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


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

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

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//
    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
  • Severity adjusted data leads to morbidity and
    mortality rates

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

(No Transcript)
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/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
  • CC time 1hr 45 minutes
  • John Smith MD

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
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
Profiles Come from Severity Adjusted Statistics
lt1 preferred provider ????? significantly
1 as good as the next guy???
  • Observed mortality
  • Expected mortality
  • From severity adjusted DRGs

gt1 excessive mortality find another provider -
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Patient Safety
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
  • 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, 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
  • 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 411 pm EDT
    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.

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.

Clinical Integration
  • CMS proposes to pay separately for complex
    chronic care management services starting in
  • "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
  • Vascular catheter associated infections
  • Pressure ulcers
  • Iatrogenic pneumothorax following central line
  • Object accidentally left in patient
  • Air embolism
  • Reaction from blood incompatibility

Goals of Implementation Prove You Are Value
  • Exceptional severity adjusted data
  • Reasonable occurrence of PSIs/HACs
  • Lower than average Readmissions for Pneumonia,
    Heart Failure, AMI
  • Cooperation with quality initiatives
  • Patient satisfaction

Change in the Entire System
  • ICD-9

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)

Dont Wait Till Tomorrow for ICD-10
How Close Are We?
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
  • 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.
Documentation Needs Whats The Surgery For?
  • Provide the diagnosis for which the surgery is
    being performed
  • Provide acuity, complexity
  • Tell why its necessary for that diagnosis
  • DONT just say that the patient is being admitted
    for the surgery
  • DONT just provide signs and symptoms

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

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

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?
Risk Stratification for Pulmonary Complications
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 gt 4 units
Modified NSQIP Data Sheet
Was It Present on Admission?
  • Patient safety indicators may give us a black eye
    if its 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 dont document it, we get
  • charged with it!

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
  • (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
Strabismus/Esotropia ICD-9
  • 378.0 Esotropia
  • Convergent concomitant strabismus
  • Excludes intermittent esotropia (378.20-378.22)
  • 378.00 Esotropia, unspecified
  • 378.01 Monocular esotropia
  • 378.02 Monocular esotropia with A pattern
  • 378.03 Monocular esotropia with V pattern
  • 378.04 Monocular esotropia with other
  • Monocular esotropia with X or Y pattern
  • 378.05 Alternating esotropia
  • 378.06 Alternating esotropia with A pattern
  • 378.07 Alternating esotropia with V pattern
  • 378.08 Alternating esotropia with other
  • Alternating esotropia with X or Y pattern

Strabismus/Esotropia ICD-10
6th digits 1 right eye 2 - left eye 3
bilateral 9 - unspecified
  • H50.00 Unspecified esotropia
  • H50.01 Monocular esotropia
  • H50.011 Monocular esotropia, right eye
  • H50.012 Monocular esotropia, left eye
  • H50.02 Monocular esotropia with A pattern
  • H50.021 Monocular esotropia with A pattern,
    right eye
  • H50.022 Monocular esotropia with A pattern,
    left eye
  • H50.03 Monocular esotropia with V pattern
  • H50.031 Monocular esotropia with V pattern,
    right eye
  • H50.032 Monocular esotropia with V pattern,
    left eye
  • H50.04 Monocular esotropia with other
  • H50.041 Monocular esotropia with other
    noncomitancies, right eye
  • H50.042 Monocular esotropia with other
    noncomitancies, left eye
  • H50.05 Alternating esotropia
  • H50.06 Alternating esotropia with A pattern
  • H50.07 Alternating esotropia with V pattern
  • H50.08 Alternating esotropia with other

  • 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.

  • 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.)

Diabetic Retinopathy ICD-9 Up to 3 codes for a
  • 362.0 Diabetic retinopathy
  • Code first diabetes (249.5 for DM due to other
    cause, 250.5 for Type 1 or Type 2 DM)
  • 362.01 Background diabetic retinopathy
  • 362.02 Proliferative diabetic retinopathy
  • 362.03 Nonproliferative diabetic retinopathy NOS
  • 362.04 Mild nonproliferative diabetic
  • 362.05 Moderate nonproliferative diabetic
  • 362.06 Severe nonproliferative diabetic
  • 362.07 Diabetic macular edema
  • Note 362.07 must be used with a code for
    diabetic retinopathy (362.01-362.06)

Diabetic Retinopathy ICD-10 Only one combinmation
code for a patient
  • E11.3 Type 2 diabetes mellitus with ophthalmic
  • E11.31 Type 2 diabetes mellitus with unspecified
    diabetic retinopathy
  • E11.32 Type 2 diabetes mellitus with mild
    nonproliferative diabetic retinopathy
  • E11.33 Type 2 diabetes mellitus with moderate
    nonproliferative diabetic retinopathy
  • E11.34 Type 2 diabetes mellitus with severe
    nonproliferative diabetic retinopathy
  • E11.35 Type 2 diabetes mellitus with
    proliferative diabetic retinopathy
  • E11.36 Type 2 diabetes mellitus with diabetic
  • E11.39 Type 2 diabetes mellitus with other
    diabetic ophthalmic complication

6th digit for .31 through .35 1 with macular
edema 9 without macular edema
E08.3 series for other cause of DM E09.3 series
drug or chemical induced DM E10 series for Type 1
DM E11 series for Type 2 DM
Cataract ICD-9
  • 366.0 Infantile, juvenile, and presenile cataract
  • 366.00 Nonsenile cataract, unspecified
  • 366.01 Anterior subcapsular polar cataract
  • 366.02 Posterior subcapsular polar cataract
  • 366.03 Cortical, lamellar, or zonular cataract
  • 366.04 Nuclear cataract
  • 366.09 Other and combined forms of nonsenile
  • 366.1 Senile cataract
  • 366.10 Senile cataract, unspecified
  • 366.11 Pseudoexfoliation of lens capsule
  • 366.12 Incipient cataract
  • 366.13 Anterior subcapsular polar senile
  • 366.14 Posterior subcapsular polar senile
  • 366.15 Cortical senile cataract
  • 366.16 Nuclear sclerosis
  • 366.17 Total or mature cataract
  • 366.18 Hypermature cataract
  • 366.19 Other and combined forms of senile

Cataract ICD-10
6th digits 1 right eye 2 - left eye 3
bilateral 9 - unspecified
  • H26.0 Infantile and juvenile cataract
  • H26.00 Unspecified infantile and juvenile
  • H26.01 Infantile and juvenile cortical,
    lamellar, or zonular cataract
  • H26.03 Infantile and juvenile nuclear cataract
  • H26.04 Anterior subcapsular polar infantile and
    juvenile cataract
  • H26.05 Posterior subcapsular polar infantile and
    juvenile cataract
  • H26.06 Combined forms of infantile and juvenile
  • H26.09 Other infantile and juvenile cataract
  • H25.0 Age-related incipient cataract
  • H25.01 Cortical age-related cataract
  • H25.03 Anterior subcapsular polar age-related
  • H25.04 Posterior subcapsular polar age-related
  • H25.09 Other age-related incipient cataract
  • H25.1 Age-related nuclear cataract
  • H25.2 Age-related cataract, morgagnian type
  • H25.8 Combined forms of age-related cataract

Corneal Ulcer ICD-9
  • 370.0 Corneal ulcer
  • 370.00 Corneal ulcer, unspecified
  • 370.01 Marginal corneal ulcer
  • 370.02 Ring corneal ulcer
  • 370.03 Central corneal ulcer
  • 370.04 Hypopyon ulcer
  • Serpiginous ulcer
  • 370.05 Mycotic corneal ulcer
  • 370.06 Perforated corneal ulcer
  • 370.07 Mooren's ulcer

Corneal Ulcer ICD-10
  • H16.0 Corneal ulcer
  • H16.00 Unspecified corneal ulcer
  • H16.01 Central corneal ulcer
  • H16.02 Ring corneal ulcer
  • H16.03 Corneal ulcer with hypopyon
  • H16.04 Marginal corneal ulcer
  • H16.05 Mooren's corneal ulcer
  • H16.06 Mycotic corneal ulcer
  • H16.07 Perforated corneal ulcer

6th digits 1 right eye 2 - left eye 3
bilateral 9 - unspecified
Blindness Categories ICD-9
  • 369.4 Legal blindness, as defined in U.S.A.
  • Blindness NOS according to U.S.A. definition
  • Excludes legal blindness with specification of
    impairment level (369.01-369.08, 369.11-369.14,
  • 369.6 Profound impairment, one eye
  • 369.60 Impairment level not further specified
  • 369.61 One eye total impairment other eye not
  • 369.62 One eye total impairment other eye
    near-normal vision
  • 369.63 One eye total impairment other eye
    normal vision
  • 369.64 One eye near-total impairment other
    eye not specified
  • 369.65 One eye near-total impairment other
    eye near-normal vision
  • 369.66 One eye near-total impairment other
    eye normal vision
  • 369.67 One eye profound impairment other eye
    not specified
  • 369.68 One eye profound impairment other eye
    near-normal vision
  • 369.69 One eye profound impairment other eye
    normal vision

Blindness Categories ICD-10
  • H54.8 Legal blindness, as defined in USA
  • Blindness NOS according to USA definition
  • Excludes1 legal blindness with specification of
    impairment level (H54.0-H54.7)
  • H54.1 Blindness, one eye, low vision other eye
  • Visual impairment categories 3, 4, 5 in one eye,
    with categories 1 or 2 in the other eye.
  • H54.10 Blindness, one eye, low vision other eye,
    unspecified eyes
  • H54.11 Blindness, right eye, low vision left eye
  • H54.12 Blindness, left eye, low vision right eye
  • H54.4 Blindness, one eye
  • Visual impairment categories 3, 4, 5 in one eye
    normal vision in other eye
  • H54.40 Blindness, one eye, unspecified eye
  • H54.41 Blindness, right eye, normal vision left
  • H54.42 Blindness, left eye, normal vision right

Retinal Detachment ICD-9
  • 361.0 Retinal detachment with retinal defect
  • Excludes detachment of retinal pigment
    epithelium (362.42-362.43)
  • retinal detachment (serous) (without defect)
  • 361.00 Retinal detachment with retinal defect,
  • 361.01 Recent detachment, partial, with single
  • 361.02 Recent detachment, partial, with multiple
  • 361.03 Recent detachment, partial, with giant
  • 361.04 Recent detachment, partial, with retinal
  • 361.05 Recent detachment, total or subtotal
  • 361.06 Old detachment, partial
  • 361.07 Old detachment, total or subtotal
  • 361.3 Retinal defects without detachment
  • Excludes chorioretinal scars after surgery for
    detachment (363.30-363.35)
  • peripheral retinal degeneration without defect
  • 361.30 Retinal defect, unspecified
  • 361.31 Round hole of retina without detachment
  • 361.32 Horseshoe tear of retina without
  • 361.33 Multiple defects of retina without
  • 361.8 Other forms of retinal detachment

Retinal Detachment ICD-10
  • H33.0 Retinal detachment with retinal break
  • Excludes1 serous retinal detachment (without
    retinal break) (H33.2-)
  • H33.00Unspecified retinal detachment with
    retinal break
  • H33.01 Retinal detachment with single break
  • H33.02 Retinal detachment with multiple breaks
  • H33.03 Retinal detachment with giant retinal
  • H33.04 Retinal detachment with retinal dialysis
  • H33.05 Total retinal detachment
  • H33.3 Retinal breaks without detachment
  • Excludes1 chorioretinal scars after surgery for
    detachment (H59.81-)
  • peripheral retinal degeneration without break
  • H33.30 Unspecified retinal break
  • H33.31 Horseshoe tear of retina without
  • H33.32 Round hole of retina without detachment
  • H33.33 Multiple defects of retina without

6th digits 1 right eye 2 - left eye 3
bilateral 9 - unspecified
  • ICD-9
  • 190.5 Differentiated
  • 190.5 Undifferentiated
  • same code
  • Add 198.4 for invasion of optic nerve or choroid
  • Add 365.7x for neovascular glaucoma
  • ICD-10
  • C69.2 Differentiated
  • C69.2 Undifferentiated
  • same code
  • Add C79.49 for invasion of optic nerve or choroid
  • Add H40.5xx for glaucoma due to neoplasm of eye

Malignant Neoplasm Choroid
  • ICD-9
  • 190.6 Melanoma
  • 190.6 Nonmelanoma malignancies of choroid
  • 198.4 Malignancy metastatic to choroid
    Secondary malignant neoplasm other parts of
    nervous system
  • ICD-10
  • C69.3 Melanoma
  • C69.3 Nonmelanoma malignancies of choroid
  • C79.49 Malignancy metastatic to choroid
    Secondary malignant neoplasm other parts of
    nervous system

5th digits for C69.3 1 right eye 2 - left eye 3
bilateral 9 - unspecified
Ophthalmic Manifestations of Systemic Diseases
  • M31.0 Hypersensitivity angiitis
  • Goodpasture's syndrome
  • M31.1 Thrombotic microangiopathy
  • Thrombotic thrombocytopenic purpura
  • M31.2 Lethal midline granuloma
  • M31.3 Wegener's granulomatosis
  • Necrotizing respiratory granulomatosis
  • M31.30 Wegener's granulomatosis without renal
  • M31.31 Wegener's granulomatosis with renal
  • M31.4 Aortic arch syndrome Takayasu
  • M31.5 Giant cell arteritis with polymyalgia
  • M31.6 Other giant cell arteritis
  • M31.7 Microscopic polyangiitis
  • M31.8 Other specified necrotizing vasculopathies
  • Assign the code for the ophthalmic disorder
  • Assign the code for the systemic disease
  • Despite the fact that up to 60 of Wegeners
    patients have ophthalmic manifestations, there is
    no combination code yet.
  • Proptosis
  • Conjunctivitis
  • Dacryocystitis
  • Orbital retraction syndrome

Use Problem List for Systemic Disorder Codes
  • Genetic and chromosomal disorders, eg
  • Cri du chat
  • Pataus trisomy 13
  • Viral disorders, eg
  • Herpes simplex
  • Adenovirus diseases
  • Bacterial disorders, eg
  • Lyme disease
  • Metastatic bacterial endophthalmitis
  • Fungal disorders
  • Collagen diseases
  • Skin disorders

Hypertension ICD-10
  • Essential hypertension (I10) includes high
    blood pressure, hypertension, malignant
    hypertension, accelerated hypertension, benign
  • Secondary hypertension (I15)
  • I15.0 renovascular
  • I15.1 hypertension secondary to other renal
  • I15.2 hypertension secondary to endocrine
    disorders (thyrotoxicosis, pheochromocytoma,
  • 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 14
  • N18.1, 2, 3, 4, 5, 6, 9 for CKD stages 1, 2, 3,
    4, 5, ESRD, unspecified
  • Hypertensive retinopathy H35.03x plus code for
  • H35.031 Hypertensive retinopathy, right eye
  • H35.032 Hypertensive retinopathy, left eye
  • H35.033 Hypertensive retinopathy, bilateral
  • H35.039 Hypertensive retinopathy, unspecified eye

6th digits 1 right eye 2 - left eye 3
bilateral 9 - unspecified
Craniofacial Fractures I-9
  • 801 series for base of skull fractures included
  • fossa
  • anterior
  • middle
  • posterior
  • occiput bone
  • orbital roof
  • sinus
  • ethmoid
  • frontal
  • sphenoid bone
  • temporal bone

Subclassified into closed fracture with 801.0 No
brain injury 801.1 Cerebral contusion or
laceration 801.2 Subarachnoid, subdural or
extradural hemorrhage 801.3 Other intracranial
hemorrhage 801.4 Other intracranial injury 801.5
Open fracture with no brain injury
Craniofacial Fractures I-9
  • 5th digit breakdown into level and state of
  • 801.x0 unspecified state of consciousness
  • 801.x1 with no loss of consciousness
  • 801.x2 with brief less than one hour loss of
  • 801.x3 with moderate 1-24 hours loss of
  • 801.x4 with prolonged more than 24 hours loss
    of consciousness and return to pre-existing
    conscious level
  • 801.x5 with prolonged more than 24 hours loss
    of consciousness, without return to pre-existing
    conscious level
  • 801.x6 with loss of consciousness of unspecified
  • 801.x9 with concussion, unspecified

CranioFacial Fractures
  • S02.19 Other fracture of base of skull
  • Fracture of anterior fossa of base of skull
  • Fracture of ethmoid sinus
  • Fracture of frontal sinus
  • Fracture of middle fossa of base of skull
  • Fracture of orbital roof
  • Fracture of posterior fossa of base of skull
  • Fracture of sphenoid
  • Fracture of temporal bone
  • But must add separate code for intracranial
    injury and additional code for Glasgow coma scale

CranioFacial Fractures
  • S02.2 Fracture of nasal bones
  • S02.3 Fracture of orbital floor
  • S02.2 Fracture of nasal bones
  • S02.3 Fracture of orbital floor
  • S02.4 Fracture of malar, maxillary and zygoma
  • S02.40 Fracture of malar, maxillary and zygoma
  • S02.400 Malar fracture
  • S02.401 Maxillary fracture
  • S02.402 Zygomatic fracture
  • S02.41 LeFort Fracture
  • S02.411 LeFort I fracture
  • S02.412 LeFort II fracture
  • S02.413 LeFort III fracture
  • S02.42 Fracture of alveolus of maxilla

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

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.)

Seventh Digits
  • A initial encounter for closed fracture
  • B initial encounter for open fracture
  • D subsequent encounter for fracture with routine
  • G subsequent encounter for fracture with delayed
  • K subsequent encounter for fracture with nonunion
  • S Sequela

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

(No Transcript)
  • 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
  • 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,
  • R40.23 Coma scale, best motor response (6 levels)
  • R40.231 Coma scale, best motor response, none
  • R40.232 Coma scale, best motor response,
  • R40.233 Coma scale, best motor response,
  • R40.234 Coma scale, best motor response, flexion

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
Anemia Designations
D62 D50.0 D63.1 D63.0 D63.8
  • 285.1 anemia due to acute blood loss FROM
    name it
  • 280.0 anemia due to chronic blood loss FROM
    name it
  • 285.21 anemia due to chronic renal failure and
    what caused the renal failure?
  • 285.22 anemia due to malignant disease effect
    of the tumor!
  • 285.29 anemia due to a specific chronic illness
    and name that illness (chronic hepatitis,
    lupus, osteomyelitis, etc.)

Anemia/Cytopenias in Malignancy
  • There is no code for anemia of chronic disease
  • 280.0 D50.0 anemia due to chronic blood loss
    from bleeding colon cancer
  • 284.11 D61.810 pancytopenia from chemo
  • 284.12 D61.811 pancytopenia from other drugs
  • 284.2 D61.82 pancytopenia from cancer taking
    over bone marrow (myelophthisis) code the
    cancer causing it
  • 284.89 D61.1 aplastic anemia due to chemo,
    other drugs
  • 284.89 D61.2 radiation induced aplastic anemia
  • 285.22 D63.0 anemia due to neoplastic disease
    code the cancer causing it
  • 285.3 D64.81 antineoplastic chemotherapy induced

Sickle Cell Disease
  • Ocular manifestations of sickle cell disease
    result from vascular occlusion, which may occur
    in the conjunctiva, iris, retina, and choroid.
    Because the ocular changes produced by SCD can be
    seen in other diseases, it is important to rule
    out other causes of occlusion, including central
    retinal vein occlusion, Eales disease, and
    retinopathy secondary to diabetes and other
  • Other causes of ocular changes that should also
    be considered include familial exudative
    vitreoretinopathy, polycythemia vera, talc and
    cornstarch emboli, and uveitis.
  • H34.81 Central retinal vein occlusion
  • H34.82 Venous engorgement
  • H34.83 Tributary (branch) retinal vein occlusion
  • H35.02 Exudative retinopathy

Sixth digits 1 OD 2 OS 3 OU 9
unspec Identify the manifestation then identify
the disease
Sickle Cell Disease
  • D57.0 Hb-SS disease with crisis
  • D57.1 Sickle-cell disease without crisis
  • D57.2 Sickle-cell/Hb-C disease
  • D57.20 Sickle-cell/Hb-C disease without crisis
  • D57.21 Sickle-cell/Hb-C disease with crisis
  • D57.3 Sickle-cell trait
  • D57.4 Sickle-cell thalassemia
  • D57.40 Sickle-cell thalassemia without crisis
  • D57.41 Sickle-cell thalassemia with crisis
  • D57.8 Other sickle-cell disorders
  • D57.80 Other sickle-cell disorders without
  • D57.81 Other sickle-cell disorders with crisis

5th or 6th digits for crisis 1 acute chest
syndrome 2 splenic sequestration 0 or 9
unspecified crisis
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
Nutritional Status
  • Malnutrition dietary consult or estimate
  • Mild (lt10 loss)
  • Moderate (10-20 loss)
  • Severe (gt20 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 -
  • Sleep apnea - Secondary hypercoagulable state -
    Diabetes with
  • Cellulitis - Hypertensive heart disease - Chronic
    cor pulmonale

Clinical What it IS!
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.

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
  • 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

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 dont
    document it, YOU DIDNT DO IT.
  • VS, labs, IO, 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 1715.

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!

Handling the Problem List
  • Its 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,
Progress Note Management
  • Copy and paste of massive amounts of trash leads
  • useless notes,
  • inability of others to determine what is wrong
    with the patient NOW
  • inability to validate that ANYTHING YOU DID WAS
  • 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
  • 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
  • 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
  • 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

If the docs don't get it, nothing else matters!
Paint the picture of the patient properly with
may not be
So the coder can paint the same picture with
Motto For The Age
If you dont look good, we dont look good
Vidal sassoon, ca 1985 Father of modern medical
Questions and Answers Your Ideas and
Question 1 Which is True?
  1. ICD-10 shows a totally different appreciation of
    diseases than ICD-9
  2. ICD-10 codes are exact walkovers from the ICD-9
    codes they just look different
  3. ICD-10 codes may look different but the diseases
    didnt change proper documentation will lead to
    proper code assignment
  4. ICD-10 codes are different from ICD-9 only by
    adding the differentiation of Right vs Left

Question 2 Which is False?
  1. Value of purchasing of healthcare is dependent on
    data streams derived from ICD codes
  2. Specific documentation of diseases in ICD-9 will
    be all that is necessary for specific code
    assignments in ICD-10
  3. Bundled payments for healthcare will lead to
    cooperation between practitioners and facilities
  4. We are the only country in the world billing for
    healthcare by ICD codes