Value Based Purchasing, Changes for ICD-10 and the Future of Physical Medicine and Rehab Robert S. Gold, MD - PowerPoint PPT Presentation

Loading...

PPT – Value Based Purchasing, Changes for ICD-10 and the Future of Physical Medicine and Rehab Robert S. Gold, MD PowerPoint presentation | free to download - id: 5fa82e-NTY5Y



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Value Based Purchasing, Changes for ICD-10 and the Future of Physical Medicine and Rehab Robert S. Gold, MD

Description:

Title: Slide 1 Author: User Last modified by: BobGold Created Date: 10/29/2010 3:17:37 PM Document presentation format: On-screen Show Other titles – PowerPoint PPT presentation

Number of Views:1440
Avg rating:3.0/5.0
Slides: 106
Provided by: healthsyst
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Value Based Purchasing, Changes for ICD-10 and the Future of Physical Medicine and Rehab Robert S. Gold, MD


1
Value Based Purchasing, Changes for ICD-10 and
the Future of Physical Medicine and Rehab Robert
S. Gold, MD
2
Medicine Under the Microscope
  • Morbidity
  • Mortality
  • Cost per patient
  • Resource utilization
  • Length of stay
  • Complications
  • Outcomes
  • ARE YOU SAFE avoiding harm, avoidable
    readmissions?

3
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.

4
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

5
World Health Organization and ICD Codes
  • 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

6
(No Transcript)
7
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.

8
Is There a Diagnosis?
  • Assessment/Plan
  • 82 YO F patient presented to ER with
  • 1. Sepsis,
  • 2. Septic Shock,
  • 3. Acute Hypercapnic Respiratory Failure,
  • 4. Acute Renal Failure due to 2, (dont 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

9
So Whats the Difference?
Principal Diagnosis Chills and Fever Sepsis
Secondary Diagnoses Altered mental status Septic Shock Acute Respiratory Failure Aspiration Pneumonia Acute Renal Failure (or AKI) Respiratory Acidosis Metabolic Encephalopathy
Medicare MS-DRG 864 Fever w/o CC/MCC 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
10
What Is An Index?
11
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
12
Profiles Come from Severity Adjusted Statistics
lt1 preferred provider ????? significantly
better
1 as good as the next guy???
  • Observed mortality
  • Expected mortality
  • From severity adjusted DRGs

gt1 excessive mortality find another provider -
?
13
(No Transcript)
14
Patient Safety
15
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

16
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.

17
Florida Blue and Holy Cross Create Accountable
Care Arrangement
  • Jacksonville and Fort Lauderdale, Fla. Florida
    Blue, Floridas 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.

18
Aetna, Baptist Memorial Health Care Announce
Collaborative Care Agreement
  • Thursday, April 25, 2013 411 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.

19
Getting Studies Paid For Laboratory/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

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.

21
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
22
Patient Safety Indicators
  • Hospital acquired preventable diagnoses
  • Hospital falls that lead to patient damage
    (fractures, etc.)
  • Mediastinitis post-CABG
  • Catheter-associated UTIs
  • Vascular catheter associated infections
  • Pressure ulcers
  • Object accidentally left in patient
  • Air embolism
  • Reaction from blood incompatibility

23
Participation and Success in Reporting of Core
Measures
  • Acute MI
  • Heart failure
  • Pneumonia
  • Postoperative wound infections
  • Venous thromboembolism
  • Stroke
  • Asthma in childrens hospitals

24
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

25
Inpatient Rehab Coding
  • Coding Clinic, Third Quarter 2006 Page 3
  • The Central Office on ICD-9-CM has continued to
    receive questions regarding the coding and
    sequencing of diagnoses in inpatient
    rehabilitation facilities (IRF). These
    facilities are required to complete a data
    collection instrument called Inpatient
    Rehabilitation Facility-Patient Assessment
    Instrument (IRF-PAI), as well as a claim form.
    The IRF-PAI requires the assignment of ICD-9-CM
    diagnosis codes for the etiologic diagnosis to
    indicate the condition for which the patient is
    receiving rehabilitation, as well as other
    comorbid conditions. As stated in Coding Clinic,
    First Quarter 2002, pages 18-19, a different set
    of instructions/rules apply to the IRF-PAI.
    Hospitals should be guided by the Medicare
    IRF-PAI Manual for the coding and reporting of
    the etiologic diagnosis and comorbidities for the
    IRF-PAI.
  • A code from category V57, Care involving use of
    rehabilitation procedures, should be assigned as
    the principal diagnosis on the claim form when
    the patient is admitted for rehabilitative
    services. The following questions and answers
    apply to the coding and reporting of secondary
    diagnoses on the claim form for IRF patients.
    This information is being published in order to
    clarify some of the confusion that has resulted
    from dual reporting requirements.

26
Change in the Entire System
  • ICD-9

ICD-10
27
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)

28
Dont Wait Till Tomorrow for ICD-10
29
Rehab ICD-9
  • V57Care involving use of rehabilitation
    procedures
  • Use additional code to identify underlying
    condition
  • V57.0 Breathing exercises
  • V57.1 Other physical therapy
  • Therapeutic and remedial exercises, except
    breathing
  • V57.2 Occupational therapy and vocational
    rehabilitation
  • V57.21 Encounter for occupational therapy
  • V57.22 Encounter for vocational therapy
  • V57.3 Speech-language therapy
  • V57.4 Orthoptic training
  • V57.8 Other specified rehabilitation procedure
  • V57.81 Orthotic training
  • Gait training in the use of artificial limbs
  • V57.89 Other
  • Multiple training or therapy
  • V57.9 Unspecified rehabilitation procedure

30
Rehab ICD-10
Z51.89 Encounter for other specified aftercare
PLUS . . .
31
Subarachnoid Bleed
  • Specify when traumatic
  • Specify vessel of origin - aneurysm
  • Specify right or left side of the brain
  • If hemiparesis, specify dominant or nondominant
    side

32
Intracerebral Bleed
  • Specify when traumatic or nontraumatic
  • Specify by location in brain (cortical,
    subcortical, brainstem, intraventricular)

33
Intracerebral Bleed I-9
  • 431 Intracerebral hemorrhage
  • Hemorrhage (of)
  • basilar
  • bulbar
  • cerebellar
  • cerebral
  • cerebromeningeal
  • cortical
  • internal capsule
  • intrapontine
  • pontine
  • subcortical
  • ventricular

34
Intracerebral Bleed I-10
  • I61.0 Nontraumatic intracerebral hemorrhage in
    hemisphere, subcortical
  • Deep intracerebral hemorrhage (nontraumatic)
  • I61.1 Nontraumatic intracerebral hemorrhage in
    hemisphere, cortical
  • Cerebral lobe hemorrhage (nontraumatic)
  • Superficial intracerebral hemorrhage
    (nontraumatic)
  • I61.2 Nontraumatic intracerebral hemorrhage in
    hemisphere, unspecified
  • I61.3 Nontraumatic intracerebral hemorrhage in
    brain stem
  • I61.4 Nontraumatic intracerebral hemorrhage in
    cerebellum
  • I61.5 Nontraumatic intracerebral hemorrhage,
    intraventricular
  • I61.6 Nontraumatic intracerebral hemorrhage,
    multiple localized
  • I61.8 Other nontraumatic intracerebral hemorrhage
  • I61.9 Nontraumatic intracerebral hemorrhage,
    unspecified

35
Subdural Bleed
  • Specify traumatic or nontraumatic
  • Specify acute, subacute or chronic
  • Specify
  • laterality

36
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
  • patients handedness

37
Stroke ICD-9 Caused by Occlusion Precerebral
Artery
  • 433.0 Basilar artery
  • 433.00 without mention of cerebral infarction
  • 433.01 with cerebral infarction
  • 433.1 Carotid artery
  • 433.10 without mention of cerebral infarction
  • 433.11 with cerebral infarction
  • 433.2 Vertebral artery
  • 433.20 without mention of cerebral infarction
  • 433.21 with cerebral infarction
  • 433.3 Multiple and bilateral
  • 433.30 without mention of cerebral infarction
  • 433.31 with cerebral infarction
  • 433.8 Other specified precerebral artery
  • 433.80 without mention of cerebral infarction
  • 433.81 with cerebral infarction
  • 433.9 Unspecified precerebral artery
  • 433.90 without mention of cerebral infarction
  • 433.91 with cerebral infarction

38
Stroke ICD-9 Cerebral Artery
  • 434.0 Cerebral thrombosis
  • 434.00 without mention of cerebral infarction
  • 434.01 with cerebral infarction
  • 434.1 Cerebral embolism
  • 434.10 without mention of cerebral infarction
  • 434.11 with cerebral infarction
  • 434.9 Cerebral artery occlusion, unspecified
  • 434.90 without mention of cerebral infarction
  • 434.91 with cerebral infarction

39
Stroke ICD-10
  • I63.0 Cerebral infarction due to thrombosis of
    precerebral arteries
  • I63.00 Cerebral infarction due to thrombosis of
    unspecified precerebral artery
  • I63.01 Cerebral infarction due to thrombosis of
    vertebral artery
  • I63.011 Cerebral infarction due to thrombosis of
    right vertebral artery
  • I63.012 Cerebral infarction due to thrombosis of
    left vertebral artery
  • I63.02 Cerebral infarction due to thrombosis of
    basilar artery
  • I63.03 Cerebral infarction due to thrombosis of
    carotid artery
  • I63.031 Cerebral infarction due to thrombosis of
    right carotid artery
  • I63.032 Cerebral infarction due to thrombosis of
    left carotid artery
  • I63.09 Cerebral infarction due to thrombosis of
    other precerebral artery

40
Stroke ICD-10
  • I63.10 Cerebral infarction due to embolism of
    unspecified precerebral artery
  • I63.11Cerebral infarction due to embolism of
    vertebral artery
  • I63.111 Cerebral infarction due to embolism of
    right vertebral artery
  • I63.112 Cerebral infarction due to embolism of
    left vertebral artery
  • I63.12 Cerebral infarction due to embolism of
    basilar artery
  • I63.13Cerebral infarction due to embolism of
    carotid artery
  • I63.131 Cerebral infarction due to embolism of
    right carotid artery
  • I63.132 Cerebral infarction due to embolism of
    left carotid artery

41
Stroke I-10
  • I63.30 Cerebral infarction due to thrombosis of
    unspecified cerebral artery
  • I63.31 Cerebral infarction due to thrombosis of
    middle cerebral artery
  • I63.311 Cerebral infarction due to thrombosis of
    right middle cerebral artery
  • I63.312 Cerebral infarction due to thrombosis of
    left middle cerebral artery
  • I63.32 Cerebral infarction due to thrombosis of
    anterior cerebral artery
  • I63.321 Cerebral infarction due to thrombosis of
    right anterior cerebral artery
  • I63.322 Cerebral infarction due to thrombosis of
    left anterior cerebral artery

42
Stroke I-10
  • I63.33 Cerebral infarction due to thrombosis of
    posterior cerebral artery
  • I63.331 Cerebral infarction due to thrombosis of
    right posterior cerebral artery
  • I63.332 Cerebral infarction due to thrombosis of
    left posterior cerebral artery
  • I63.34 Cerebral infarction due to thrombosis of
    cerebellar artery
  • I63.341 Cerebral infarction due to thrombosis of
    right cerebellar artery
  • I63.342 Cerebral infarction due to thrombosis of
    left cerebellar artery
  • I63.349 Cerebral infarction due to thrombosis of
    unspecified cerebellar artery

43
Glasgow Coma Scale
  • The 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).

44
(No Transcript)
45
  • R40.20 Unspecified coma
  • Coma NOS
  • Unconsciousness NOS
  • R40.21 Coma scale, eyes open (4 levels)
  • R40.211 Coma scale, eyes open, never
  • R40.212 Coma scale, eyes open, to pain
  • R40.213 Coma scale, eyes open, to sound
  • R40.214 Coma scale, eyes open, spontaneous
  • R40.22 Coma scale, best verbal response (5
    levels)
  • R40.221 Coma scale, best verbal response, none
  • R40.222 Coma scale, best verbal response,
    incomprehensible words
  • R40.223 Coma scale, best verbal response,
    inappropriate words
  • R40.224 Coma scale, best verbal response,
    confused conversation
  • R40.225 Coma scale, best verbal response,
    oriented
  • R40.23 Coma scale, best motor response (6 levels)
  • R40.231 Coma scale, best motor response, none
  • R40.232 Coma scale, best motor response,
    extension
  • R40.233 Coma scale, best motor response,
    abnormal
  • R40.234 Coma scale, best motor response, flexion
    withdrawal

7th digit when analyzed 0 unspecified time 1
in the field (EMT or ambulance 2 at arrival
in ED 3 at hospital admission 4 24 hours or
more after admission
46
Late Effects
  • Identify specific late effects
  • Aphasia, dysphagia, neglect, hemiparesis
    (dominant or nondominant), etc.
  • Identify specific insult
  • Late effect SAH, SDH, ICH
  • Late effect embolic stroke or localized occlusive
    stroke
  • Identify when monoplegia, hemiplegia

47
Late Effects ICD-9
  • 438.0 Cognitive deficits
  • 438.1 Speech and language deficits
  • 438.10 Speech and language deficit, unspecified
  • 438.11 Aphasia
  • 438.12 Dysphasia
  • 438.13 Dysarthria
  • 438.14 Fluency disorder
  • 438.19 Other speech and language deficits
  • 438.2 Hemiplegia/hemiparesis
  • 438.20 Hemiplegia affecting unspecified side
  • 438.21 Hemiplegia affecting dominant side
  • 438.22 Hemiplegia affecting nondominant side
  • 438.3 Monoplegia of upper limb
  • 438.30 Monoplegia of upper limb affecting
    unspecified side
  • 438.31 Monoplegia of upper limb affecting
    dominant side
  • 438.32 Monoplegia of upper limb affecting
    nondominant side
  • 438.4 Monoplegia of lower limb
  • 438.40 Monoplegia of lower limb affecting
    unspecified side
  • 438.41 Monoplegia of lower limb affecting
    dominant side

48
  • 438.5 Other paralytic syndrome
  • Use additional code to identify type of
    paralytic syndrome, such as
  • locked-in state (344.81)
  • quadriplegia (344.00-344.09)
  • 438.50 Other paralytic syndrome affecting
    unspecified side
  • 438.51 Other paralytic syndrome affecting
    dominant side
  • 438.52 Other paralytic syndrome affecting
    nondominant side
  • 438.53 Other paralytic syndrome, bilateral
  • 438.6 Alterations of sensations
  • Use additional code to identify the altered
    sensation
  • 438.7 Disturbances of vision
  • Use additional code to identify the visual
    disturbance
  • 438.8 Other late effects of cerebrovascular
    disease
  • 438.81 Apraxia
  • 438.82 Dysphagia
  • Use additional code to identify the type of
    dysphagia, if known (787.20-787.29)
  • 438.83 Facial weakness
  • 438.84 Ataxia
  • 438.85 Vertigo

49
Sequelae ICD-10
4th digits 0 nontraumatic subarachnoid
hemorrhage, 1 nontraumatic intracerebral
hemorrhage, 2 nontraumatic intracranial
hemorrhage, 3 cerebral infarction
  • I69.x0 Unspecified sequelae of specific type of
    stroke
  • I69.x1 Cognitive deficits following specific type
    of stroke
  • I69.x2 Speech and language deficits following
    specific type of stroke
  • I69.x20 Aphasia following specific type of
    stroke
  • I69.x21 Dysphasia following specific type of
    stroke
  • I69.x22 Dysarthria following specific type of
    stroke
  • I69.x23 Fluency disorder following specific type
    of stroke
  • I69.x28 Other speech and language deficits
    following specific type of stroke
  • I69.x3 Monoplegia of upper limb following
    specific type of stroke plus 6th digit for side
  • I69.x4 Monoplegia of lower limb following
    specific type of stroke plus 6th digit for side

50
4th digits 0 nontraumatic subarachnoid
hemorrhage, 1 nontraumatic intracerebral
hemorrhage, 2 nontraumatic intracranial
hemorrhage, 3 cerebral infarction
  • I69.x5 Hemiplegia and hemiparesis following
    specific type of stroke plus 6th digit for
    laterality
  • I69.x6 Other paralytic syndrome following
    specific type of stroke plus 6th digit for
    laterality
  • I69.x9 Other sequelae of specific type of stroke
  • I69.x90 Apraxia following specific type of
    stroke
  • I69.x91 Dysphagia following specific type of
    stroke
  • Use additional code to identify the type of
    dysphagia, if known (R13.1-)
  • I69.x92 Facial weakness following specific type
    of stroke
  • Facial droop following specific type of stroke
  • I69.x93 Ataxia following specific type of stroke
  • I69.x98 Other sequelae of specific type of stroke

51
Cardiac Rehab Do You Use 428/L50 for Your Billing?
  • 428.1 L50.1 Acute pulmonary edema from
    acute left heart failure
  • 428.20 L50.20 Unspecified systolic heart
    failure
  • 428.21 L50.21 Acute systolic heart failure
  • 428.22 L50.22 Chronic systolic heart failure
  • 428.23 L50.23 Acute on chronic systolic heart
    failure
  • 428.30 L50.30 Unspecified diastolic heart
    failure
  • 428.31 L50.31 Acute diastolic heart failure
  • 428.32 L50.32 Chronic diastolic heart failure
  • 428.33 L50.33 Acute on chronic diastolic heart
    failure
  • 428.40 L50.40 Unspecified combined systolic
    and diastolic heart failure
  • 428.41 L50.41 Acute combined systolic and
    diastolic heart failure
  • 428.42 L50.42 Chronic combined systolic and
    diastolic failure
  • 428.43 L50.43 Acute on chronic combined
    systolic and diastolic heart failure

52
Cardiomyopathy is not the same as chronic LV
systolic failure
53
Cardiomyopathy The Other Causes
  • Hypertensive
  • Infectious myocarditis
  • Collagen vascular diseases
  • Transplant rejection
  • Sarcoidosis
  • Alcohol toxicity
  • Chemotherapeutic agents
  • Lead poisoning
  • Cocaine or amphetamine use
  • Ischemic
  • Alcoholic
  • Nutritional deficiencies
  • Thyroid disease
  • Diabetic CMP
  • Obesity
  • Amyloidosis
  • Hemochromatosis
  • Scleroderma
  • Radiation myocarditis
  • Septal hypertrophy
  • IHSS

49
54
NYHA Classes of Heart Failure All of these are
Chronic Heart Failure
Class Patient Symptoms
Class I (Mild) No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea (shortness of breath).
Class II (Mild) Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea.
Class III (Moderate) Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea.
Class IV (Severe) Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased.
55
Heart Failure Caveat
  • CODERS MAY NOT Assign codes from Lab results
  • Diastolic failure is only diastolic failure when
    you CALL it diastolic failure or heart failure
    due to chronic diastolic dysfunction
  • Systolic failure is only systolic failure
  • when you CALL it systolic failure or heart
    failure due to chronic systolic dysfunction

56
Rehab for Fractures Example Specificity in
Fractures
Category 13 Etiology, anatomic site, severity,
other detail 46 Extension 7
S52 Fracture of forearm S52.5 Fracture of
lower end of radius S52.52 Torus fracture of
lower end of radius S52.521 Torus fracture of
lower end of right radius S52.521A Torus
fracture of lower end of right radius, initial
encounter for closed fracture
57
Be Acquainted with Second Digit
  • 0 Head
  • Neck
  • Thorax
  • Abd/low back/pelv
  • Shoulder/upper arm
  • Elbow/forearm
  • Wrist/hand
  • Hip/thighs
  • Knee/lower leg
  • Ankle/foot/toes

http//www.ncbi.nlm.nih.gov
58
Third Digit 4/5 Greater
Specificity General type of injury
of location of injury
  • 0 Contusion
  • Open wound
  • Fracture
  • Dislocation
  • Injury nerves
  • Injury vessels
  • Muscle/fascia/tendon
  • Crush injury
  • Traumatic amputation
  • Unspecified
  • Proximal or distal
  • Displaced or nondisplaced
  • Eponyms of specific fracture types (Colles,
    Bartons, etc.)

59
Be Acquainted with Sixth Digit
60
And Then There Were Seven (Digits) for Injuries
61
Seventh Digit - Code extension
  • Type of Encounter for Injuries Chapter 19
  • Sequelae
  • Complications or
  • conditions that
  • arise as a direct
  • result of the injury
  • Identifies injury
  • responsible for
  • sequelae
  • Initial Encounter
  • Active treatment
  • Surgery
  • ED
  • E/M by new phys
  • Subsequent Encounter
  • Routine care
  • Healing or recovery phase

62
7th Digit Understanding
  • A, B, C Examples of active treatment are
    surgical treatment, emergency department
    encounter, and evaluation and treatment by a new
    physician. The appropriate 7th character for
    initial encounter should also be assigned for a
    patient who delayed seeking treatment for the
    fracture or nonunion.
  • D, E, F Fractures are coded using the
    appropriate 7th character for subsequent care for
    encounters after the patient has completed active
    treatment of the fracture and is receiving
    routine care for the fracture during the healing
    or recovery phase. Examples of fracture aftercare
    are cast change or removal, removal of external
    or internal fixation device, medication
    adjustment, and follow-up visits following
    fracture treatment.

63
  • A  Initial encounter for closed fracture
  • B  Initial encounter for open fracture type I or
    II
  • C  Initial encounter for open fracture type IIIA,
    IIIB, or IIIC
  • D  Subsequent encounter for closed fracture with
    routine healing
  • E  Subsequent encounter for open fracture type I
    or II with routine healing
  • F  Subsequent encounter for open fracture type
    IIIA, IIIB, or IIIC with routine healing
  • G  Subsequent encounter for closed fracture with
    delayed healing
  • H  Subsequent encounter for open fracture type I
    or II with delayed healing

64
  • J  Subsequent encounter for open fracture type
    IIIA, IIIB, or IIIC with delayed healing
  • K Subsequent encounter for closed fracture with
    nonunion
  • M Subsequent encounter for open fracture type I
    or II with nonunion
  • N Subsequent encounter for open fracture type
    IIIA, IIIB, or IIIC with nonunion
  • P Subsequent encounter for closed fracture with
    malunion
  • Q Subsequent encounter for open fracture type I
    or II with malunion
  • R Subsequent encounter for open fracture type
    IIIA, IIIB, or IIIC with malunion
  • S  Sequela

65
7th Digit Understanding
  • Care of complications of fractures, such as
    malunion and nonunion, should be reported with
    the appropriate 7th character for subsequent care
    with nonunion (K, M, N,) or subsequent care with
    malunion (P, Q, R).
  • Closed fracture code
  • Open fracture with Gustilo classification
    designation

66
Open Fractures
  • Forearm (S52), Femur (S72) and lower leg (S82)
  • Seventh character extensions to identify open
    fractures (Gustilo classification)
  • I Low energy, wound less than 1 cm
  • II Greater than 1 cm with moderate soft
    tissue damage
  • III High energy wound greater than 1 cm with
    extensive soft tissue damage
  • IIIA Adequate soft tissue cover
  • IIIB Inadequate soft tissue cover
  • IIIC Associated with arterial injury

67
Gustilo Open Fracture Classification
Complete version Complete version
Grade I Skin lesion lt 1 cm clean simple bone fracture with minimal comminution
Grade II Skin lesion gt 1 cm no extensive soft tissue damage minimal crushing moderate comminution and contamination
Grade III Extensive skin damage with muscle and neurovascular involvement AND/OR High-speed crush injury Segmental of highly comminuted fracture Segmental diaphyseal loss Wound from high velocity weapon Extensive contamination of the wound bed Any size open injury with farm contamination
Grade IIIA Extensive laceration of soft tissues with bone fragments covered usually high-speed traumas with severe comminution or segmental fractures
Grade IIIB Extensive lesion of soft tissues with periosteal stripping and contamination severe comminution due to high-speed traumas usually requires replacement of exposed bone with a local or free flap as a cover
Grade IIIC Exposed fracture with arterial damage that requires repair
68
Allay the Fears
  • Think about the fracture and how you would
    describe it to an internist
  • Name the bone
  • Name the part of the bone involved
  • Name the kind of fracture (Colles, Bartons) if
    there is a common name
  • Identify if its displaced or not, open or closed
  • If open, describe how extensive is the local
    damage
  • Choose the code that has those words in it

69
Clavicle Fractures
  • According to the American Academy of Family
    Physicians (AAFP), the anatomic site of the
    clavicle fracture is typically described using
    the Allman classification, which divides the
    clavicle into thirds.
  • Group I (midshaft) fractures occur on the middle
    third of the clavicle
  • Group II fractures on the lateral (distal) third
    and
  • Group III fractures on the medial (proximal)
    third.

70
Coding Clavicles
  • S42.0       Fracture of clavicle
  • S42.01     Fracture of sternal end of clavicle
  • S42.011 anterior displaced right 5th digits
  • S42.012 anterior displaced left
  • S42.014 posterior displaced right
  • S42.015 posterior displaced left
  • S42.017 nondisplaced right
  • S42.018 nondisplaced left
  • S42.02     Fracture of shaft of clavicle
  • S42.03     Fracture of lateral end of clavicle

Should never use 4th digit of 0 for unspecified
part of clavicle nor 5th digit of 3, 6 or 9 for
not knowing if right or left clavicle
71
Femoral Neck Fractures 9 vs 10
  • 820.0 Transcervical fracture, closed
  • 820.00 Intracapsular section, unspec.
  • 820.01 Epiphysis (separation) (upper)
  • 820.02 Midcervical section
  • 820.03 Base of neck
  • 820.09 Other (head, subcapital)
  • 820.1 Transcervical fracture, open
  • 820.10 Intracapsular section, unspec.
  • 820.11 Epiphysis (separation) (upper)
  • 820.12 Midcervical section
  • 820.13 Base of neck
  • 820.19 Other
  • 820.2 Pertrochanteric fracture, closed
  • 820.20 Trochanteric section, unspecified
    (greater, lesser, etc.)
  • 820.21 Intertrochanteric section
  • 820.22 Subtrochanteric section
  • 820.3 Pertrochanteric fracture, open
  • 820.30 Trochanteric section, unspec.
  • 820.31 Intertrochanteric section
  • S72.00 Fracture unspec part neck of femur
  • S72.01 Unspecified intracapsular fracture R/L
  • S72.02 Fracture (separation) epiphysis femur
    (displaced, nondisplaced digits, R/L)
  • S72.03 Midcervical fracture (d, nonD, R/L)
  • S72.04 Base of neck fracture (d, nonD, R/L)
  • S72.05 Unspecified fracture head R/L
  • S72.06 Articular fracture head of femur (d,
    nonD, R/L)
  • S72.09 Other fx head and neck of femur R/L
  • S72.10 Unspec trochanteric fracture R/L
  • S72.11 Fracture greater trochanter (d, nonD,
    R/L)
  • S72.12 Fracture lesser trochanter (d, nonD, R/L)
  • S72.13 Apophyseal fracture (d, nonD, R/L)
  • S72.14 Intertrochanteric fracture (d, nonD, R/L)
  • S72.2 Subtrochanteric fracture (d, nonD, R/L)

72
Femoral Neck Fractures
  • Name the part of the neck as usual
  • Identify if its nondisplaced or displaced
  • State which side of the body
  • It just makes sense

73
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)

74
Traumatic Fracture vs Pathologic
  • M84.3 Stress fracture
  • M84.4 Pathologic fracture NEC
  • M84.5 Pathologic fracture in neoplastic disease
  • M84.6 Pathologic fracture in other specified
    disease name the disease, too (eg.,
    osteoporosis M80.x)

75
Now the Fifth Digit for the Bone
  • 0 Head
  • Neck
  • Thorax
  • Abd/low back/pelv
  • Shoulder/upper arm
  • Elbow/forearm
  • Wrist/hand
  • Hip/thighs
  • Knee/lower leg
  • Ankle/foot/toes

76
Be Acquainted with Sixth Digit
77
Specificity is NOT Always Possible
  • Sign/Symptom/Unspecified Codes
  • In 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 patients 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 isnt 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 patients
    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.
78
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

79
Anemia and Complexity of Medical Decision Making
  • Non Specific
  • Anemia
  • Specific
  • Anemia DUE TO chronic renal failure
  • Anemia 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

80
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.

81
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.)

82
What IS Encephalopathy?
  • Internally produced toxins in liver disease
    (hepatic encephalopathy), renal disease (uremic
    encephalopathy), persistent effects of lack of
    blood flow to the brain (hypoxic brain damage),
    sepsis, hypertensive, hypernatremic (gt160),
    hypercalcemic
  • Externally introduced toxins as bromidism, lead
    encephalopathy, persistent effects of long term
    alcohol use (Korsakoffs, Wernickes)

83
Other Encephalopathies
  • Mitochondrial encephalopathy
  • Hashimotos encephalopathy
  • Lyme encephalopathy
  • Transmissible spongiform encephalopathy
  • Lyme encephalopathy
  • Hypoxic ischemic encephalopathy (HIE) newborns
    only

84
What ISNT Encephalopathy
  • Alzheimers, Picks, senile, presenile dementia
    with or without delirium, with or without
    behavioral disturbances
  • Coma after stroke or head trauma
  • Drunkenness
  • Effects of illicit drugs or poisoning with
    overdosage of prescribed drugs
  • Adverse effects or desired effects of sedative
    medications

85
Other Encephalopathy ICD-9
  • 349.82 Toxic encephalopathy
  • 348.31 Metabolic encephalopathy
  • 348.39 Other encephalopathy
  • 291.2 Alcoholic
  • 437.2 Hypertensive

86
Encephalopathy ICD-10
  • G92 Toxic encephalopathy
  • G93.41 Metabolic encephalopathy
  • G93.49 Other encephalopathy
  • F10.26 Alcoholic (Wiernicke-Korsakoff psychosis)
  • E51.2 Wiernickes nutritional encephalopathy
  • I67.4 Hypertensive encephalopathy
  • P91.6X Hypoxic ischemic encephalopathy
  • P91.61 mild, P91.62 moderate, P91.63 severe

87
Hepatic Encephalopathy Not Due to Viral Hepatitis
  • ICD-9
  • 572.2 Hepatic encephalopathy
  • ICD-10
  • K71.11 Toxic liver disease with hepatic necrosis,
    with coma
  • K72.01 Acute and subacute hepatic failure with
    coma
  • K72.11 Chronic hepatic failure with coma
  • K72.91 Hepatic failure, unspecified with coma

88
Intellectual Disability Mental Retardation
  • Identify cause (hypoxic ischemic encephalopathy
    occurred at birth, anoxic brain damage occurred
    after the birth processany other cause, other
    brain damage or defect)
  • Stratification
  • Mild IQ level 50-55 up to about 70
  • Moderate IQ level 35-40 up to about 50-55
  • Severe IQ level 20-25 up to about 35-40
  • Profound IQ level below 20-25

89
Malnutrition
  • Malnutrition, not specified
  • Mild (lt10 loss)
  • Moderate (10-20 loss)
  • Severe (nutritional atrophy - marasmus)
  • Consider this with chronic disease, massive
    weight loss, cachexia (gt20 weight loss)
  • Consider the acute malnutrition of surgery,
    trauma and sepsis
  • All of the above add risk to any disease and any
    surgery

90
SGA / A.N.D. A.S.P.E.N. Stratification
Subjective Global Assessment Scoring
Sheet Patient Name_________________________Patien
t ID_____________Date_______________ Part 1
Medical History S GA Score 1. Weight Change A B
C A. Overall change in past 6 months kgs. B.
Percent change ______ gain - lt 5 loss _____
5-10 loss _____ gt 10 loss C. Change in past 2
weeks ______ increase ______ no change ______
decrease 2. Dietary Intake A. Overall change
_______no change _______change B. Duration
______weeks C. Type of change ______suboptimal
solid diet ________ full liquid
diet _______hypocaloric liquid ________
starvation 3. Gastrointestinal Symptoms
(persisting for gt2 weeks) ____none _______nausea
_____vomiting____ diarrhea ________ anorexia 4.
Functional Impairment (nutritionally related) A.
Overall impairment none moderate severe B.
Change in past 2 weeks improved no
change regressed Part 2 Physical Examination S
GA Score Normal Mild Moderate Severe 5.
Evidence of Loss of subcutaneous fat Muscle
wasting Edema Ascites (hemo only) Part 3 SGA
Rating (check one) A??. Well-Nourished B??.
Mildly-Moderately Malnourished C??. Severely
Malnourished
91
(No Transcript)
92
(No Transcript)
93
(No Transcript)
94
Clinical What it IS!
95
Excisional Debridement
  • Is considered a surgical removal or cutting
    away of devitalized tissue, necrosis, or slough
    down to healthy tissue that can heal
  • Surgical procedure with MS-DRG impact
  • This includes burns, wounds or infection
  • Depending on the circumstances, this can be
    accomplished in the surgical suite, or at the
    bedside, emergency room, etc.

95
96
Non-excisional Debridement
  • Flushing, brushing and washing of the burn, wound
    or infection (waterjet is included) -
    nonoperative in nature
  • Removal of devitalized tissue, necrosis, or
    slough
  • This could include minor snipping of tissue
    followed by Hubbard Tank therapy
  • Also includes minor removal of loose fragments
    via scissors
  • This includes wounds, burns and/or infection

96
97
Paint the picture of the patient properly with
WORDS
may not be
So the coder can paint the same picture with
codes.
98
Motto For The Age
If you dont look good, we dont look good
Vidal sassoon, ca 1985 Father of modern medical
economics
99
Handling the Problem List
  • Its an Epic Task

100
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_at_virginia.edu
101
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.
102
  • 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.

103
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?

104
If the docs don't get it, nothing else matters!
105
Questions and Answers Your Ideas and
Comments
About PowerShow.com