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Clinical Documentation Improvement
Medical Staff Transition to ICD-10
DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.
Conflict of Interest Disclosure
Robert S. Gold, MD
Has no real or apparent
conflicts of interest to report.
© 2012 HIMSS
Session Objectives
Learn what your facility needs to know in order to attract the cooperation of the medical staff in the
transition to ICD-10 ... and what to avoid.
Learning Objectives:
1. Evaluate the needs of the members of the medical staff
2. Discuss how to effectively market ICD-10 to
doctors and their midlevels
3. Describe how CDI can get you there with universal acceptance by the medical staff and avoid alienating them
• Cost per patient
• Resource utilization
• Length of stay
• Complications
• Morbidity
• Mortality
• Outcomes
• Fraud and abuse
Medicine Under the Microscope
• Documentation leads to identification of
diagnoses and procedures
• Recognition of diagnoses and procedures lead to ICD codes – THE TRUE KEY
• ICD codes lead to DRG assignment
• DRG assignment massaged to “Severity
Adjusted DRGs”
• Severity adjusted data leads to morbidity and mortality rates
Where Does Data Come From?
• The DRG – hospital reimbursement
• APR-DRGs – physician/hospital profiles
• Documentation’s relationship to code assignments
• Codes and APR-DRGs
• Codes and profiles
ICD-9-10-CM
Relationship Between the Medical
Record and the ―Data‖
7
Issues of Concern
• Severity of illness – conditions that make the principal diagnosis more costly – ALL diagnoses, ALL procedures
• Risk of mortality – conditions that add to the likelihood that a patient will die – ALL diagnoses, ALL procedures
• Patient safety – identification of risk issues that can be minimized or controlled
• Teaching your medical staff the important facts of the business of medicine – things that will affect them the rest of their professional careers
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
What is an Index?
• HealthGrades.com tells everyone about the reputation of the hospital and the medical staff with no input from the physicians.
• Patients can access this data to determine where they will seek care.
Hospital Report Card
Observed mortality
Expected mortalityFrom severity adjusted DRGs
=1; as good as the next guy
<1; preferred provider – significantly better
>1; excessive mortality; find another provider -
Profiles Come from
Severity Adjusted Statistics
S t F ra n c is S o u th e a s t H e a r t la n d S S M M is s o u r i S t. M a ry 's M id d le s e x
M e d C e n H o s p ita l R e g io n a l S t C la re D e lta C e n tra lia H o s p ita l
R e s p ira to ry D is e a s e s
C O P D
H o s p p lu s 6 m o n th s
P n e u m o n ia
H o s p p lu s 6 m o n th s
R e s p ira to ry F a ilu re
H o s p p lu s 6 m o n th s
S e p s is
H o s p p lu s 6 m o n th s
C a rd io v a s c u la r D is e a s e s
H e a r t F a ilu re
H o s p p lu s 6 m o n th s
A c u te M I
H o s p p lu s 6 m o n th s
S tro k e
H o s p p lu s 6 m o n th s
In te rv C a rd io lo g y N R N R N R
H o s p p lu s 6 m o n th s N R N R N R
C A B G N R N R N R
H o s p p lu s 6 m o n th s N R N R N R
S u rg e ry
O R IF H ip M a j C o m p l N R
P ro s ta te M a j C o m p
C h o le c ys te c to m y M a j C
• Physician quality profiles (M&M)
• Physician utilization profiles (efficiency of treating patients)
• Physician E&M levels now
• Physician E&M levels in the future including P4P
• Interference of daily smooth work flow by needs of Utilization Review
• HOW I LOOK TO THE WORLD
How Does This Affect Me?
• The sicker your patient is…
• The higher the complexity of
medical decision making…
• Justifying an appropriately higher level of E&M
Documentation’s Effect on E&M Coding and Physician Income
Effect on Quality of Care
• Identifying a condition with the proper words permits retrieval of mortality data
• Identifying a condition by your thoughts permits others who treat your patients and follow you to know what you’re thinking
• Identifying a condition specifically permits quality indicators to be extracted retrospectively
• Hierarchical condition category risk adjustment – the more complex the disease, the higher the risk, the higher your reimbursement
• Billing only vanilla codes reaps least rewards– 250.00 is diabetes type 2, not stated as
uncontrolled – is this ALL of your patients?
– 428.0 is CHF with no additional risk – is this ALL of your patients?
HCC RAs - Here Since 2004
HCC Cat # Description Weight
15 DM with renal (250.4x) or circulatory manif (250.7x)
.508
16 DM with neurol (250.6x) or other spec manif (250.8x)
.408
17 DM with acute complications (250.1x, 250.2x, 250.3x)
.339
18 DM with retinopathy (250.5x) or unspecified manif (250.9x)
.259
19 DM uncomplicated (250.00) .162
The More Complex the Diabetic, the Higher the Payments
Provider Members Risk Score PMPM
Average 5,011 0.963 $688.22
Providers
A 14 0.650 $508.77
B 11 0.820 $594.48
C 9 1.080 $760.94
D 14 1.220 $803.54
E 14 1.380 $866.56
F 12 1.750 $1,127.34
IDEAL 1.08-1.10
Risk Adjusted Capitation
Disclosed May 16, 2008
Acute Care Episode project
Combine Part B payments with Part A
“Value Based Centers” to be identified trial
starting with Texas, Oklahoma, New
Mexico and Colorado
Value based purchasing
28 cardiac and 9 orthopedic inpatient
surgical services
Gainsharing also permitted here
ACEs Are Wild
September 2, 2011
Bundles physician and hospital payment into one lump sum could represent a long-term, revolutionary solution to that age-old question.
Testing four new bundled payment plans, according to a Fact Sheet released August 23
Three models involve retrospective payment, one a prospective payment determined by MS-DRG
Aggregate Medicare payment for the episode will be reconciled against the target price. Savings beyond the discount reflected in the target price will be paid to the participants to share among the participating providers.
News: CMS releases bundled payment information
A s s o c ia te d P re s s
B y R IC A R D O A L O N S O -Z A L D IV A R
F e d s to a l lo w u s e o f M e d ic a re d a ta to r a te d o c to r s
W A S H IN G T O N —
P ic k in g a s p e c ia lis t fo r a d e lic a te m e d ic a l p ro c e d u re lik e a h e a rt
b y p a s s c o u ld g e t a lo t e a s ie r in th e n o t - to o -d is ta n t fu tu re .
T h e g o v e rn m e n t a n n o u n c e d M o n d a y th a t M e d ic a re w ill f in a lly a llo w
its e x te n s iv e c la im s d a ta b a s e to b e u s e d b y e m p lo y e rs , in s u ra n c e
c o m p a n ie s a n d c o n s u m e r g ro u p s to p ro d u c e re p o rt c a rd s o n lo c a l
d o c to rs — a n d im p ro v e c u rre n t ra t in g s o f h o s p ita ls .
B y a n a ly z in g m a s s e s o f b illin g re c o rd s , e x p e rts c a n g le a n s u c h
c r it ic a l in fo rm a tio n a s h o w o f te n a d o c to r h a s p e rfo rm e d a p a rt ic u la r
p ro c e d u re a n d g e t a g e n e ra l s e n s e o f p ro b le m s s u c h a s
p re v e n ta b le c o m p lic a t io n s .
D o c to rs w ill b e in d iv id u a lly id e n t if ia b le th ro u g h th e M e d ic a re f ile s ,
b u t p e rs o n a l d a ta o n th e ir p a t ie n ts w ill re m a in c o n f id e n t ia l.
C o m p ile d in a n e a s ily u n d e rs to o d fo rm a t a n d re le a s e d to th e p u b lic ,
m e d ic a l re p o rt c a rd s c o u ld b e c o m e a p o w e rfu l to o l fo r p ro m o tin g q u a lity c a re .
M e d ic a re a c t in g a d m in is tra to r M a r ily n T a v e n n e r c a lle d th e n e w p o lic y "a g ia n t s te p fo rw a rd in
m a k in g o u r h e a lth c a re s y s te m m o re tra n s p a re n t a n d p ro m o tin g in c re a s e d c o m p e tit io n ,
a c c o u n ta b ility , q u a lity a n d lo w e r c o s ts ."
• 1662: London Bills of Mortality–attempt to define mortality rate and causes under age 6 in England; no particular classification
• “Having premised these general Advertisements, our first observations upon the Casualties shall be, that in twenty years there dying of all Diseases and Casualties, 229,150 that 71,124 dyed of the Thrush, Convulsions, Rickets, Teeth, and Worms; and as Abortives, Chrysomes, Infants, Livergrowns, and Overlaids; that is to say, that about 1/3 of the whole dies of those Diseases, which we guess did all light upon children under four or five years old”
Origins
• 1853–1855: Uniform Classification of Causes of Death–England and France– first divided diseases by anatomic site
• 1855: Revision added; England, Germany and Switzerland distinguished between general diseases and those specified by anatomic site
Advancements
• 1898: American Public Health Association
recommended adoption of “Bertillon
Classification of Causes of Death” for all North America
• 1899: Agreement to update system every
ten years
• 1900: First international conference for
Revision of the Bertillon or “International List of Causes of Death” – 26 nations met in
Paris; next three revisions held there
Progress
• 1900: New parallel list of nonfatal diseases proposed and adopted in 1909
• Changed title to International Classification of Causes of Sickness and Death
• 1928: League of Nations “Mixed Commission” drafted proposals for the 4th
and 5th revisions of the International List of Causes of Death – became WHO
• 1929: U.S. government volunteered to spearhead further statistical tabulations
• 1938: Update added causes of stillbirth
More Growth
• Uniform list containing both causes of
mortality and causes of morbidity initiated
• 1946: Sixth Revision formally adopted need for a single listing International Classification
of Diseases, Injuries and Causes of Death
• 1955: Seventh Revision – amended errors
and inconsistencies
• 1965: Eighth Revision – classified by etiology rather than particular manifestation
Toward the Present
• 1975: Ninth Revision updated, added detail with 4th and 5th digit specificity, reclassified where appropriate; added impairments, handicaps, and procedures for the first time –implemented 1979
• The world adopted ICD-10 in 1999–except…
Back to the Future
Prep for the EHR Mandate
Is It Y2K All Over Again?
• 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
Is the EHR a Friend or Foe?
ICD-9
ICD-10
Change in the Entire System
• 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 7
alphanumeric places
• ICD-9 14,000 codes; ICD-10 68,000 codes
• ICD-9 has no specificity as to which side of
the body (eg., percent burn on right or left arm or leg – side of paralysis after stroke)
Notable Changes
Example - Fracture
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
Category 1 – 3
Etiology,
anatomic site,
severity, other
detail 4 – 6
Extension 7
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
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
Example Specificity - Location
It’s a retrospective system –NOT a concurrent help!
Enter diagnosis
_______________
Ella McPherson 1323 Jefferson St.112233445 OtowannaJan 22, 1934
I50Heart failureI50.1 Left ventricular failureI50.2 Systolic (congestive) heart
failureI50.20 Unspecified systolic (congestive) heart failure
I50.21 Acute systolic (congestive) heart failure
I50.22 Chronic systolic (congestive) heart failure
I50.23 Acute on chronic systolic (congestive) heart failure
I50.3Diastolic (congestive) heart failure
I50.30 Unspecified diastolic (congestive) heart failure
I50.31 Acute diastolic (congestive) heart failure
I50.32 Chronic diastolic (congestive) heart failure
Enter diagnosis
___CHF______
Ella McPherson 1323 Jefferson St.112233445 OtowannaJan 22, 1934
Enter diagnosis
____________
Ella McPherson 1323 Jefferson St.112233445 OtowannaJan 22, 1934
Enter diagnosis
___CHF_________
Ella McPherson 1323 Jefferson St.112233445 OtowannaJan 22, 1934
Is it:
Acute now?
Chronic heart
failure patient?
Chronic heart
failure with acute
exacerbation?
Enter diagnosis
___CHF______
Ella McPherson 1323 Jefferson St.112233445 OtowannaJan 22, 1934
Is it:
Acute now?
X Chronic heart
failure patient?
Chronic heart
failure with acute
exacerbation?
Enter diagnosis
___CHF_________
Ella McPherson 1323 Jefferson St.112233445 OtowannaJan 22, 1934
Is it
Right heart failure
Left heart failure
Biventricular
Shunt
hyperperfusion
Don’t know
Enter diagnosis
___CHF_______
Chronic heart failure
patient
Ella McPherson 1323 Jefferson St.112233445 OtowannaJan 22, 1934
Is it
Right heart failure
X Left heart failure
Biventricular
Shunt
hyperperfusion
Don’t know
Enter diagnosis
___CHF______
Chronic heart failure
patient
Ella McPherson 1323 Jefferson St.112233445 OtowannaJan 22, 1934
Is it due to:
Systolic dysfunction
(EF<40)
Diastolic
dysfunction
(normal EF)
Combination
Don’t know
Enter diagnosis
___CHF_______
Chronic left heart
failure patient
Ella McPherson 1323 Jefferson St.112233445 OtowannaJan 22, 1934
Is it due to:
X Systolic dysfunction
(EF<40)
Diastolic
dysfunction
(normal EF)
Combination
Don’t know
Enter diagnosis
___CHF_______
Chronic left heart
failure patient
Ella McPherson 1323 Jefferson St.112233445 OtowannaJan 22, 1934
As best you know, what is the cause?
Ischemic CMP
Alcoholic CMP
Hypertensive CMP
Valvular CMP
Hypertrophic CMP
Amyloid CMP
Other __________
Unknown
Enter diagnosis
___CHF_____
Chronic systolic left
heart failure
patient
Ella McPherson 1323 Jefferson St.112233445 OtowannaJan 22, 1934
As best you know,
what is the cause?
X Ischemic CMP
Alcoholic CMP
Hypertensive CMP
Valvular CMP
Hypertrophic CMP
Amyloid CMP
Other __________
Unknown
Enter diagnosis
___CHF______
Chronic systolic left
heart failure
patient
Ella McPherson 1323 Jefferson St.112233445 OtowannaJan 22, 1934
Enter diagnosis
___CHF_________
I50.22 Chronic systolic left heart failure
I50.9 Congestive heart
failure
I25.5 Ischemic cardiomyopathy
Ella McPherson 1323 Jefferson St.112233445 OtowannaJan 22, 1934
Remember …
Recent Progression
• ICD-9 has had a flurry of activity over past 4 years– Added specificity
– Added E codes
– Added pediatric diseases, dental, eye
• Docs must be fluent in ICD-9 needs to make an easy transition
• Docs who can’t speak 9 will be lost with 10
52
So the coder can paint the same
picture with codes.
What you want…
what you might get.
may not
be…
Paint the picture of the patient properly with WORDS
Res Ipsa Loquiter
• The physician’s pen leads to all data
• The physician’s pen leads to all payments for healthcare
• No EHR product in the inpatient setting provides help to the practicing physician
• If the docs don’t know how to fill the gaps in the data, how to document diagnostic entities properly …
So What’s GOING to Happen?
Our Mandate – Meaningful Use
How can there be meaningful use of a medical record if nobody knows what’s wrong with the patient?
Frustration in the Field
• “Since we went live, we can’t code anything anymore. There are no useful diagnoses anywhere.”
• “If you have any influence with our EHR people, please ask them to provide a textbox in the Critical Care Nursing Notes. As it is now, we have no idea what’s wrong with our patients.”
• “I’m not going to waste time picking from these lists – my patients are sick.”
What We SORELY Need
• An EHR in the cloud that can be accessed by all healthcare givers with patient authorization
• A common pathway of interaction with the cloud
• An app for the physician’s smart phone/ tablet/computer that communicates with the cloud, the hospital, the office that provides algorithms for diagnoses and procedures in doc-speak
There are various views
regarding the President
Obama’s ability to ensure that
all medical records in the
United States are converted
into the electronic format by
2014 but there is no denying
the fact that an increased
adoption of EMR or electronic
medical records by
physicians, healthcare
organizations and their
related business associates
is now a gradually-
progressing certainty.
Set Your Benchmarks
Share Data with the Med Staff
• Severity adjusted mortality rate by:– Whole hospital
– Medical DRGs whole hospital
– Surgical DRGs whole hospital
– Service line
– Individual physician or groups
• Severity adjusted LOS
• Severity adjusted complication rate
• Severity adjusted costs/patient
“If you don’t look good, we don’t
look good” Vidal sassoon, ca 1985
Father of modern medical economics
Motto For The Age
Questionsand Answers
Your Ideas and Comments