Value Based Value Based Purchasing, Changes for Purchasing, Changes for ICD-10 and the Future of ICD-10 and the Future of

UrologyUrologyRobert 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 VCU Retreat Augusta Culpeper Rockingham Henrico2013 2013 Doctors Health Regional Memorial Doctors

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

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.

20

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.

Patient Safety Indicators

Hospital acquired preventable diagnoses• Hospital falls that lead to patient damage (fractures, etc.) • Mediastinitis post-CABG• Catheter-associated UTIs – Foley, suprapubic

cystostomy, nephrostomy, ureteral stents• Vascular catheter associated infections• Pressure ulcers• Iatrogenic pneumothorax following central line insertion• Object accidentally left in patient• Air embolism• Reaction from blood incompatibility

What Does This Mean?

• Properly identify complication of care when complication – specify when due to a disease

• We don’t want to assign complication codes when not complication– If event due to disease, not a complication– If even doesn’t exist, not a complication

• Don’t use the word “post-op” in the post-op period!

Is an Adverse Event Always a Complication?

• Not at all.• Stuff happens.• Diseases cause adverse effects• Anemia due to blood loss is usually due to the

disease and not to the surgeryState so: anemia of chronic blood loss due

to right renal cell carcinoma; anemia of acute blood loss due to femur fracture

• Adverse effects are easily explained and defended in a patient with more risk factors. If you didn’t name these, you lose.

NOT Acute Respiratory Failure

• Patients being purposely maintained on the ventilator after surgery because of weakness, chronic lung disease, massive trauma are NOT in acute respiratory failure – unless they are

• Patients being purposely maintained on the ventilator after extensive surgery in the face of morbid obesity or COPD are NOT in acute respiratory failure – unless they are.

• Prevention of acute respiratory failure from angioedema, stroke, trauma when patient does NOT HAVE acute respiratory failure when intubated for airway protection

Goals of Implementation – Prove You Are Value Based

• Competitive severity adjusted mortality and morbidity statistics

• 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

Documentation Needs:What’s The Surgery For?

• Provide the diagnosis for which the surgery is being performed

• Tell why it’s necessary for that diagnosis• DON’T just say that the patient is being

admitted for the surgery (Admitted for radical suprapubic prostatectomy)

• DON’T just provide signs and symptoms• Tell the story of the workup that led to

the diagnosis

Documentation Needs:Complexity of Patient

• Name other diseases patient has coming through the door – chronic, stable conditions

• Avoid “Resume home meds” unless you identify each disease being treated

• Permit other physicians to follow serious co-morbidities, but name each at least ONCE, especially in discharge summary

ACS NSQIP Data Collection Overview

The ACS NSQIP collects data on 136 variables, including preoperative risk factors, intraoperative variables, and 30-day postoperative mortality and morbidity outcomes for patients undergoing major surgical procedures in both the inpatient and outpatient setting.

Surgical Risk Stratification • NSQIP databases depend on

identification of risk factors

Heart – failure? MI? Lungs – chronic?

Nutrition – over? mal? Diabetes – cont?

Renal status – chr, ac. Malignancy?

Smoking, ETOH? Stroke – residua?

Hepatic fxn – name it Encephalopathy?

Immunocomp – how? Sepsis? Org fail?

Use ster, insul, chemo Periph vasc?

Age Obstructive sleep apnea

Chronic lung disease Impaired sensorium

Cigarette use Surgical site

Congestive heart failure Elective vs emergency

ASA Class of comorbids Prolonged surgery

Functional dependence General anesthesia

Obesity Transfusion > 4 units

Risk Stratification for Pulmonary Complications

Modified NSQIP Data Sheet

WEIGHT/HEIGHT: . WEIGHT (KG) . HEIGHT (Cm) BMI . NUTRITIONAL STATUS (Overnutrition risk) Obese Morbidly obese Obes/hypovent synd Sleep apnea MALNUTRITION (% Body Weight Loss) N Mild (<10% loss) Moderate (10 – 20%) Severe (>20%) HISTORY OF SMOKING: (any tobacco use) N Pack year history _________ Current (within 30 days) _____ PPD FAMILY HX CORONARY ARTERY DISEASE <55: N Y ____________________________ (family members) DIABETES: N Type 1 Type 2 on insulin Other secondary diabetes ____________ DIABETES CONTROL CONTROLLED UNCONTROLLED OTHER ORGAN INVOLVEMENT Neuropathy Nephropathy Vascular disease Ulcers DYSLIPIDEMIA: N Hypercholesterolemia Hypertriglyceridemia KIDNEY DISEASE (STAGE) GFR _______: CKD 1 2 3 4 5 ESRD Acute renal failure DIALYSIS PATIENT: N Y Hemodialysis Peritoneal dialysis STROKE: N Hemorrhagic Ischemic Recent (<2 wks) Remote (> 2 wks) CEREBROVASCULAR DISEASE: N Prior carotid surgery Coma TIAs CNS DEFICITS N Quad Parapl Hemipl dom Nondom Nerve damage ___________ FUNCTIONAL HEALTH STATUS Independent ADLs Partially Dependent Totally Dependent INFECTIOUS ENDOCARDITIS: N Mitral Aortic Tricuspid Pulmonic CHRONIC LUNG DISEASE: N COPD Bronchiectasis Emphysema Chronic respiratory failure IMMUNOSUPPRESSIVE THERAPY N Chronic steroids Antiinflammatories Antineoplastics

The Mayo Model ofPreOperative Medical

Evaluation• Initial medical evaluation for risk stratification

– fill out POME• Lab and radiographic studies as indicated – fill

out POME• Consultative visits and tests as needed – fill

out POME• Visit to Anesthesiology with recommendations

and results – fill out preop anesthesia forms• Visit to surgeon with all needed risk factors

complete – complete H&P• Eliminate cancelled surgeries, delays

Was It Present on Admission?

Patient safety indicators may give us a black eye if it’s not documented!

• Ileus from perforated bowel or from peritonitis – was it present on admission?

• DVT in patient from nursing home – was it present on admission?

• Decubitus ulcer – is it an ulcer - was it present on admission?

• Atelectasis in a morbidly obese patient – was it present on admission?

If we don’t document it, we get charged with it!

Change in the Entire System

ICD-9

ICD-10

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)

Don’t Wait Till Tomorrow for ICD-10

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

How Close 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

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.

Renal Malignancies ICD-9

189.0 Kidney, except pelvis (Includes Wilms tumor, renal cell carcinoma, urothelial cell ca)

189.1 Renal pelvis189.2 Ureter189.3 Urethra189.4 Paraurethral glands189.8 Other specified sites of urinary organsMalignant neoplasm of contiguous or

overlapping sites of kidney and other urinary organs whose point of origin cannot be determined

189.9 Urinary organ, site unspecified

Renal Malignancies ICD-10

C64.1 Malignant neoplasm of right kidney, except renal pelvis (includes all cell types)

C64.2 Malignant neoplasm of left kidney, except renal pelvis (includes all cell types)

C64.9 Malignant neoplasm of unspecified kidney, except renal pelvis (includes all cell types)

C65 Malignant neoplasm of renal pelvisC65.1 Malignant neoplasm of right renal pelvisC65.2 Malignant neoplasm of left renal pelvisC65.9 Malignant neoplasm of unspecified renal pelvis

C66Malignant neoplasm of ureterC66.1 Malignant neoplasm of right ureterC66.2 Malignant neoplasm of left ureterC66.9 Malignant neoplasm of unspecified

Similarities and Differences

• Now identify right or left kidney, pelvis, ureter

• Same differentiation by part of renal system

• No breakdown as to cell types

• Do we need this?– Wilms tumor (nephroblastoma)– Renal cell carcinoma– Urothelial cell carcinoma

Mets to Bone

ICD-9

198.5 Bone and bone marrow

ICD-10

C79.51 Bone

C79.52 Bone marrow

Stones in 9 and 10

592.0 Calculus of kidneyNephrolithiasis NOSRenal calculus or stoneStaghorn calculusStone in kidneyExcludes: uric acid

nephrolithiasis (274.11)592.1 Calculus of ureterUreteric stoneUreterolithiasis592.9 Urinary calculus,

unspecified

N20.0 Calculus of kidneyNephrolithiasis NOSRenal calculusRenal stoneStaghorn calculusStone in kidneyN20.1 Calculus of ureterUreteric stoneN20.2 Calculus of kidney

with calculus of ureterN20.9 Urinary calculus,

unspecified

Benign Prostatic Disease – ICD-9

600.0 Hypertrophy (benign) of prostate600.00 Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptoms (LUTS)600.01 Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS)

600.1 Nodular prostate600.10 Nodular prostate without obstruction600.11 Nodular prostate with urinary obstruction

600.2 Benign localized hyperplasia prostate600.20 Benign localized hyperplasia of prostate without urinary obstruction and other lower urinary tract symptoms (LUTS)600.21 Benign localized hyperplasia of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS)

600.3 Cyst of prostate

Use additional code to identify symptoms:incomplete bladder emptying (788.21)nocturia (788.43)straining on urination (788.65)urinary frequency (788.41)urinary hesitancy (788.64)urinary incontinence (788.30-788.39)urinary obstruction (599.69)urinary retention (788.20)urinary urgency (788.63)weak urinary stream (788.62)

Benign Prostatic Disease ICD-10

N40.0 Enlarged prostate without lower urinary tract symptoms

N40.1 Enlarged prostate with lower urinary tract symptoms

N40.2 Nodular prostate without lower urinary tract symptoms

N40.3 Nodular prostate with lower urinary tract symptoms

No code for benign localized hyperplasia prostate

N42.83 Cyst of prostate

Use additional code for associated symptoms, when specified:incomplete bladder emptying (R39.14)nocturia (R35.1)straining on urination (R39.16)urinary frequency (R35.0)urinary hesitancy (R39.11)urinary incontinence (N39.4-)urinary obstruction (N13.8)urinary retention (R33.8)urinary urgency (R39.15)weak urinary stream (R39.12)

Adhesions

• Specify in females if due to pelvic inflammatory diseases or post uterine or adnexal surgery

• General adhesions, male or female, due to other than diseases of the female pelvic organs are assigned the same code

• Distinguish with or without obstruction

Endocrine Complications or Metabolic Disorders After

Endocrine Surgery or Other Surgery

• Postop hypoadrenalism, hypothyroidism, hypoparathyroidism, hypopituitrism, ovarian failure (symptomatic or asymptomatic)

• Specify when these are desired outcomes of (integral to) the surgery performed

• Identify accidental puncture or laceration and hematoma or hemorrhage in renal, adrenal surgeries

Nephritis

• Identify cause (disease) and if hereditary

• Identify when acute– Identify when rapidly progressive– With or without persistent hematuria

• Identify when chronic– Identify when with nephrotic syndrome

Nephritic Syndrome (acute)1. Hematuria2. Oliguria3. Azotemia4. Hypertension

Nephrotic Syndrome (chronic)1. Massive proteinuria2. Hypoalbuminemia3. Edema4. Hyperlipidemia/hyperlipiduria

Cystitis

• Provide specificity– Acute cystitis– Interstitial cystitis– Trigonitis– Radiation cystitis

• Specify if with or without hematuria and microscopic or gross hematuria

Urethral Stricture

• Identify cause– Posttraumatic– Postinfectious– Other

• Identify sex of patient – in female, if due to childbirth

• Identify part of urethra involved as appropriate– Meatus– Bulbous urethra

Urinary Incontinence

• Stress incontinence• Urge incontinence• Incontinence without sensory awareness• Post-void dribbling• Nocturnal enuresis• Continuous leakage• Mixed incontinence (stress and urge)

GU Surgery Complications

• Urethral stricture• Vaginal adhesions, prolapse• Postop pelvic adhesions from pelvic

surgery• Complications of cystostomy, other

external or internal stoma of urinary tract (hemorrhage, infection, malfunction)

• Hemorrhage, hematoma, accidental puncture or laceration in genitourinary surgery–specify if identified during or after surgery

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 0l5 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).”

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

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.)

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

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

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

Encephalopathies

• Metabolic encephalopathy G93.41– Includes due to sepsis, hyper and

hyponatremia, uremic 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

Post-Op Progress Notes

• We were all taught to examine certain parts of the body on every post-op visit.

• No matter how many times you did it, if you don’t document it, YOU DIDN’T DO IT.

• VS, labs, I&O, mental status, chest, belly, legs, wound, ambulation, bowel activity – every visit.

Post-Op Progress Notes

Prosecuting attorneys LOVE:

6/17 Doing well

6/18 No new problems

6/19 Events of last night noted

6/20 Called to see patient in full code. Pronounced dead at 17:15.

Handling the Problem List

It’s an Epic Task

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, lyman@virginia.edu

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

Questions and Answers

Your Ideas and Comments

               

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