Coding Overview and the Data Quality Statement

DQMC – March 2011

Goal

• Quality data on which to base sound decisions– For you– For your Department– For your Commander– For your Service– For the Military Health System (MHS)

Purposes of Coding• Validates medical necessity of services

based on diagnosis• Identifies why patients are being seen • Identifies and quantifies the services you have

provided• Permits retrieval of information for users

• Research and Benchmarking• Administrative and funding decisions• HEDIS reporting

• Key to Population Health - identify trends

Medical Record Documentation

Complete Documentation

Correct Coding

Appropriate Reimbursement and Workload

The critical factor in determining the level of care:

Not what you did….but what you documented!

Types of Coding• ICD-9-CM

– Diagnoses used for all types of encounters/admissions– Procedures used only for inpatients– MS-DRGs are based upon these codes– Updated annually 1 October

• CPT– E&M and procedure codes– Updated annually 1 January

• HCPCS– Supplies, pharmaceuticals/injectables– Updated annually 1 January

Background Information

• ICD-9-CM: Clinical Modification developed in the US and implemented in 1979– Volumes 1&2 Diagnosis Codes (used by all providers)– Volume 3 Procedure Codes (used by hospitals for

inpatient reporting)• ICD-10: Diagnosis classification system

developed by the World Health Organization to replace ICD-9

• ICD-10-CM: US Clinical Modification for ICD-10 diagnosis classification system

• ICD-10-PCS: US procedure classification system to replace ICD-9-CM Volume 3

ICD-10• Tenth addition of ICD was issued in 1993

– Currently used in Europe and Canada

• 5010 electronic transaction standards requirement by 1 January 2012

• US ICD-10 Compliance date is 1 October 2013– ICD-10-CM has expanded upon ICD-9-CM– ICD-10-PCS requires building a 7 character code– Requires coding and documentation training– NO GRACE PERIOD FOR IMPLEMENTATION

ICD-9 & ICD-10 Code Freeze• The last regular, annual updates to both ICD-9-CM and

ICD-10 code sets will be made on October 1, 2011.• On October 1, 2012, there will be only limited code updates

to both the ICD-9-CM and ICD-10 code sets to capture new technologies and diseases as required by section 503(a) of Pub. L. 108-173.

• On October 1, 2013, there will be only limited code updates to ICD-10 code sets to capture new technologies and diagnoses. There will be no updates to ICD-9-CM, as it will no longer be used for reporting.

• On October 1, 2014, regular updates to ICD-10 will begin.  

AHIMA Coder ICD-10 Training Strategy

• Increase ICD-10-CM/PCS awareness• Review and refresh knowledge of A&P• Begin studying ICD-10-PCS definitions• Learn about the General Equivalency Mappings

(GEMS) between ICD-9-CM and ICD-10-CM/PCS• Provide training on clinical documentation

improvement (CDI) strategies

RECOMMENDED ACTION STEPS2009 thru first half of 2011

AHIMA Coder ICD-10 Training Strategy

• Coding Manager’s Challenge:

50 hours of training:– 16 hours ICD-10-CM– 24 hours ICD-10-PCS– 10 additional hours of practice

Key is to provide appropriate training to the right

individuals at the right time

ICD-10 Final Rule

• Inpatient coders on ICD-10-CM/PCS recommends 50 hours of training

• Outpatient coders on ICD-10-CM recommends 10 hours of training

• Physicians recommends 8 hours of training

• Auxiliary staff recommends 8 hours of training

ICD-9-CM vs. ICD-10-CM Diagnosis

ICD-9-CM ICD-10-CM

Three to five characters Three to seven characters

First digit is numeric but can be alpha (E or V)

First character always alpha

2-5 are numeric All letters used except U

Always at least three digits Character 2 always numeric: 3-7 can be alpha or numeric

Decimal placed after the first three characters

Always at least three digits

Alpha characters are not case-sensitive

Decimal placed after the first three characters

Alpha characters are not case-sensitive

ICD-10-CM ICD-9-CM

E11341 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema

25050 Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled

362 Severe nonproliferative diabetic retinopathy

36207 Diabetic macular edema

ICD-10-CM ICD-9-CM

S72031A Displaced midcervical fracture of right femur, initial encounter for closed fracture

82002 Fracture of midcervical section of femur, closed

Diagnosis GEMs

ICD-9-CM vs. ICD-10-PCS

ICD-9-CM (vol. 3):• Minimum of 3

digits/maximum of 4 digits; decimal point after the second digit

• Numeric

ICD-10-PCS:• Minimum/maximum 7 digits; no decimal point

• Alphanumeric with all codes starting with three alphanumeric characters

X X X X

Category

.Etiology, anatomic

site, severity

Added code extensions (7th character) for obstetrics, injuries, and external causes of injury

Coding and 7th Character Extensions

X X XAMS 0 2 6. 5 x A

Additional Characters

Alpha (Except U)

2 - 7 Numeric or Alpha

3 – 7 Characters

Section Medical and Surgical 0Body System

Hepatobiliary System and Pancreas F

Root Fragmentation FBody Part Common Bile Duct 9Approach Via Natural or Artificial Opening,

Endoscopic8

Device No Device ZQualifier No Qualifier Z

ICD-10 AHIMA Training Example - ERCP

Index: Lithotripsy, see Fragmentation. The Endoscopic Retrograde Cholangiopancreatography (ERCP) with lithotripsy is coded to Fragmentation. ERCP is performed with a scope entering through the mouth to the biliary system via the duodenum, so the approach value is Via Natural or Artificial Opening Endoscopic. 16

Procedure GEMs

ICD-9-CM ICD-10-PCS

65.63 Laparoscopic removal of both ovaries and tubes at same operative episode

0UT24ZZ Resection of bilateral ovaries, percutaneous endoscopic approach

0UT74ZZ Resection of bilateral fallopian tubes, percutaneous endoscopic approach

ICD-10-PCS ICD-9-CM

02713DZ Dilation of coronary artery, two sites using intraluminal device, percutaneous approach

00.66 PTCA or coronary atherectomy

00.41 Procedure on two vessels

00.46 Insertion of two vascular stents

36.06 Insertion of non-drug-eluting coronary artery stents

Procedure GEMs

Coding Basics

• Codes are assigned based on documentation • Diagnosis codes are assigned differently based

on the setting (inpatient or outpatient)• Military Health System has special coding

requirements and are needed to accurately reflect services that are unique to the military.

http://www.tricare.mil/ocfo/bea/ubu/coding_guidelines.cfm

DoD Unique Diagnosis Codes

• DoD Extender Codes• Root code V70.5 Health examination of

defined subpopulations• V70.5_0 Armed Forces medical exam• V70.5_1 Aviation Exam• V70.5_2 Periodic Health Assessments

(PHA) or Prevention Assessment• V70.5_3 Occupational exam

DoD Unique Procedure Codes

Utilize existing codes for unique reporting

• 99199 is used to identify the Institutional component of an APV

• Case Management:– G9002 Monthly CM Summary Reporting – Acuity level 1– G9005 Monthly CM Summary Reporting – Acuity level 2– G9009 Monthly CM Summary Reporting – Acuity level 3– G9010 Monthly CM Summary Reporting – Acuity level 4– G9011 Monthly CM Summary Reporting – Acuity level 5

Inpatient Record

• An admission generates an institutional record based upon the MS-DRG = SIDR– MS-DRG based upon correct assignment of ICD-9

diagnoses and procedures• MS-DRG accuracy is reported for 5.a.• Data elements within MS-DRG is on the Review List (C.5.c-d)

– All diagnoses, any Procedures done, Sex and Age of patient, Discharge/Disposition

– Medical Severity DRGs (MS-DRG)• Diagnoses requires supporting Present on Admission (POA)

Indicators • CCE updated to add POA • CHCS 11-segment SIDR implemented Nov 2010

Inpatient Record - Rounds

• An inpatient professional services encounter or rounds (formerly called IBWA) = “A” CAPER– Services performed by the Attending Service– E&M and procedures performed– Same records as the MS-DRG audit– Inpatient Consults and follow-up captured in the “B”

CAPER

Inpatient Record - Rounds

• Auditing Sampling Methodology (for questions C.5.f,g,h)

– One calendar day of the attending professional services during each audited hospitalization will be audited from the randomly selected sample. – For hospitalizations which begin and terminate the same

calendar day, that calendar day will be audited. – For all other hospitalizations, the registration number will

determine if services for the first or second calendar day will be audited.

– Odd registration numbers will be audited for the first day and even registration numbers will be audited for the second day.

Outpatient Record

• Professional services are coded and generate a “B” CAPER

• The following services are considered outpatient:– Clinic– Emergency Department– Observation status with doctors written order– APV (Same Day Surgery)– Consults – Rounds are captured in the “A” CAPER

Coding Compliance

• The key to coding compliance is• Correct documentation • Correct codes• Correct guidelines• Standardized audit methodology

Timeliness

• Question 2 - Was your facility compliant with the following metrics?– What percentage of Outpatient Encounters,

other than APVs, have been coded within 3 business days of the encounter? (B.6.(a))

– What percentage of APVs have been coded within 15 days of the Encounter? (B.6.(b)

– What percentage of Inpatient records have been coded within 30 days after discharge? (B.6.(c))

Completeness

Encounters/admissions must be complete in order to code:

• Patient identification is correct and present• Dated• Signed (ink or electronic signature)• Legibility (if paper)• Documentation is complete

– Patient medical history– Reason for encounter– Assessment and Plan– Surgical report (if applicable)

• Review List C.5.a,b– Percentage of inpatient medical records

located?– Percentage of documentation that was

complete.• Questions 6a, 7a

– Is adequate documentation of the encounter selected to be audited available? (C.6.a, C.7.a)

Completeness

Accuracy

• Questions 5a-d, 6b-d and 7b-c• Was the MS-DRG correct (inpatient)?• Was the Primary Diagnosis (outpatient)

present and in the first position?• Was the E&M code correct and present

(non-APVs)?• Were CPT procedure codes correct?• NOTE In the absence of MHS guidance, follow civilian

coding guidelines and/or conventions.

Reporting Coding Accuracy

TMA/UBU calculation methodology:

Number of correct codes

Total number of codes• Provides standardized business rules

across MHS • More accurate representation of metric

Consistency

• Was there a sudden change in metrics - what happened?– Software change– Table update– Change in staff– System is down

• Did you file a trouble ticket?• Did you put a comment on your Data Quality Statement

to explain identified problem and estimated correction date?

Trending

Reporting Month Dec-07 Jan-08 Feb-08 Mar-08 Apr-08

Data Month Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Andrews 98% 98% 100% 92% 99% Langley 87% 93% 76% 49% 88%

Mountain Home 100% 100% 100% 90% 80% Nellis 96% 98% 100% 100% 99% Offutt 95% 95% 100% 100% 100%

Keesler 66% 75% 77% 61% 64% Lackland (Wilford Hall) 59% 69% 69% 64% 67%

Eglin 93% 97% 97% 93% 95% Kirtland 99% 66% 87% 89% 100%

Wright-Patterson 71% 84% 82% 59% 90% MacDill 0% 0% 0% 0% 0% Travis 99% 99% 100% 100% 99%

Elmendorf 94% 92% 83% 70% 75% Misawa 92% 100% 100% 100% 100% Osan 100% 100% 97% 100% 100%

Yokota 96% 93% 59% 68% 93% Air Force Academy 99% 96% 98% 100% 98%

Aviano AB 0% 0% 0% 0% 39% Incirlik 100% 94% 89% 100% 92%

Lakenheath 100% 100% 100% 100% 100%

2b. % APVs

coded in 15 days

  95% - 100%  80% - 94%  79% and Below

Trending

Oct Nov Dec Jan Feb Mar Apr May June July Aug Sept

75%

80%

85%

90%

95%

2b. APV Coding 15 Day Timeliness

Army Navy

Air Force Svc Avg

Trending

Oct Nov Dec Jan Feb Mar Apr May June July Aug Sept

90%

91%

92%

93%

94%

95%

96%

97%

98%

99%

100%

1a. End of Day Processing-Appts.

Army Navy

Air Force Svc Avg

Summary

• Use your DQ metrics appropriately• Bottom line - your coding is as good as the

documentation it is based upon• Focus on

– Completeness– Timeliness– Accuracy– Consistency

Useful Web Sites• Data Quality -  

http://www.tricare.mil/ocfo/mcfs/dqmcp/metrics_reports.cfm

• UBU - http://www.tricare.mil//ocfo/bea/ubu/index.cfm• ICD-10 – www.icd10prepared.com• UBO -

http://www.tricare.mil/ocfo/mcfs/ubo/about.cfm• MEPRS – http://meprs.info• DMHRSi - https://dmhrsi.satx.disa.mil• MEWACS - http://www.meprs.info/mol3/mol3.cfm• HIPAA -

 http://tricare.osd.mil/ocfo/mcfs/ubo/hipaa.cfm• SAIC -  http://www.chcs-dm.com/

Questions?