value based purchasing, changes for icd-10 and the future of neurology robert s. gold, md
TRANSCRIPT
Value Based Value Based Purchasing, Changes for Purchasing, Changes for ICD-10 and the Future of ICD-10 and the Future of
NeurologyNeurologyRobert S. Gold, MDRobert S. Gold, MD
Medicine Under the Microscope
• Morbidity • Mortality• Cost per patient• Resource utilization• Length of stay• Complications• Outcomes • ARE YOU SAFE –
avoiding harm, avoidable readmissions?
Value-Based Purchasing Program
• Beginning in FY 2013 and continuing annually, CMS will adjust hospital payments under the VBP program based on how well hospitals perform or improve their performance on a set of quality measures. The initial set of 13 measures includes three mortality measures, two AHRQ composite measures, and eight hospital-acquired condition (HAC) measures. The FY 2012 IPPS final rule (available at http://tinyurl.com/6nccdoc) includes a complete list of the 13 measures.
Where Does This Data Come From?
• Documentation leads to identification of diagnoses and procedures
• Recognition of diagnoses and procedures lead to ICD codes – THE TRUE KEY
• ICD codes lead to APR-DRG assignment• APR-DRG assignment massaged to “Severity
Adjustments• Severity adjusted data leads to morbidity and
mortality rates
• Semantics
• Coding guidelines and conventions
• Use of signs, symbols, arrows
• Accuracy and specificity
• Relationship between accuracy and specificity of code assignment and Complexity of Medical Decision Making
World Health Organization and ICD Codes
Is There a Diagnosis?
82 yo WF altered mental status, shaking chills, fevers, decr UO, T = 103, P = 124, R = 34, BP = 70/40 persistent despite 1 L NS, on Dopamine, pO2 = 78 on non-rebreather, pH = 7.18, pCO2 = 105, WBC = 17,500, left shift, BUN = 78, Cr = 5.4, CXR – Right UL infiltrates, start Cefipime, Clinda, Tx to ICU. May have to intubate – full resusc.
Is There a Diagnosis?
Assessment/Plan82 YO F patient presented to ER with:
1. Sepsis,2. Septic Shock, 3. Acute Hypercapnic Respiratory Failure, 4. Acute Renal Failure due to #2, (don’t forget CKD and stage, if present)5. Aspiration Pneumonia,6. Metabolic Encephalopathy
Will transfer to ICU, continue Dopamine and monitor respiratory status for possible ARDS, renal status with hydration and initiate Cefapime/clindamycin for possible aspiration pneumonia
CC time 1hr 45 minutes John Smith MD
So What’s the Difference?Principal Diagnosis Chills and Fever Sepsis
Secondary Diagnoses Altered mental status Septic Shock
Acute Respiratory Failure
Aspiration PneumoniaAcute Renal Failure (or AKI)Respiratory AcidosisMetabolic Encephalopathy
Medicare MS-DRG 864 Fever w/o CC/MCC 871 Septicemia or severe Sepsis w/o MV 96+ hrs w/ MCC
APR-DRG 722 Fever 720 Septicemia & Disseminated infection
APR-DRG Severity Illness 1 – Minor 4 – Extreme
APR-DRG Risk of Mortality
1 – Minor 4 - Extreme
Medicare MS-DRG Rel Wt 0.8153 1.8437
APR DRG Relative Weight 0.3556 2.9772
National Mortality Rate (APR Adjusted)
0.04% 62.02%
What Is An Index?
What Is An Index?
• Mortality index• Complication index• Length of stay index• Cost per patient index
Observed Rate of Some Thing
Severity Adjusted Expected Rate of That Thing
=1
Profiles Come from Severity Adjusted
Statistics
Observed mortalityExpected mortalityFrom severity adjusted DRGs
=1; as good as the next guy
<1; preferred provider – significantly better
>1; excessive mortality; find another provider -
Univ. VA Univ VA VCU Retreat Martha Augusta Rockingham2009 2013 2013 Doctors Jefferson Health Memorial
Respiratory Diseases
Pneumonia
Hosp plus 6 months
COPD
Hosp plus 6 monthsCritical Care
Respiratory Failure
Hosp plus 6 months
Sepsis
Hosp plus 6 monthsCardiac Diseases
Heart Failure
Hosp plus 6 months
Acute MI
Hosp plus 6 monthsCardiac Surgery
CABG
Hosp plus 6 months
Interv Cardiology
Hosp plus 6 months
Heart Valve
Hosp plus 6 monthsSurgery
ORIF Hip Maj Compl
GI Surgery
Hosp plus 6 months
THA Maj Compl
Cholecystectomy Maj C
Patient SafetyWorse than
Better than
Average Average
Death in procedures where mortality is usually very low ●Pressure sores or bed sores acquired in the hospital ●Death following a serious complication after surgery ●Collapsed lung due to a procedure or surgery in or around the chest ●Catheter-related bloodstream infections acquired at the hospital ●Hip fracture following surgery ●Excessive bruising or bleeding as a consequence of a procedure or surgery ●Electrolyte and fluid imbalance following surgery ●Respiratory failure following surgery ●Deep blood clots in the lungs or legs following surgery ●Bloodstream infection following surgery ●Breakdown of abdominal incision site ●Accidental cut, puncture, perforation or hemorrhage during medical care ●
Foreign objects left in body during a surgery or procedure
Average
0 Events
Surgery Bundling Test Model
• Disclosed May 16, 2008• ACE (Acute Care Episode) project• Combine Part B payments with Part A• “Value Based Centers” started with Texas,
Oklahoma, New Mexico and Colorado• Value based purchasing• 28 cardiac and 9 orthopedic inpatient surgical
services• Gainsharing also permitted here• Based on severity adjusted financial outcomes
Florida Blue and Mayo Clinic Introduce Knee Replacement Bundled Payment Program
Friday, December 14, 2012
JACKSONVILLE, Fla. — Florida Blue and Mayo Clinic jointly announce a new collaboration aimed at providing the utmost in quality care for knee replacement patients in Florida. The two Florida health care leaders are teaming up to create a bundled payment agreement specific to the treatment of knee replacement surgery.
Knee replacement surgery is the most common joint replacement procedure. According to the Agency for Healthcare Research and Quality, health care professionals perform more than 600,000 knee replacements annually in the United States.
Florida Blue and Holy Cross Create Accountable Care
Arrangement Jacksonville and Fort Lauderdale, Fla. – Florida Blue,
Florida’s Blue Cross and Blue Shield Company, and Holy Cross Physician Partners are pleased to announce that effective January 1, 2013, Holy Cross Physician Partners will participate in the Florida Blue Accountable Care Program.
“Florida Blue is excited to expand our relationship with Holy Cross surrounding this exciting new partnership,” said Dr. Jonathan Gavras, chief medical officer and senior vice president for Florida Blue. “In the age of reform, both organizations realize the importance of moving away from the fee-for-service model to one that focuses on quality outcomes that will benefit our members in South Florida.”
Aetna, Baptist Memorial Health Care Announce
Collaborative Care Agreement Thursday, April 25, 2013 4:11 pm EDT
MEMPHIS, Tenn.--(BUSINESS WIRE)--Aetna (NYSE: AET) and Baptist Memorial Health Care today announced a collaborative care agreement to bring a new health care model to Aetna members and introduce Aetna Whole HealthSM, a commercial health care product.
This collaboration will give employers and their workers access to highly coordinated care from physicians and facilities in the Baptist Select Health Alliance. The Baptist Select Health Alliance is a clinically integrated group of physicians focused on tracking outcomes, sharing data and measuring clinical standards to improve quality and efficiency.
In collaborative care models, a group of health care providers delivers more coordinated care for patients to drive better quality and lower overall costs. Through Baptist Memorial Health Care, Aetna members will receive an enhanced level of coordinated care in addition to the member benefits of their current Aetna plan.
Getting Studies Paid ForLaboratory/Radiographic
• Bundled payment modes rely on payment being made for lab or x-ray studies
• Validation of reason for performing any procedure or test depends on Medical Necessity
• Local Medical Review Policies (LMRPs), Local or National Coverage Determinations (LCDs, NCDs)
• Not giving a reason for a test you order (symptom or diagnosis) could result in:– Advance Beneficiary Notification (ABN) saying
patient may have to pay for the test– Somebody bugging you for a reason for the test
Banner Announces Joint Venture with Blue Cross Blue Shield of Arizona
Banner Health and Blue Cross Blue Shield of Arizona have entered into a new joint venture, Blue Cross Blue Shield of Arizona Advantage, which will bring enhanced Medicare services to Arizonans. This collaboration brings together two premier organizations with the common goal of improving the quality of patient care, enhancing wellness and assuring affordability.
"The activities of this joint venture will be a further demonstration of how Banner is rapidly transitioning to population health management models to enhance care and control costs through an emphasis on wellness and care coordination," said Banner Health President and CEO Peter S. Fine.
"This and our other partnerships with Aetna, HealthNet and United Healthcare in Arizona and Kaiser Permanente in Colorado, as well as our selection as a Medicare Pioneer ACO organization, are helping to position Banner for continued success in a challenging and transformational health care environment."
Readmissions Initiative
• Identify hospitals with excess readmissions for certain selected conditions beginning in FY 2013 for discharges on or after October 1, 2012.
– Acute myocardial infarction (i.e., heart attack) – Heart failure – Pneumonia
• Definition of readmission: “occurring when a patient is discharged from the applicable hospital and then is admitted to the same or another acute care hospital within a specified time period from the time of discharge from the index hospitalization.” The specified time period would be 30 days.
21
Clinical Integration• CMS proposes to pay separately for complex chronic
care management services starting in 2015. • "Specifically, we proposed to pay for non-face-to-face
complex chronic care management services for Medicare beneficiaries who have multiple, significant, chronic conditions (two or more)." Rather than paying based on face-to-face visits, CMS would use "G-codes" to pay for revision of care plans, communication with other treating professionals, and medication management over 90-day periods.
• These code payments would require that beneficiaries have an annual wellness visit, that a single practitioner furnish these services, and that the beneficiary consent to this arrangement over a one-year period.
Goals of Implementation – Prove You Are Value Based
• Low incidence of HACs
• Reasonable occurrence of PSIs
• Lower than average Readmissions for Pneumonia, Heart Failure, AMI
• Cooperation with quality initiatives
• Decent responses to a new questionnaire on discharge
Notable Changes
• ICD-9 has maximum of 5 digits with rare alphanumeric codes (V-, E-) limiting breakdown for specificity or addition of categories; ICD-10 has three to seven alphanumeric places
• ICD-9: 14,000 codes; ICD-10: 73,000 codes• ICD-9 has no specificity as to which side of the
body (e.g., percent burn on right or left arm or leg, side of paralysis after stroke)
How Ready Are We?
Anesthesiology 87% Ophthalmology 69%Cardiology 65% Orthopedic 73%Dermatology 86% Otorhinolaryngology (ENT) 74%Emergency Medicine 71% Pathology 75%Endocrinology 63% Pediatrics 53%Family Practice 68% Plastic Surgery 98%Gastroenterology 48% PMR 65%General Surgery 86% Primary Care 63%Hospital Medicine 73% Psychiatry 61%Infectious Disease 78% Psychology 81%Internal Medicine 58% Pulmonary 56%Nephrology 64% Rheumatology 71%Neurology 70% Sleep Medicine 68%Neurosurgery 75% Urgent Care 56%Obstetrics & Gynecology 84% Urology 80%Oncology 63% Overall 63%
AAPC AUDIT RESULTSData compiled from results of 20,000 medical charts audited the First half of 2013
% Documentation Sufficient to Transition To ICD-10CLIENT SERVICES
Example - Integration
ICD-9 – Multiple codes
707.03 – Chronic skin ulcer, lower back
707.21 – Pressure ulcer, stage I
No code for which side
ICD-10 – Single code
L89.131 – Pressure ulcer right lower back, stage I
(stages II, III, IV, unspecified have 6th digits 2, 3, 4, 9)
Example Specificity - Location
M67.4 Ganglion– M67.41 shoulder
• M67.411, right• M67.412, left• M67.419, unspecified
– M67.42 elbow– M67.43 wrist– M67.44 hand– M67.45 hip– M67.46 knee– M67.47 ankle and foot
Sixth digits
1 – right
2 – left
9 - unspecified
Overall Stroke ICD-9430 Subarachnoid hemorrhage431 Intracerebral hemorrhageHemorrhage (of) Basilar, bulbar,
cerebellar, cerebral, etc.432 Other and unspecified
intracranial hemorrhage432.0 Nontraumatic
extra(epi)dural hemorrhage432.1 Subdural hemorrhage432.9 Unspecified intracranial
hemorrhage433 Occlusion and stenosis of
precerebral arteries433.01 Basilar artery with cerebral
infarction433.11 Carotid artery with cerebral
infarction
433.21 Vertebral artery with cerebral infarction
433.31 Multiple and bilateral with cerebral infarction
433.81 Other specified precerebral artery with cerebral infarction
433.91 Unspecified precerebral artery with cerebral infarction
434 Occlusion of cerebral arteries434.01 Cerebral thrombosis with
cerebral infarction434.11 Cerebral embolism with
cerebral infarction434.91 Cerebral artery occlusion,
unspecified with cerebral infarction
Intracerebral Bleed
• Specify if traumatic or nontraumatic
• Specify by location in brain (cortical, subcortical, brainstem, intraventricular)
Intracerebral Bleed I-9
431 Intracerebral hemorrhage (nontraumatic)Hemorrhage (of):
basilarbulbarcerebellarcerebralcerebromeningealcorticalinternal capsuleintrapontinepontinesubcorticalventricular
Intracerebral Bleed I-10
I61.0 Nontraumatic intracerebral hemorrhage in hemisphere, subcorticalDeep intracerebral hemorrhage (nontraumatic)
I61.1 Nontraumatic intracerebral hemorrhage in hemisphere, corticalCerebral lobe hemorrhage (nontraumatic)Superficial intracerebral hemorrhage (nontraumatic)
I61.2 Nontraumatic intracerebral hemorrhage in hemisphere, unspecified
I61.3 Nontraumatic intracerebral hemorrhage in brain stemI61.4 Nontraumatic intracerebral hemorrhage in cerebellumI61.5 Nontraumatic intracerebral hemorrhage, intraventricularI61.6 Nontraumatic intracerebral hemorrhage, multiple localizedI61.8 Other nontraumatic intracerebral hemorrhageI61.9 Nontraumatic intracerebral hemorrhage, unspecified
Subdural Bleed
• Specify traumatic or nontraumatic
• Specify acute, subacute or chronic
• Specify
laterality
Cerebral Infarct
• Specify artery involved
• Specify precerebral vessel and which one
• Specify when embolic and origin (ulcerated plaque, heart)
• Specify right vs left
side of brain (and
patient’s handedness)
Glasgow Coma ScaleThe coma scale codes (R40.2-) can be used in conjunction with
traumatic brain injury codes, acute cerebrovascular disease or sequelae of cerebrovascular disease codes. These codes are primarily for use by trauma registries, but they may be used in any setting where this information is collected. The coma scale codes should be sequenced after the diagnosis code(s).
These codes, one from each subcategory, are needed to complete the scale. The 7th character indicates when the scale was recorded. The 7th character should match for all three codes.
At a minimum, report the initial score documented on presentation at your facility. This may be a score from the emergency medicine technician (EMT) or in the emergency department. If desired, a facility may choose to capture multiple coma scale scores.
Assign code R40.24, Glasgow coma scale, total score, when only the total score is documented in the medical record and not the individual score(s).
R40.20 Unspecified comaComa NOSUnconsciousness NOSR40.21 Coma scale, eyes open (4 levels)
R40.211 Coma scale, eyes open, neverR40.212 Coma scale, eyes open, to painR40.213 Coma scale, eyes open, to soundR40.214 Coma scale, eyes open, spontaneous
R40.22 Coma scale, best verbal response (5 levels)R40.221 Coma scale, best verbal response, noneR40.222 Coma scale, best verbal response, incomprehensible wordsR40.223 Coma scale, best verbal response, inappropriate wordsR40.224 Coma scale, best verbal response, confused conversationR40.225 Coma scale, best verbal response, oriented
R40.23 Coma scale, best motor response (6 levels)R40.231 Coma scale, best motor response, noneR40.232 Coma scale, best motor response, extensionR40.233 Coma scale, best motor response, abnormalR40.234 Coma scale, best motor response, flexion withdrawalR40.235 Coma scale, best motor response, localizes painR40.236 Coma scale, best motor response, obeys commands
R40.24 Glasgow coma scale, total scoreUse codes R40.21 - through R40.23 - only when the individual score(s) are documentedR40.241Glasgow coma scale score 13-15R40.242Glasgow coma scale score 9-12R40.243Glasgow coma scale score 3-8
R40.244 Other coma, without documented Glasgow coma scale score, or with partial score
reported
7th digit – when analyzed0 – unspecified time1 – in the field (EMT or ambulance2 – at arrival in ED3 – at hospital admission4 – 24 hours or more after admission
Late Effect Issues
• Deficits on this admission are coded as new• Deficits that were from a previous admission
or are used to admit to post-acute care are late effects
• Note dominant side or handedness in hemiparesis
• Late effects designate as DUE TO:– Old stroke– Old CNS infection– Old trauma– Old CNS surgery
Severity of Intracranial Bleed
• Unconscious– Glasgow Coma Scale determinations at
site, in ED, after 24 hours, etc.
• Spastic or flaccid paralysis• Quadriplegic• Cerebral edema• Brain herniation• Brain dead
Hypertension – ICD-10
Essential hypertension (I10) – includes high blood pressure, hypertension, malignant hypertension, accelerated hypertension, benign hypertension
Secondary hypertension (I15)– I15.0 – renovascular– I15.1 – hypertension secondary to other renal
disorders– I15.2 – hypertension secondary to endocrine
disorders (carcinoid, pheochromocytoma, etc.)– I15.8 – other secondary hypertension– I15.9 – secondary hypertension, unspecified
Hypertensive Emergency?
Out the WindowI67.4 – Hypertensive encephalopathy (benign,
malignant, accelerated, essential, systemic, idiopathic)
• Hypertensive acute kidney injury?• Hypertensive acute diastolic heart failure?
With ICD-9, identify accelerated or malignant hypertension (401.0) and the stroke (434.91), or acute heart failure (428.21), or acute renal failure (584.9)
Hypertension – ICD-10
Hypertensive heart disease - I11
• I11.0 - with heart failure
• I11.9 - without heart failure
Hypertensive kidney disease - I12
• I12.0 - with stage 5 CKD or ESRD
• I12.9 - with CKD stages 1–4
N18.1, 2, 3, 4, 5, 6, 9 for CKD stages 1, 2, 3, 4, 5, ESRD, unspecified
Respiratory Failure in ICD-10
• Document acute or chronic or both
• Specify if hypoxemic or hypercapnic respiratory failure for either acute or chronic
• Without specificity,
defaults to unspecified,
with least severity
NOT Acute Respiratory Failure
• Patients being purposely maintained on the ventilator after heart surgery or any surgery because of weakness, chronic lung disease, massive trauma are NOT in acute respiratory failure
• Prevention of acute respiratory failure from angioedema, stroke, trauma when patient does NOT HAVE acute respiratory failure when intubated for airway protection
Hydrocephalus
• Be as specific as possible– Default 331.4 – acquired,
noncommunicating, obstructive, etc.– Due to stricture of aqueduct 742.3
• With spina bifida 741.0
– Normal pressure 331.3
Hydrocephalus ICD-9
742.3 Congenital hydrocephalus – ONE CODEAqueduct of Sylvius:
anomalyobstruction, congenitalstenosis
Atresia of foramina of Magendie and LuschkaHydrocephalus in newborn
331.3 Communicating (secondary NP hydrocephalus)331.4 Obstructive acquired hydrocephalus331.5 Idiopathic normal pressure hydrocephalusExcludes:due to congenital toxoplasmosis (771.2)with any condition classifiable to 741.9 (741.0)
Congenital Hydrocephalus – ICD-10
Q03.9 Congenital (external) (internal)Q05.0 Cervical spina bifida with hydrocephalusQ05.1 Thoracic (dorsal/thoracolumbar) spina bifida
with hydrocephalusQ05.2 Lumbar (LS) spina bifida with hydrocephalusQ05.3 Sacral spina bifida with hydrocephalusQ05.4 Unspecified spina bifida with hydrocephalus
Q05.5 Cervical spina bifida without hydrocephalusQ05.6 Thoracic (dorsal/thoracolumbar) spina bifida
without hydrocephalusQ05.7Lumbar (LS) spina bifida without hydrocephalusQ05.8Sacral spina bifida without hydrocephalus
Acquired Hydrocephalus ICD-10
G91.0 Communicating hydrocephalusSecondary normal pressure hydrocephalus
G91.1 Obstructive acquired hydrocephalusG91.2 (Idiopathic) normal pressure hydrocephalus
Normal pressure hydrocephalus NOS
G91.3 Post-traumatic hydrocephalus, unspecifiedG91.4 Hydrocephalus in diseases classified
elsewhereCode first underlying condition, such as:congenital syphilis (A50.4-)neoplasm (C00-D49)
due to congenital toxoplasmosis (P37.1)
Encephalopathies
• Metabolic encephalopathy G93.41– Includes due to sepsis, hyper and
hyponatremia, diabetic encephalopathy– Hepatic encephalopathy K72
• Toxic encephalopathy G92– Lead encephalopathy, bromidism– Polypharmacy over prolonged periods
leading to CNS damage
Encephalopathies • Hypoxic ischemic encephalopathy
– P91.61 mild, P91.62 moderate, P91.63 severe
• Other encephalopathy G93.49– Lyme encephalopathy + A69.21 Lyme
disease– Wiernicke’s nutritional encephalopathy
E51.2– Alcoholic (Wiernicke-Korsakoff psychosis)
F10.26– Hypertensive encephalopathy I67.4
AMS is not Encephalopathy
When a patient is determined to have one of the following as cause of AMS, specify as:– Hypoxic ischemic encephalopathy (at birth)– Alcoholic encephalopathy– Anoxic encephalopathy (after the birth process)– Hepatic encephalopathy– Hypertensive encephalopathy– Metabolic (internal source) encephalopathy– Toxic (external source) encephalopathy– Traumatic (post-concussive) encephalopathy
HIE – ICD-9only for use for hypoxemia related to the birth process – intrauterine or during the
trip down the canal
768.7 Hypoxic-ischemic encephalopathy (HIE)
768.70 Hypoxic-ischemic encephalopathy, unspecified
768.71 Mild hypoxic-ischemic encephalopathy
768.72 Moderate hypoxic-ischemic encephalopathy
768.73 Severe hypoxic-ischemic encephalopathy
HIE – ICD-10only for use for hypoxemia related to the birth process – intrauterine or during the
trip down the canal
P91.6 Hypoxic ischemic encephalopathy [HIE]
P91.60 Hypoxic ischemic encephalopathy [HIE], unspecified
P91.61 Mild hypoxic ischemic encephalopathy [HIE]
P91.62 Moderate hypoxic ischemic encephalopathy [HIE]
P91.63 Severe hypoxic ischemic encephalopathy [HIE]
What ISN’T Encephalopathy
• Coma after stroke or head trauma
• Postictal state
• Drunkenness
• Effects of illicit drugs or poisoning with overdosage of prescribed drugs
• Adverse effects or desired effects of sedative medications
Seizures Convulsions Epilepsy
• The terms convulsion and seizure can be used interchangeably.
• The term epilepsy is used to describe seizures that occur repeatedly over time without an acute illness or brain injury.
• A convulsion that involves the whole body (sometimes called a “generalized tonic-clonic” or “grand mal” seizure) is the most dramatic type of seizure, causing rapid, violent movements and occasionally loss of consciousness. Don’t call it grand mal epilepsy when it’s not epilepsy.
• By contrast, “absence” seizures (previously called “petit mal” seizures) are momentary episodes with a vacant stare or a brief lapse of attention.
Epilepsy ICD-9
345.0+ Generalized nonconvulsive epilepsy345.1+ Generalized convulsive epilepsy345.2 Petit mal status345.3 Grand mal status345.4+ Localization-related (focal) (partial) epilepsy and
epileptic syndromes with complex partial seizures345.5+ Localization-related (focal) (partial) epilepsy and
epileptic syndromes with simple partial seizures345.6+ Infantile spasms345.7+ Epilepsia partialis continua345.8+ Other forms of epilepsy and recurrent seizures345.9+ Epilepsy, unspecified348.81 Hippocampal (temporal lobe) epilepsy
Fifth Digit0 – Not intractable1 – Intractable
Epilepsy ICD-10
G40.0 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of local onset
G40.1 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures
G40.2 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures
G40.3 Generalized idiopathic epilepsy and epileptic syndromes
G40A Absence epileptic syndromesG40B Juvenile myoclonic epilepsyG40.4 Other generalized epilepsyG40.5 Epileptic seizures related to external
causes (eg, alcohol, drugs)G40.8 Other epilepsy and recurrent seizures
Fifth Digit0 – Not intractable1 – Intractable
Sixth Digit0 – With status9 – Without status
Other Seizures ICD-9
780.31Simple febrile convulsions
780.32Complex febrile convulsions
780.33Post-traumatic seizure
780.39 Other convulsions
eg. alcohol withdrawal, adverse reaction to a drug, neurocystocercosis
Other Seizures ICD-10
R56.0 Febrile convulsions
R56.00 Simple febrile convulsions
R56.01 Complex febrile convulsions
R56.1 Post traumatic seizures
R56.9Unspecified convulsions
DNR vs Comfort Measures Z51.5
(ICD-9 V66.7)
When it’s time to give up hope:
“The physician documentation in the medical record must substantiate that end of life care is being given. Terms such as comfort care, end-of-life care are appropriate. These, or similar terms, need to be written in the record to support the use of code V66.7. The care provided must be aimed only at relieving pain and discomfort for the palliative care code to be applicable.”
Palliative care consults are NOT the same!
Specificity is NOT Always Possible
Sign/Symptom/Unspecified CodesIn both ICD-9-CM and ICD-10-CM, sign/symptom and “unspecified” codes have
acceptable, even necessary, uses. While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter.
Each healthcare encounter should be coded to the level of certainty known for that encounter.
If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis.
When sufficient clinical information isn’t known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate “unspecified” code (e.g., a diagnosis of pneumonia has been determined, but not the specific type).
In fact, unspecified codes should be reported when they are the codes that most accurately reflects what is known about the patient’s condition at the time of that particular encounter. It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code.
Source: Cooperating Parties for ICD-10-CM/PCS and ICD-9-CM Coding, May 2013.
KDIGO Kidney Disease Improving Global
Outcomes
Stage GFR Description Treatment stage
1 90+ Normal kidney function but urine or other abnormalities point to kidney disease
Observation, control of blood pressure
2 60-89 Mildly reduced kidney function, urine or other abnormalities point to kidney disease
Blood pressure control, monitoring, find out why.
3 30-59 Moderately reduced kidney function
More of the above, and probably diagnosis, if not already made.
4 15-29 Severely reduced kidney function
Planning for endstage renal failure.
5 14 or less
Very severe, or endstage kidney failure (established renal failure)
See treatment choices for endstage renal failure.
AKI or ARF Insufficiency is NOT a synonym
Stg Serum creatinine criteria Urine output criteria
1 Increase in serum creatinine of more than or equal to 0.3 mg/dl or increase to more than or equal to 150% to 200% from baseline
Less than 0.5 ml/kg per hour for more than 6 hours
2 Increase in serum creatinine to more than 200 – 300% from baseline
Less than 0.5 ml/kg per hour for more than 12 hours
3 Increase in serum creatinine to more than 300% from baseline or serum creatinine of more than or equal to 4.0 mg/dl with an acute increase of at least 0.5 mg/dl
Less than 0.3 ml/kg per hour for 24 hours or anuria for 12 hours
Caveat
• The writings of the AKIN state that, in cases of dehydration (and dehydration is still, truly the number one cause of acute renal failure in the US), it is imperative to NOT CALL changes in creatinine AKI until the patient has been volume repleted for at least six hours. If creatinine bump persists after fluid resuscitation, there was likely AKI. If not, there was NOT AKI.
• “Acute kidney injury should be both abrupt (within 1–7 days) and sustained (more than 24 hours).”
Diabetes
• Juvenile (IDDM) –Type 1 diabetes occurs in a state of insulin deficiency resulting from pancreatic beta cell destruction
• Adult (NIDDM) – Type 2 diabetes results from increased resistance to the effects of insulin. These patients may require insulin for control.
Diabetes
• Identify type 1, type 2, due to other secondary cause, gestational
• In type 2 or secondary cause, identify when using insulin long term
• Identify all body systems affected by the diabetes (neuropathy and its manifestation, retinopathy and proliferative or nonproliferative, nephropathy and stage of CKD, dermopathy, vasculopathy, periodontopathy)
• Identify all manifestations (ulcer, coma, gangrene, osteomyelitis, etc.)
Nutritional Status
• Malnutrition – dietary consult or estimate– Mild (<10% loss)– Moderate (10-20% loss)– Severe (>20% weight loss)
• Consider the acute malnutrition of surgery, trauma and sepsis
• Morbid obesity and all of its manifestations and risks for surgery and anesthesia
– GER - Obesity Hypoventilation Syndrome - Hypertension– Sleep apnea - Secondary hypercoagulable state - Diabetes with …– Cellulitis - Hypertensive heart disease - Chronic cor pulmonale
Primary and Metastatic Cancer
• Tell where the primary is (was) and if it was previously removed or treated and treatment is over or currently under treatment
• State where the metastatic sites are and if they (any) are symptomatic and if they are currently under treatment
• State if new site is found and if it led to the symptoms that required admission – ALWAYS LINK SYMPTOMS TO THE CANCER, when you can
The Future Must Be Started Now
ICD-9-CM995.91 Sepsis (SIRS due
to infection without organ dysfunction
995.92 Severe sepsis (SIRS due to infection with organ dysfunction
995.93 SIRS due to noninfection without organ dysfunction
995.94 SIRS due to noninfection with organ dysfunction
ICD-10-CM*****
R65.20 Severe sepsis without septic shock
R65.21 Severe sepsis with septic shock
R65.10 SIRS due to noninfection without organ dysfunction
R65.11 SIRS due to noninfection with organ dysfunction
Conditions Related to …
Sepsis due to:
UTI
Pneumonia
Cholangitis
Decubitus
Osteomyelitis
Infected dialysis cath
Subphrenic abscess
All are infections!
SIRS due to:
Hemorrh pancreatitis
Burns (not infected)
Pulmonary embolism (clot, fat, amniotic fluid)
Multiple trauma
Allergy
None are infections!
Severe Sepsis
Sepsis with distant organ failure:– Acute renal failure (due to sepsis)– ARDS or acute respiratory failure– Acute hepatic failure (due to sepsis)– Encephalopathy (metabolic – due to sepsis)– DIC (Disseminated intravascular
coagulopathy)– Critical care myopathy– Circulatory system failure – inability to
maintain a blood pressure to perfuse vital organs – CALLED SEPTIC SHOCK
What We Are SeeingBAD
ARI
CHF
CRF
NaHb – 6.8
BPMODS
Transaminitis
NEEDEDAcute renal failureChronic systolic failureCKD stage 3HyponatremiaAnemia – cause?Shock – cause?The names of the
failed organsAcute liver failure
Anemiaand Complexity of Medical Decision Making
Non Specific
Anemia
SpecificAnemia DUE TO chronic renal
failureAnemia DUE TO chronic blood
loss from a fungating cecal lesion
Anemia DUE TO acute blood loss from a hip fracture
Anemia DUE TO chronic osteo/hepatitis
Anemia DUE TO antineoplastics
Bad Terms – Good Terms
• Low hematocrit• Infiltrate• Purulent drainage
• Point tenderness• Hypotension
• Symptom or sign
• Anemia … due to• Pneumonia or CHF• Abscess or wound
infection• Peritonitis• Septic shock or
dehydration or hypovolemia or whatever cause
• A disease!
Is the EHR a Friend or Foe?
• State that the programs are ready for ICD-9, ICD-10 and SnoMED
• State that they provide “meaningful use”
• State that they aid with “pick lists”
• State that they help with “problem lists”
• State that they help with physician professional billing because you can cut and paste
Example Changes in Epic to Support ICD-10
• Diagnosis Calculator– For providers who directly enter diagnoses
(encounter diagnoses, charge capture, order-association), guides users to more specific code by prompting for laterality, acuity, etc.
• Updating Documentation Tools– To facilitate documentation of needed detail for
the coders– Epic builders will work with you to update
SmartTexts, SmartPhrases, Note templates, etc.
Questions: Contact Dr. Jason Lyman, ICD-10 Physician Champion, [email protected]
Progress Note Management
• Copy and paste of massive amounts of trash leads to – useless notes, – inability of others to determine what is
wrong with the patient NOW – inability to validate that ANYTHING YOU
DID WAS EFFECTIVE! And– inability to assign ICD codes – what was
ruled out what was ruled in
Beware of cloned documentation
RACs and other auditors are on the lookout for cloned documentation, often a problem in teaching hospitals and large academic medical centers. "Auditors look for instances when the attending physician cuts and pastes from the resident's note into his own," says Nguyen.
CMS requires documentation of each encounter so that the note stands on its own and represents the actual services provided by the attending physician for each date of service or encounter. Data, including vital signs, may not be copied from one visit to the next. CMS states that note cloning raises concerns about the medical necessity of continued hospitalization.
• The U.S. Department of Health & Human Services and the Department of Justice have promised to come down hard on providers who misuse electronic health records to financially game the healthcare system.
• HHS Secretary Kathleen Sebelius and U.S. Attorney General Eric Holder warned that law enforcement agencies are keeping an eye out for fraud and "will take action where warranted," in a letter sent to the American Hospital Association, Association of Academic Health Centers, Association of American Medical Colleges and others
• Sebelius and Holder point to potential cloning of medical records as one of several indications that fraud could be on the rise. Medicare administrative contractor National Government Services earlier this month issued a notice, stating that cloned documents from EHRs mostly likely would result in payment denials.
Progress Note Needs
• What was the problem that brought the patient to your attention (one to two sentences)
• What did you see today? Labs, x-rays, physical findings, consults, other tests
• What are the diagnoses?• What has changed? Worse? Better?
More specific? Ruled in or ruled out?• What are you going to do today?
Three Major Sections
Active diseases, decompensated for which inpatient care required – update as issues resolve
Chronic stable conditions that are currently under treatment
Past Medical Historical conditions, not currently affecting health status nor being treated (appy age 12, s/p hysterectomy, Gr3/Para3, left hip replaced)
Paint the picture of Paint the picture of the patient properly the patient properly
with WORDSwith WORDS
So the coder can paint the same picture with codes.
What you want…
what you might get.
may notbe…
Motto For The AgeMotto For The Age
“If you don’t look good, we don’t look good” Vidal
sassoon, ca 1985Father of modern medical economics
Question #1 – Which is True?
A. ICD-10 shows a totally different appreciation of diseases than ICD-9
B. ICD-10 codes are exact walkovers from the ICD-9 codes – they just look different
C. ICD-10 codes may look different but the diseases didn’t change – proper documentation will lead to proper code assignment
D. ICD-10 codes are different from ICD-9 only by adding the differentiation of Right vs Left
Question #2 – Which is False?
A. Value of purchasing of healthcare is dependent on data streams derived from ICD codes
B. Specific documentation of diseases in ICD-9 will be all that is necessary for specific code assignments in ICD-10
C. Bundled payments for healthcare will lead to cooperation between practitioners and facilities
D. We are the only country in the world billing for healthcare by ICD codes