

Signs :RR> 26, accessory muscles use, altered mental status

Arterial blood gas and pH:

pH of <7.30 or >7.50

pCO2 of >50

pO2 of <60 (impacted by hemoglobin level)

Type I Hypoxemic : pO2 60 mm Hg normal or low pCO2

Type II Hypercapnic: pH < 7.30 and increased bicarbonate;pCO2 >50 Chronic : As above and low flow 02 at home; polycythemia ;cor pulmonale; heart

failure

28



Postoperative Respiratory Failure

Respiratory failure in a postsurgical patient, clarify if: The surgery caused the failure The patient failed weaning off vent The patient has underlying respiratory problems that could have been the

cause of the failure Quality Concepts

Respiratory failure not present on admission and occurs after an operative episode is considered a patient safety indicator (PSI 11)

Important to get confirmation of the following: POA status (present on admission vs. occurs after admission) Confirmation of diagnosis if condition documented without corresponding clinical

picture Cause of the respiratory failure following surgery (related or unrelated to surgery)

29



29

Altered Mental Status Alternatives

ComaMS-DRGs 080/081

RW = 1.2252

Encephalopathy and Metabolic

EncephalopathyMS-DRGs 070/071/072

RW = 1.6593

SeizuresMS-DRGs 100/101

RW = 1.5185

Hepatic Encephalopathy

MS-DRGs 441/442/443RW = 1.8534

Hypertensive Encephalopathy

MS-DRGs 077/078/079RW = 1.6290

TIAMS-DRG 069RW = 0.6948

CVAMS-DRGs

064/065/066RW = 1.7417

Acute Confusional State

MS-DRGs 880 RW = 0.6388

Diabetic Ketoacidosis

MS-DRGs 637/638/639RW = 1.3888

Drug-Induced and Alcoholic Delirium

and DementiaMS-DRGs 896/897

RW = 1.5146

UTIMS-DRGs 689/690

RW = 1.1300

Altered Mental Status

MS-DRGs 947/948RW = 1.1324

Alzheimer’s Disease

Parkinson’s Disease

MS-DRGs 056/557RW = 1.7368

Toxic and Anoxic Encephalopathy

MS-DRGs 091/092/093RW = 1.5851

Dementia and Vascular Dementia

MS-DRG 884RW = 1.0060

30



Cerebral Infarction Specify etiology or cause of the infarct:

― Thrombosis― Embolism― Occlusion or stenosis

Document specific artery involved and laterality:― Precerebral arteries which include:

• Carotid artery• Basilar artery• Vertebral artery

― Cerebral arteries which include:• Anterior cerebral artery• Cerebellar artery• Middle cerebral artery• Posterior cerebral artery

31



Document etiology of cerebral infarction:― Embolism― Thrombosis― Occlusion― Stenosis

Specify artery involved:― Anterior cerebral artery― Basilar artery― Carotid artery― Cerebellar artery― Middle cerebral artery― Posterior cerebral artery― Vertebral artery

Document the link between the occluded vessel and the CVA, if appropriate

Requires laterality distinction (left vs. right)

Intraoperative or postprocedural cerebral infarction occurring during cardiac or other type of surgery

Cerebral Infarction Following Surgery

32



Documentation of Encounter Specificity Initial – patient is receiving active treatment for the condition such as:

Surgical treatment Emergency department encounter, and Evaluation and treatment by a new physician

Subsequent – patient has received active treatment of the condition and is currently receiving routine care for the condition during the healing or recovery phase. Cast change or removal Removal of external or internal fixation device Adjustment of medication Other aftercare and follow-up visits following treatment of the injury or condition

Sequela – used for complications or conditions – late effects that arise as a direct result of a condition.

Documentation Requirements for Injuries

33



33

Injury of Spleen

Specify type of injury― Contusion

• Minor – contusion of spleen less than 2 cm

• Major – contusion of spleen greater than 2 cm

― Laceration• Superficial/minor – laceration of spleen less than 1 cm

• Moderate – laceration of spleen 1 to 3 cm

• Major/massive – laceration of spleen greater than 3 cm; multiple lacerations of spleen

34



34

Injury of Liver

Specify type of injury― Contusion

― Laceration• Minor – laceration involving capsule only, or, without significant

involvement of hepatic parenchyma (i.e., less than 1 cm deep)

• Moderate – laceration involving parenchyma but without major disruption of parenchyma (i.e., less than 10 cm long and less than 3 cm deep)

• Major – laceration with significant disruption of hepatic parenchyma (i.e., greater than 10 cm long and 3 cm deep); multiple moderate lacerations, with or without hematoma

35



ICD-10 documentation for pneumothorax will need to include:

Spontaneous – primary, secondary or tension

• Also note underlying cause such as due to underlying lung disease or connective tissue disorder

Postprocedural Traumatic Chronic

If postoperative pneumothorax, please specify the significance or that it is an insignificant finding not impacting the patient.

Pneumothorax

36



36

Injury of Heart

Specify type of injury― Contusion (EKG changes, elevated troponin)

― Laceration

• Mild – laceration of heart without penetration of heart chamber

• Moderate – laceration of heart with penetration of heart chamber

• Major – laceration of heart with penetration of multiple heart chambers

Document presence of hemopericardium

37



Document the underlying cause or etiology if known or suspected

Indicate a linkage to the known or suspected etiology by selecting words such as “due to” or “secondary to”

Cardiac Arrest

38



Many of the following terms may be considered nonspecific: Closed head injury (CHI) Traumatic brain injury (TBI) - diffuse or focal Intracranial injury

Please document the specific type of injury: Cerebral edema Compression of brain/brain herniation – diffuse or focal injury Concussion Contusion of brain Hemorrhage of brain Laceration of brain

Also specify if any loss of consciousness and the time duration

Head Injury

39



Traumatic Brain Hemorrhage Specify site

― Left or right cerebrum

― Cerebellum

― Brainstem

― Epidural

― Subdural

― Subarachnoid

Specify if with LOC and for how long in order to accurately report time.

40



Spinal Cord Injury Document by specific type of injury:

― Anterior cord syndrome― Brown-Séquard syndrome ― Central cord syndrome― Complete lesion― Spinal concussion― Spinal edema

Specific level for each vertebral segment (C1), rather than a range (C1-C4)

Encounter: initial, subsequent or sequela Example: “C4 and C5 spinal cord injury with closed nondisplaced

fracture of C4 & C5 vertebrae, initial encounter"

41



Glasgow Coma Scale (GCS) Based on 3 categories of responsiveness: eye opening, best motor response,

and best verbal response.

Lower the GCS, the deeper the level of unconsciousness.

90% with a score < or equal to 8 are in a coma

50% with score < than or equal to 8 at six hours die

Head injury classification:

Severe – GCS 8 or less

Moderate – GCS 9 to 12

Mild – GCS 13 to 15

Coma

42



Gustilo Open Fracture Classification The following is required for open fractures of the forearm, femur, lower leg or

ankle: Type I: clean wound less than 1 cm with minimal soft tissue injury. Bone fracture is simple with

minimal comminution. Type II: moderately contaminated wound greater than 1 cm with moderate soft tissue injury.

Fracture contains moderate comminution. Type III: extensive skin damage involving muscle or nerves. Type III is further subdivided as

follows: Type III A: extensive laceration of soft tissues with bone fragments from severe

comminution or segmental fractures Type III B: extensive lesion of soft tissues with periosteal stripping and contamination

which usually requires a flap to cover the exposed bone Type III C: exposed fracture with major vascular injury requiring repair for limb salvage

Documentation Requirements for Fractures

43



Salter-Harris Classification The following is required on growth plate fractures

Type I – transverse fracture through the hypertrophic zone of the physis

Type II – fracture through the physis and metaphysis, but does not involve the epiphysis. This is the most common type and may cause minimal shortening, but rarely results in functional limitations

Type III – fracture though the hypertrophic layer of the physis extending to split the epiphysis thereby damaging the reproductive layer of the physis

Type IV – fracture through epiphysis, physis and metaphysis

Type V – fracture involving only the physis which results in a compressive deformity of the growth plate

Documentation Requirements for Fractures

44



Examples of specificity: Nondisplaced intertrochanteric fracture of right femur, initial encounter for open

fracture type II (S72.144B)

Torus fracture of lower end of left humerus, subsequent encounter for fracture with delayed healing (S42.482G)

Displaced oblique fracture of shaft of right tibia, initial encounter for closed fracture (S82.231A)

Documentation Examples for Fractures

45



Traumatic Vertebral Fractures

Document: Level of vertebral column

― For example, L1

Part of vertebra fractured― For example, posterior arch

Displaced versus nondisplaced

Specify: Type of fracture

― For example:

• Type II dens fracture of the 2nd cervical vertebra

• Type III spondylolisthesis of the 2nd cervical vertebra

• Stable or unstable burst fracture of L1

• Traumatic wedge compression fracture

• Zone I-III or Type 1-4 sacral fracture

46



Documentation Requirements for Pathological Fractures Specify:

― Exact location of fracture Site Laterality

― Etiology of fracture Bone disease/lesion Neoplastic disease Osteoporosis (age related or disuse)

― Encounter type Initial encounter for fracture Subsequent encounter for fracture Sequela

― Cause of fracture• A fracture will default to traumatic unless otherwise documented

47



Blood Loss Anemia

Blood loss anemia may be due to trauma, gastrointestinal conditions, obstetrical delivery or surgery or other causes

Document:― Anemia due to acute blood loss― Anemia due to chronic blood loss― Postoperative anemia due to blood loss

Link anemia to the blood loss, when appropriate Anemia following surgery with an expected amount of blood

loss may be documented as acute blood loss anemia.

48



Adult Malnutrition Classification of adult malnutrition is based on the documented

known or suspected etiology:― Starvation-related ― Chronic disease-related ― Acute disease or injury-related

Two or more of the following six characteristics required:*― Insufficient energy intake ― Weight loss ― Loss of muscle mass― Loss of subcutaneous fat― Localized or generalized fluid accumulation that may mask weight loss― Diminished functional status as measured by hand grip strength

*May 2012, the Academy of Nutrition and Dietetics (Academy) and the American Society for Parenteral and Enteral Nutrition (ASPEN)

49



49

Neoplasms Document specific site and laterality:

― Example: Malignant neoplasm of right upper lobe of the lung

― Example: Benign neoplasm of splenic flexure

Document primary and all secondary sites In the case of admission for treatment of secondary malignancy,

specify if the primary site is still present

It’s perfectly acceptable to state a diagnosis or anatomical site as probable or suspected

― Example: Probable osteosarcoma of left femur

50



Sepsis Urosepsis imprecise No IDD-10 a code for urosepsis

Sepsis is classified by the bacteria causing the infection― Streptococcal sepsis (group A, group B,

Streptococcus pneumoniae, other streptococcal) or

― Other sepsis (e.g., MRSA, pseudomonas)

Severe sepsis is associated with organ dysfunction/failure― Document the specific associated organ

dysfunction (not MOD) and

― Document presence of septic shock

51



“Postoperative” Diagnosis: Two Definitions

Clinical Definition

“A condition occurring in the postoperative period”.

Coder Definition

“A diagnosis related to the surgical procedure” Complication-900 code

“Coder cannot make the determination if it is a complication or an expected outcome”

(Coding Clinic 4/27/2011)

.

52



Examples

Complication Postop ileus (997.4 + 560.1) Ileus secondary to surgery

(997.4 + 560.1)

Post op atelectasis (997.39 + 518.0)

Post op anemia (998.11 + 285.1)

Non-Complication Ileus

Prolonged ileus

Expected ileus

Incidental atelectasis

Atelectasis

Acute blood loss anemia

53



ICD-10 Documentation Requirements for Procedures Laterality of site

― Left― Right― Bilateral

Specificity of approach• Open • Percutaneous • Percutaneous endoscopic • Via natural or artificial opening• Via natural or artificial opening- endoscopic • Open with percutaneous endoscopic assistance • External

54



00 22 77 BB 33 44 ZZ

Med/SurgMed/Surg

Heart & Great Vessels

Heart & Great Vessels

DilatationDilatation

Coronary Artery

Coronary Artery

PercutaneousPercutaneous

Transluminal Device, Drug

Eluting

Transluminal Device, Drug

Eluting

NoneNone

SectionSectionBody

SystemBody

SystemRoot

OperationRoot

OperationBodyPart

BodyPart ApproachApproach DeviceDevice QualifierQualifier

Documentation of a procedure: Example stent ICD-10-PCS

55



Reduction: open vs. closed Fixation: internal vs. external vs. no fixation device Reduction = “reposition” in ICD-10-PCS

― Example “Closed reduction with percutaneous internal fixation of right femoral neck fracture”

Fracture Treatment

56



Amputation Status

ICD-9-CM ICD-10-CM

57



Joint Replacement Status

ICD-9-CM ICD-10-CM

58



Specific location of both bypass attachmentsCoronary to coronaryCoronary to thoracic artery or abdominal arteryCoronary to aorta Internal mammary, right or left

Specific graft usedAutologous venous tissue/Autologous arterial tissueSynthetic substituteNonautologous tissue substitute

Number of bypass grafts Approach

OpenPercutaneous endoscopic

Specific vein harvested for graft (greater/lesser saphenous vein: left/right)

Coronary Artery Bypass Graft (CABG)

59



Coronary Angioplasty Specify the number of sites If stent inserted, drug-eluting versus non-drug eluting

60



Objective of the procedure ― Root operation “dilation” is defined as “expanding an orifice

or the lumen of a tubular body part”

Coronary artery and the number of sites receiving treatment (e.g., one, two, three or four more sites)

Approach is open, percutaneous, or percutaneous endoscopic Drug-eluting or non-drug-eluting device

Coronary Angioplasty

61



Heart Biopsy Specific site of heart from which tissue is taken

62



Mechanical Ventilation

Root operation: Performance (Completely taking over a physiological function by extracorporeal means)

Body system: Respiratory Duration:

• Less than 24 consecutive hours• 24-96 consecutive hours• Greater than 96 consecutive hours

Document durationcharacter 1 character 2 character 3 character 4 character 5 character 6 character 7

Section Body System Operation Body System Duration Function Qualifier5 A 1 9 4 5 Z

Extracorporeal Assistance & Performance

Physiological systems Performance Respiratory24-96

Consecutive Hours

Ventilation No Qualifier

Mechanical Ventilation 36 Hours5A1945Z

Mechanical Ventilation 36 Hours5A1945Z

63



Document the type of debridement:― Excisional debridement or “cutting away or excision of tissue”

― Non-excisional debridement or “minor removal of loose fragments”

Specify the depth of debridement: ― Skin

― Subcutaneous tissue

― Fascia

― Muscle

― Bone

Document instruments used during procedure

Wound Debridement

64



Suture of Laceration Example: Suture of 6x2 cm, left supraorbital deep facial laceration.

Closure was performed of subcutaneous tissue with #5-0 Vicryl followed by skin closure with #5-0 nylon.

65



Use of flexible material that stabilizes the vertebrae

Device is used in conjunction with surgery or separately

Surgical approach― Open― Percutaneous― Percutaneous endoscopic

Spinal Stabilization Device Specific device used to accomplish the

stabilization― Interspinous process― Pedicle-based― Facet Replacement

66



Excision of Intervertebral Disc

Example: “removal of some adjacent disc material”

Since only a portion of the disc was removed, a code for excision will be assigned

3m health information systems, inc. 3m provides these slides to better understand 3m's software...

Documents

health information systems

rights reserved slide

customers internal review

confidential information

innovating health language

rom level

soi level

inpatint prior approval