ICD-10 for Clinicians January 27-30, 2015 Puerto Rico ICD-10 Implementation Assistance Site Visit Training segments to assist Puerto Rico with ICD-10 transition

ICD-10 Overview

Program Integrity

Code Structure & Definition

GEMS, Translation & Dual Processing

Claims Management

Provider Communications

Analytics & IT Infrastructure

ICD-10 Testing

Post Implementation Impacts & Opportunities

Mapping & Policy Remediation

ICD-10 for Provider Administrative Staff

ICD-10 for Clinicians

ICD-10 for Clinicians

January 27-30, 2015

Puerto Rico ICD-10 Implementation Assistance Site VisitTraining segments to assist Puerto Rico with ICD-10 transition

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Agenda

Health care data in a changing environment ICD-10 basics Clinical documentation – the key to data and good care Getting specific Clinical case examples Measuring coding patterns Reducing the burden of data capture

Source: Health Affairs

Japan – 8.5% of the GDP (2008)US – 16% of the GDP (2008)

Healthcare ExpendituresUnsustainable

Japa

n

Ital

y

Spai

n

U.K

.

Aus

tral

ia

Swed

en

Bel

gium

Fran

ce

Ger

man

y

Aus

tria

Net

herlan

ds

Can

ada

Switz

erla

nd

Nor

way

U.S

.A.

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

$2,729 $2,870 $2,902$3,129

$3,353 $3,470$3,677 $3,696 $3,737

$3,970 $4,063 $4,079

$4,627$5,003

$7,538

Total Health Expenditure per Capita, U.S. and Selected Countries, 2008

Per

Cap

ita S

pen

din

g -

PPP A

dju

sted

Source: Organisation for Economic Co-operation and Development (2013), "OECD Health Data", OECD Health Statistics (database). doi: 10.1787/data-00350-en (Accessed on 14 February 2013).

Notes: Data from Australia and Japan are 2007 data. Figures for Belgium, Canada, Netherlands, Norway and Switzerland, are OECD estimates. Numbers are PPP adjusted.

• US 38th in life expectancy• Japan 1st in life expectancy

• US infant mortality is approximately 3 times Japan

Healthcare Data

Health Data Consulting © 20125

A Cornerstones of Healthcare Information

Patient Provider

Condition Service

Source: Health Data Consulting




Getting from Data to Information


Understanding the whole picture

Getting from Data to Information



Data

Standards

Information



ICD10 Quick Facts


ICD-10 international version– Adopted by WHO in 1990– Most countries other than the US currently use ICD-10– ICD-10 (International version) ~ 12,500 diagnostic codes– ICD-10 used for mortality reporting in the US - 1999

ICD-10-CM (US version) – ~ 69,000 diagnostic codes– Final rule published – 2009– Compliance date – Oct 1, 2015

ICD-10-PCS– ~72,000 codes– Not part of an international standard– Inpatient procedures only– Compliance date – Oct 1, 2015



Same Condition – Different Codes

September 2015


What’s the Difference?

October 2015

ICD-9 ICD-1082111:

Open fracture of Shaft of FemurS72351C:

Displaced comminuted fracture of shaft of right femur, initial encounter for open fracture type IIIA, IIIB, or IIIC

All codes for femur fractures = 16 All codes for femur fractures = 1530



Nature of the ChangesDiagnosis Codes – Clinical Example

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A patient is admitted as the result of [rupture of the cardiac wall without bleeding into the pericardium]. The patient is [within 4 weeks] of a [myocardial infarction].

ICD9 Code Description

42979Certain sequelae of myocardial infarction, not elsewhere

classified, other


I233Rupture of cardiac wall without hemopericardium as current

complication following acute myocardial infarction


Nature of the ChangesDiagnosis Codes – Clinical Example

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A patient is admitted as the result of [rupture of the cardiac wall without bleeding into the pericardium]. The patient is [within 4 weeks] of a [myocardial infarction].


42979Certain sequelae of myocardial infarction, not elsewhere

classified, other


I233Rupture of cardiac wall without hemopericardium as current

complication following acute myocardial infarction


Why are there so many diagnosis codes?

34,250 (45%) of all ICD-10-CM codes are related to the musculoskeletal system

17,045 (25%) of all ICD-10-CM codes are related to fractures

~25,000(36%) of all ICD-10-CM codes to distinguish ‘right’ vs. ‘left’


Example



Varying Code Volume By clinical area

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Clinical Area ICD-9 ICD-10

Fractures 747 17099

Poisoning and toxic effects 244 4662

Pregnancy related conditions 1104 2155

Brain Injury 292 574

Diabetes 69 239

Migraine 40 44

Bleeding disorders 26 29

Mood related disorders 78 71

Hypertensive Disease 33 14

End stage renal disease 11 5

Chronic respiratory failure 7 4

13 Source: Health Data Consulting

Nature of the ChangesCode Distribution

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5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100%0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

Total Charges by Diagnosis Code (ICD-9)3years - $10 Bill

Charge %


Changing Reimbursement Models

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*Source: Modern Healthcare – June 2014

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Why is good documentation important?

Bad Mojo is not a diagnosis

Supports proper payment and reduced denials

Assures accurate measures of quality and efficiency

Addresses the issue of accountability and transparency

Provides better business intelligence

Supports clinical research

Supports interoperable sharing of data

It’s just good care!


DocumentationWhy is it Important?



18 Health Data Consulting © 2013

Documentation1889



Documentation1889



Documentation1889



Documentation1889



Progress?

Documentation2011


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History

Physical ExamInternal Record Review

External Record Review

Assessment/Diagnosis

Studies

Documentation and CodingWhere it all begins


Clinical / Business/Coding RelationshipsCreating a new working relationship

1. The role of the clinician is to document as accurately as possible the nature of the patient conditions and services done to maintain or improve those conditions.

2. The role of the coding professional is to assure that coding is consistent with the documentation

3. The role of the business manager is to assure that all billing is accurately coded and supported by the documented facts.


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Getting Specific

Defining and measuring specificity


Poorly Specified Coding


A proposed definition

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“Coding that does not fully define important parameters of the patient condition that could otherwise be defined given

information available to the observer (clinician) and the coder.”

Coding specificity


A place for “unspecified” codes

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Sometimes unspecified makes sense…–The patient may be early in the course of

evaluation–The claim may be coming from a provider who is

not directly related to diagnosis of the patients condition

–The clinician seeing the patient may be more of a generalist and not able to define the condition at a level of detail expected by a specialist

Coding specificity


No place for “unspecified” codes

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If there is sufficient information available to more accurately define the condition

For basic concepts such as:– Laterality (Right, Left, Bilateral, Unilateral)– Anatomical locations– Trimester– Type of diabetes– Known complications or comorbidities – Description of severity, acute or chronic or other known parameters…

Where care is implemented that demands a more specific level of detail

At specialty level that should be able to define the detail required

Coding ICD-10 CM


Suspected, probable, likely and other condition qualifiers

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The use of terms like “suspected”, “probable”, “likely” and other qualifications of conditions have different guidelines for coding in the inpatient vs. the outpatient setting.


DocumentationWhat they taught us in medical school


Type of condition– Condition categories i.e. Type I or Type II diabetes

Onset– When did it start?

Etiology / Cause– Infectious agent– Physical agent– Internal failure– Congenital





Anatomical location– Which anatomical structure

– Proximal, distal, medial, lateral, central, peripheral, superior, inferior,

anterior, posterior…

Laterality– Right side or left side

Severity– Mild, moderate or severe

Environmental factors– Smoking

– Geographic location31 Source: Health Data Consulting




Time parameters– Intermittent/Paroxysmal

– Recurring

– Acute or chronic

– Post-op, post delivery

Comorbidities or complications– Diabetes with neuropathic joint

– Intracranial injury

Manifestations– Hypoxia, Hypercapnia (Respiratory Failure)

– Loss of consciousness32 Source: Health Data Consulting




Healing level– Routing healing, delayed healing, non-union, malunion…

Findings and symptoms– Fever

– Hypoglycemia/hyperglycemia

– Wheezing

External causes– Motor vehicles, injury locations

– Assault, accidental, work related, intentional self harm

Type of encounter– Initial encounter, subsequent encounter, encounter for condition sequela,

routine evaluation, administrative encounter33 Source: Health Data Consulting

Medical Concepts


Expressing the patient condition in codes

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Medical Scenario: A [27 year old] [male] patient is seen in [follow-up] for a [Smith’s fracture] on the [right] that was exposed through an [open wound] with [minimal opening and minimal tissue damage]. The fracture has [not healed after 6 months].Though not explicitly stated in this scenario certain expressions imply other concepts:“Smith’s fracture” >> [fracture], [radius], [distal], [dorsal angulation], [extra-

articular], [displaced]

“minimal opening and minimal tissue damage” >> [Gustilo classification I]

“not healed after 6 months” >> [nonunion]




Pulmonary Disease COPD

Chronic BronchitisAsthma

ICD-10 Relevant Documentation


Chronic Pulmonary Disease Concepts:

Caused by : Chemical or environmental agents

– Define agent…

Smoking– Exposure to environmental tobacco smoke– History of tobacco use– Occupational exposure to environmental tobacco smoke– Tobacco dependence– Tobacco use

Allergic/non-allergic






38

Temporal Factors: Acute Chronic Intermittent Persistent

Severity: Mild Moderate Severe






39

Bronchitis Specific: Simple Mucopurulent Mixed simple and mucopurulent Tracheitis Tracheobronchitis






40

Emphysema Specific: Unilateral pulmonary emphysema

– MacLeod’s syndrome– Swyer-James syndrome– Unilateral hyper-lucent lung– Unilateral pulmonary artery functional hyperplasia– Unilateral transparency of lung

Panlobar emphysema– Panacinar emphysema

Centrilobar emphysema






41

Emphysema Specific: Other emphysema

– Bullous emphysema (lung)(pulmonary)– Emphysema (lung)(pulmonary) NOS– Emphysematous bleb– Vesicular emphysema (lung)(pulmonary)






42

Other COPD: With acute lower respiratory infection

– Define infectious agent… With exacerbation

– Decompensated COPD Other COPD

– Chronic obstructive airways disease– Chronic obstructive lung disease






43

Asthma Specific - Types : Detergent asthma Eosinophilic asthma Lung diseases due to external agents Miner's asthma Wheezing Wood asthma Exercise induced bronchospasms Cough variant asthma Atopic asthma






44

Asthma Specific - Types (alternate terms): Allergic (predominantly) asthma Allergic bronchitis Allergic rhinitis with asthma Atopic asthma Extrinsic allergic asthma






45

Asthma Specific - Types (alternate terms): Hay fever with asthma Idiosyncratic asthma Intrinsic non-allergic asthma Non-allergic asthma Asthmatic bronchitis Childhood asthma Late onset asthma






46

Asthma Specific: Uncomplicated

or with (acute) exacerbation

or with status asthmaticus





Code examples - COPD:

47

ICD-10 Code ICD-10 Description

J418 Mixed simple and mucopurulent chronic bronchitis

J431 Panlobular emphysema

J432 Centrilobular emphysema

J440 Chronic obstructive pulmonary disease with acute lower respiratory infection

J441 Chronic obstructive pulmonary disease with (acute) exacerbation

J4521 Mild intermittent asthma with (acute) exacerbation

J4552 Severe persistent asthma with status asthmaticus

J45990 Exercise induced bronchospasm



Measuring Performance

Coding Specificity


Unspecified (NOS), Other (NEC) or Symptom/Finding Codes


Code Type Claims Total Charges %Claims %Charges

All Professional Claims 15,352,056 $ 4,030,052,634 100% 100%

‘Unspecified’ (and not ‘Other’ or ‘Symptom or Finding’) 2,902,691 $ 709,765,341 19% 18%

‘Other’ 1,917,163 $ 509,694,935 12% 13%

‘Symptom or Finding’ 3,530,464 $ 675,662,073 23% 17%

Total 'Unspecified', 'Other' and 'Symptom or Finding' 8,350,318 $ 1,895,122,349 54% 47%


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Differences in coding distribution by condition (injury and poisoning) for these two previous providers


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Differences in coding distribution by condition (injury and poisoning) for these two previous providers


Coding Pattern Comparisons


Obstetrical providers













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Capturing Key Medical ConceptsReducing the burden of documentation


There are a limited number of clinical concepts – For each clinical condition there are a finite clinical parameters that need to

be captured from the perspective of ICD-10

– Most of these condition parameters recur in many codes

The physician does not need to capture everything– He/she must review and agree with data captured in other ways in the office

Use other resources to capture data– Patient intake forms

– Trained nursing and medical assistance interviews

Prompting for the right stuff– Documentation requirement are condition specific

– Forms or templates can help remind what is neededSource: Health Data Consulting



GEM Mapping Tool



GEM Mapping Tool



GEM Mapping Tool



GEM Mapping Tool



GEM Mapping Tool



GEM Mapping Tool

Questions?

62

Documents

ICD-10 for Clinicians January 27-30, 2015 Puerto Rico ICD-10 Implementation Assistance Site Visit Training segments to assist Puerto Rico with ICD-10 transition