Welcome to the 6th Annual ACMA Kentucky / Tennessee Chapter

Case Management Conference

© 3M 2012. All rights reserved. Confidential and Proprietary.

3M Health Information Systems The ICD-10 Coding System & Impact on CM/SW/UM

ACMA KY/TN Chapter Education

Joyce Mosier, MBA, RN, CPHQ, ACM September 6, 2012

2

Objectives

Explain the premise of ICD-10-CM/PCS ICD-10 impact for Case Management, Social Work and Utilization

Management Assess ways Case Management, Utilization Management and Social

Work can benefit from this system

3M Health Information Systems 3M Health Information Systems

Global use of ICD-10: US Catching up with the Industrialized World

Poland

Thailand

United States

Iceland

Denmark

Brazil

New Zealand

Argentina

Austria

Norway

Australia

Finland

Singapore

Canada

Sweden

China Japan

Venezuela

Germany

Switzerland

Colombia

UK Ireland Czech Republic The Netherlands

France

Costa Rica

3

Overview

The United States has been using ICD-9-CM since 1979 and is the last industrialized nation to move to ICD-10.

On January 16, 2009, CMS published final rule CMS-0013-F mandating the

adoption of the ICD-10-CM and ICD-10-PCS code sets to replace ICD-9-CM under HIPAA.

The original compliance date for implementation was October 1, 2013,

however CMS has announced a delay for some entities--the date of implementation is pending.

The delay allows more time for hospitals and physicians to prepare for the

ICD-10 transition.

4

The Need for ICD-10

The ICD-9-CM code set is 30+ years old.

ICD-9 is no longer supported or maintained by the World Health Organization (ICD-10 was adopted by WHO in 1990).

Difficulty in assigning new codes Many chapters of ICD-9-CM are full Valuable new codes are not implemented due to insufficient space.

ICD-9 is not able to provide sufficient codes for healthcare encounters for

reasons other than disease (e.g. preventive care). Terminology often insufficient, obsolete and inconsistent with current medical practice and the medical technology being developed and in use today.

ICD-9-CM does not meet all HIPAA requirements for adopted standards.

5

Federal Register January 16, 2009

The Need for ICD-10

ICD-10 is needed to obtain full benefit for: Updated medical terminology more consistent with the 21st century Tracking of diseases/procedures/preventative care Better measuring of quality outcomes - Improved data allows for more

accurate severity of illness and risk of mortality data for profiling Data exchange Full use of HIT tools and technology (e.g. computer assisted coding ,

computer assisted coding for clinical documentation improvement, computer assisted coding for physician documentation)

Better specificity of medical necessity criteria Improved data allows for more accurate reimbursement for services

provided Procedure coding system allows for expansion and addition of new

technology

7

Requirements for ICD-10-CM and ICD-10 PCS

Use of ICD-10-CM and ICD-10-PCS applies to all covered entities (health care providers, health plans, and healthcare clearing houses) that transmit electronic data based on the Health Insurance Portability and Accountability Act (HIPAA) transaction standards.

ICD-10-PCS codes are only required to be used by hospitals to report

inpatient procedures.

CPT codes will continue to be used for outpatient and physician billing. However, some entities (hospitals, ambulatory surgery centers, etc) are choosing

to assign ICD-10- PCS codes in their ambulatory settings even though it is not mandated..

8

New Code Set

9

Diagnosis ICD-9 CM ICD-10 CM

In & Outpatient In & Outpatient

# of Codes ~13,000 ~70,000

# of Characters 3-5 Alphanumeric 3-7 Alphanumeric

Procedures ICD-9 CM ICD-10 PCS Inpatient Only Inpatient Only

# of Codes ~4,000 ~72,000

# of Characters 3-4 Numeric 7 Alphanumeric

NOTE: CPT codes will continue to be used for hospital outpatient procedure coding

Effective ?

3M Health Information Systems

ICD-10-CM – Diagnosis Coding

10

Examples of ICD-9 and ICD-10 Diagnosis Codes

Acute Anterior

MI 410.11 I21.09

CHF 428.0 I50.9

CAD w/ Angina

414.00, 413.9 I25.119

MVP 424.0 I34.1

11

Myocardial infarction Documentation will need to include:

• Type of infarction • STEMI • NSTEMI

• Age of infarction • If within 4 weeks coded as initial • If older than 4 weeks coded as “old”

• Specific site of myocardium involved • anterior wall • inferior wall

• Coronary artery involved • Information regarding treatment - initial or subsequent MI

Documentation for Cardiology/Cardiothoracic Diagnoses

12

13

Unique ICD-10-CM Guidelines Circulatory System

Acute Myocardial Infarctions (AMI) are identified by the site of the infarction along with the coronary artery involved.

The acute phase of the AMI is within 4 weeks of onset.

If a patient suffers a subsequent AMI within 4 weeks, a code for both

conditions is used, and sequencing depends on the reason for admission.

Note the change in the age of the MI. In ICD-9-CM it was 8 weeks. In ICD-

10-CM it is 4 weeks. • Think about past data comparing subsequent MI prevalence to current

episodes of subsequent MI occurrence. What impact might that have on data assessment of related outcomes?

A combination (single) code identifies both ASHD or CAD and angina.

14

Documentation Changes

Combination codes - In some cases a single code has been established to classify: 2 diagnoses A diagnosis with a manifestation or secondary process A diagnosis with a complication

Examples: Pathological compression fracture of the vertebrae due to osteoporosis, initial visit -

M80.08xA Type 2 DM with gastroparesis – E11.43 Stage III Pressure Ulcer R. Heel – L89.613 CAD with unstable angina – I25.110 Diverticulitis, large intestine with perforation, abscess and bleeding – K57.21

Documentation for Cardiology/Cardiothoracic Diagnoses

Hypertension HTN and chronic kidney disease are assumed to be a causal relationship;

however, it is important to document the stage of the CKD HTN and heart disease are not assumed to be linked and must be documented

when related. It is also important to state if heart failure is present. Examples include: Heart disease due to hypertension Hypertensive heart disease Hypertensive heart disease and CKD with heart failure and Stage 4 CKD

CHF

Specify acuity - acute , chronic or acute on chronic Specify type - systolic and/or diastolic heart failure Specify if CHF is a manifestation of another etiology (cardiomyopathy, HTN

heart disease, renal failure) The above documentation rules are the same in ICD-9- CM today; however this

remains an area of poor compliance

15

Renal Diseases

Chronic Kidney Failure is assigned by Stage in both ICD-9 and ICD-10. Stage I Stage II Stage III Stage IV Stage V ESRD

Acute Kidney Failure is reported based on cause in both ICD-9 and ICD-10 (eg. Acute Kidney Failure due to tubular necrosis)

16

Dementia Dementia is classified by type, or relationship to other disease processes: Alzheimer’s Dementia

Early or late onset Dementia with or without behavioral disturbances

Aggressive behavior Combative behavior Violent behavior Wandering off

Vascular or Multi-Infarct Dementia Alcohol or drug induced Dementia Dementia with Lewy Bodies or Parkinson’s Pick’s Disease with Dementia

17

Examples of Documentation Requirements

In ICD-10, respiratory failure no longer defaults to acute. Physician must specify if acute, chronic or acute on chronic

Respiratory Failure Specify acuity - acute, chronic or acute on chronic Document if respiratory failure is due to a specify etiology

Respiratory failure is assigned as a combination code that not only details the

severity of respiratory failure, but also association with hypoxia or hypercapnia. Hypoxia – insufficient oxygen reaching the tissue Hypercapnia – excess carbon dioxide in the blood

18

Examples of Documentation Requirements Asthma

Specify severity type as mild intermittent mild persistent moderate persistent or severe persistent

Specify status of asthma - uncomplicated, with acute exacerbation, or with status asthmaticus

Specify if the patient has any other diseases associated with asthma (COPD, bronchitis, etc.)

COPD

Specify if acute component such as exacerbation, bronchitis or lower respiratory infection

Specify if oxygen dependent Specify if in chronic respiratory failure

If Asthma and COPD are reported together, they are coded separately in ICD-10.

19

Pneumonia – Core Measure Diagnosis Pneumonia is classified by type and linked to the organism in both ICD-9 and

ICD-10. Types of pneumonia: Lobar pneumonia Aspiration pneumonia Pneumonia with influenza Pneumonia due to bacteria Viral pneumonia Organizing pneumonia Hypostatic pneumonia Bronchopneumonia

In ICD-10-CM is there no specific code for ‘isolation’ or for flu shots. If running data related to number of patients over certain age or with specific diagnoses to see if they had a flu shot, proactively assigning an indicator may be needed.

20

Anemia

Anemia in both ICD-9 and ICD-10 can be classified by specific type or cause Anemia due to malignancy – anemia is principal diagnosis in ICD-9-CM. In

ICD-10-CM it is secondary and the malignancy is principal. Take this into consideration if running data for quality or readmission

reports.

21

3M Health Information Systems

Clinical examples of DRG changes in ICD-10

Change in coding • In ICD-10, malignancy must

be sequenced as PDX over the anemia

• Lung Cancer

• Anemia

MS-DRG 182

Respiratory Neoplasms

without CC/MCC

R.W. .8096

• Anemia • Lung

Cancer

MS-DRG 812 Red Blood

Cell Disorders without MCC

R.W. .7957

22

ICD-10

ICD-9

ICD-10 MS-DRG is better

Assumes blended rate of $4,500

$3,643

$3,419

Unique ICD-10-CM Guidelines

Dominant/Nondominant Hemiplegia and monoplegia codes have a digit to identify dominant versus

nondominant side. If unspecified, the default code is dominant.

Glasgow coma scale In a Traumatic Brain Injury or sequela of a CVA, the Glasgow coma scale

can be coded along with the condition to more accurately reflect the patient’s condition

Musculoskeletal Conditions in the musculoskeletal system involving bone, joint or muscle

are reported by type and cause and have specific designations for site and laterality

23

Injuries, Poisoning, Adverse Effects, Underdosing and Toxic Effects Injuries and poisonings, adverse effects, underdosing and toxic effects – For many of

the codes related to these diagnoses there is a character within the code to denote the episode of care for which the condition is being treated – the encounters with their associated characters are: A = initial encounter D = subsequent encounter S = sequela

In ICD-9 levels of the spinal cord were grouped while in ICD-10 there is specificity for levels.

Example: Each cervical level is identified. Thoracic levels have T1 separate and others grouped: T2 – T6, T7 – T10, T11 –

T12. Fractures have a unique 7th character extension which indicates open or closed

fracture, initial or subsequent encounter with delayed healing, malunion or nonunion.

24

Injuries, Poisoning, Adverse Effects, Underdosing and Toxic Effects continued

Underdosing is new in ICD-10-CM Codes for taking less of a drug, medicament or biological substance have

been added to the Table of Drugs and Chemicals Specificity exists for intentional or unintentional.

No funds? No access to medications? Taking less than prescribed?

25

3M Health Information Systems

Clinical examples of DRG changes in ICD-10

• In ICD-10-CM, two rib fractures code to multiple rib fractures and by laterality (S2241xA)

• SDX of Acute Respiratory Failure

MS-DRG 183 Major

Chest Trauma

with MCC R. W.

1.4942

• Right Rib FXs are

coded in ICD-9-CM by ribs fractured (807.02)

• SDX Acute Respiratory Failure

MS-DRG 205 Other

Respiratory System DX with MCC

R. W. 1.2972

Change in coding specificity Rib fractures in ICD-9 CM are

classified differently in ICD-10 causing a DRG change based on the increased specificity

26

ICD-10

ICD-9

ICD-10 MS-DRG is better

$6,724

Assumes Blended Rate of $4500

$5,837

Fracture of femur

S72021E Displaced fracture of epiphysis (separation) (upper) of right femur, subsequent encounter for open fracture type I or II with routine healing S72021F Displaced fracture of epiphysis (separation) (upper) of right femur, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing S72021G Displaced fracture of epiphysis (separation) (upper) of right femur, subsequent encounter for closed fracture with delayed healing 72021H Displaced fracture of epiphysis (separation) (upper) of right femur, subsequent encounter for open fracture type I or II with delayed healing S72021J Displaced fracture of epiphysis (separation) (upper) of right femur, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing S72021K Displaced fracture of epiphysis (separation) (upper) of right femur, subsequent encounter for closed fracture with nonunion 72021M Displaced fracture of epiphysis (separation) (upper) of right femur, subsequent encounter for open fracture type I or II with nonunion

28

Unique ICD-10-CM Guidelines

Diabetes (E08 – E13) A combination code identifies the type of diabetes, the associated

complication or manifestation and the body system involved. Inadequately controlled, out of control and poorly controlled

are coded to Diabetes, by type, with hyperglycemia. If the type of diabetes is indicated as secondary to another disease

process or a drug, then that diabetic code is listed as secondary to the underlying cause

Most frequent MCC/CC changes within ICD-10

Diagnoses that are no longer MCC/CCs in ICD-10 MS-DRGs Esophageal Hemorrhage (no longer a MCC) Type II Diabetic Ketoacidosis (no longer a MCC) Malignant HTN (no longer a CC) Non-healing surgical wound (no longer a CC) Schizoaffective Disorders, Specified types (no longer a CC) Major Depression, NOS (no longer a CC) Code 403.00, Mal HTN w/ CKD (no longer a CC) Hemorrhage into bladder wall (596.7) is a CC in I-9 (no longer

a CC)

29

Most frequent MCC/CC changes within ICD-10

Diagnoses that are CCs in ICD-10 MS-DRGs but are not in ICD-9: • Bi-fasicular Block(s)—Example: 426.52 (RBB/LAFB) is not a CC in

ICD-9, but I452 is a CC in ICD-10. • Concussion, Unspecified and Unspecified Duration of LOC is a CC

in ICD-10. • 344.61 Cauda Equina is not a CC in ICD-9 but G834 is a CC in

ICD-10. • Code 136.1 Behcet Syndrome (type of vasculitis) is not a CC in

ICD-9 but is a CC in ICD-10 (M352).

30

3M Health Information Systems

ICD-10-PCS - Procedure Coding System

ICD-10-PCS Code Structure

The ICD-10-PCS code structure consists of a seven character, alphanumeric code structure

Letters O and I are not used to in order to avoid confusion with the numbers 0 and 1

There are no decimal points associated with the structure Each character represents an aspect of the procedure The same value means the same thing within a section but placed in a

different character position has a different meaning

0 B 5 8 8 Z Z

32

System Structure: Section Characters - There are 16 sections

0 Medical and Surgical 1 Obstetrics 2 Placement 3 Administration 4 Measurement &

Monitoring 5 Extracorporeal Assistance

& Performance 6 Extracorporeal Therapies 7 Osteopathic

8 Other Procedures 9 Chiropractic B Imaging C Nuclear Medicine D Radiation Oncology F Physical Rehabilitation

and Diagnostic Audiology G Mental Health H Substance Abuse

Treatment

33

A character is a stable, standardized code component Holds a fixed place in the code Retains its meaning across a range of codes

A value is an individual unit defined for each character

0 2 1 1 0 9 W

Med/Surg

Heart and Great Vessels

Bypass

Coronary Artery, Two

Sites

Open

Autologous Vein Tissue

Aorta

Each Code Tells a Story: Section

Body System

Root Operation

Body Part

Approach

Device

Qualifier

ICD-10-PCS

34

Body-System Values-Medical Surgical 0 Central Nervous System 1 Peripheral Nervous System 2 Heart and Great Vessels 3 Upper Arteries 4 Lower Arteries 5 Upper Veins 6 Lower Veins 7 Lymphatic and Hemic System 8 Eye 9 Ear, Nose, Sinus B Respiratory System C Mouth and Throat D Gastrointestinal System F Hepatobiliary System and Pancreas G Endocrine System H Skin and Breast J Subcutaneous Tissue and Fascia

K Muscles L Tendons M Bursae and Ligaments N Head and Facial Bones P Upper Bones Q Lower Bones R Upper Joints S Lower Joints T Urinary System U Female Reproductive

System V Male Reproductive

System Anatomical Regions W General X Upper Extremities Y Lower Extremities 35

Body-System and Body-Part Values

Body System (2nd character) Body systems are composed of organs that work together to perform specific functions Defines the general physiological system/anatomical region on which the procedure is performed Body Part (4th character) Body parts are those organs that combine to perform specific functions Defines the specific anatomical site where the procedure is performed

36

Uniqueness of ICD-10 PCS

Procedures: Anatomically Driven

ICD-10 –PCS is more anatomically specific than ICD-9 CM procedures codes

Device characteristics (examples) Autologous vein or artery tissue Synthetic substitute Nonautologous tissue substitute Drug eluting intraluminal device Intraluminal device Zooplastic Tissue Implantable heart assist system External heart assist system

37

Uniqueness of ICD-10 PCS Procedures require: Laterality of site

Specificity of approach Open Percutaneous Percutaneous endoscopic Via natural or artificial opening Via natural or artificial opening endoscopic Open with percutaneous endoscopic assistance External

38

Root operations Coders are required to know the root operation definitions and apply them

accurately. Physicians are not required to know the root operation definitions and should

not be queried. Example root operations in Medical / Surgical section: Control – Stopping, or attempting to stop, postprocedural bleeding. Destruction – Physical eradication of all or a portion of a body part by the

direct use of energy, force, or a destructive agent. Detachment – Cutting off all or part of the upper or lower extremities Drainage – Taking or letting out fluids and/or gases from a body part. The qualifier ‘diagnostic’ is used to identify drainage procedures that are

diagnostic.

39

Root Operation Examples continued

Extirpation – Taking or cutting out solid matter from a body part. Example: Thrombectomy.

Excision – Cutting out or off, without replacement, a portion of a body part. The qualifier ‘diagnostic’ is used to identify excision procedures that are

diagnostic. Resection – Cutting out or off, without replacement, all of a body part. Repair – Restoring, to the extent possible, a body part to its normal anatomic

structure and function. Reposition – Moving to its normal location or other suitable location all or a

portion of a body part. Example: fracture reduction. Removal – Taking out or off a device from a body part. Replacement – Putting in or on a biological or synthetic material that

physically takes the place and/or function of all or a portion of a body part. Example: Total hip replacement.

40

PCS Section for Bypass

Bypass – Altering the route of passage of the contents a tubular body part. Cardiology bypass – body part is the number of distinct sites bypassed

“to” rather than the name of the vessel. The qualifier captures the origin “from” of the bypass

Example: Two vessel CABG using the right internal mammary artery.

Other bypasses – body part is the origin “from” of the bypass. The qualifier captures the body part bypassed “to”.

Examples: Transverse colon to cutaneous (colostomy to skin) Right femoral artery to right popliteal artery Tracheostomy is trachea to cutaneous Stomach to jejunum

41

Example PCS Section for Assigning a Bypass PCS Code First Three Characters are

Obtained Here

42

Coronary Bypass Coding Guideline B3.6b Coronary arteries are classified by number of distinct sites treated, rather than number

of coronary arteries or anatomic name of a coronary artery (e.g., left anterior descending). Coronary artery bypass procedures are coded differently than other bypass procedures as described in the previous guideline. Rather than identifying the body part bypassed from, the body part identifies the number of coronary artery sites bypassed to, and the qualifier specifies the vessel bypassed from. Example: Aortocoronary artery bypass of one site on the left anterior descending

coronary artery and one site on the obtuse marginal coronary artery is classified in the body part axis of classification as two coronary artery sites and the qualifier specifies the aorta as the body part bypassed from.

B3.6c If multiple coronary artery sites are bypassed, a separate procedure is coded for each

coronary artery site that uses a different device and/or qualifier. Example: Aortocoronary artery bypass and internal mammary coronary artery

bypass are coded separately.

43

3M Health Information Systems

44

45

Comparison of ICD-9-CM and ICD-10-PCS Surgery Codes

ICD-9-CM Procedures 3-4 digits All numeric Limited expandability

ICD-10-PCS 7 characters Alpha numeric Expandable

Patient ICD-9-CM Code ICD-10-PCS Codes

A patient lacerates the digital artery on his/her right index finger while washing dishes requiring suture of the digital artery

3931 Suture of Artery

03QD0ZZ Repair right hand artery, open

approach

A patient is stabbed in the chest lacerating his/her aorta requiring an open chest procedure to suture the aorta

3931 Suture of Artery

02QW0ZZ Repair Thoracic Aorta, open

approach

46

ICD-10-PCS Example

Cholecystectomy – Is this an excision or resection? Open cholecystectomy – OFT40ZZ Lap cholecystectomy – OFT44ZZ

ICD-10-PCS Code Structure

Node biopsy If an ultrasound guided fine needle biopsy of a lymph node is done, the root

operation is drainage – taking or letting out fluids and/or gases from a body part. The qualifier diagnostic is used to identify drainage procedures that are biopsies.

If one or more lymph nodes are removed but less than the entire chain, the root operation is excision – cutting out or off, without replacement, a portion of a body part. The qualifier diagnostic is used to identify drainage procedures that are biopsies. Example: 07B53ZX Excision right axillary lymphatic percutaneous approach

diagnostic

If the entire chain is removed the root operation is resection – cutting out or off, without replacement, all of a body part. No qualifier for diagnostic is used. Example: 07T60ZZ – Resection left axillary lymphatic via open approach

Documentation detail on forms

Administration of blood products Specificity is required for

Site – peripheral vein, central vein, peripheral artery or central artery Donor type – as autologous or non-autologous

Ventilator assistance - are forms clear with start time and end time, when

weaning is in progress? ICD-10-CM/PCS delineates time as <24 consecutive hours, 24-96

consecutive hours and > 96 consecutive hours. The chart must be clear with the start and end times.

Where are the gaps today?

Largest gaps identified from readiness assessment roadmaps: • Budgetary needs • IT remediation • Lack of physician documentation • Impact to coding/CDI productivity Plans to dual code prior to October 2014

• Training and education of coding/CDI staff and physicians • Need for assistance in translating ICD-9 codes into

ICD-10 codes

49

Common Question- What is the Impact to Reimbursement??

Here is what we know today: The ICD-10 version of MS-DRGs posted on the CMS website replicates the ICD-9

version of the MS-DRGs (subject to change between now and implementation date) The posted version of ICD-10 version MS-DRGs is unlikely to cause a

significant redistribution of payments across hospitals Once sufficient data code in ICD-10-CM/PCS becomes available, CMS will

likely use the increased specificity of ICD-10-CM/PCS to enhance the MS-DRGs

If hospitals are losing money in current MS-DRG’s with ICD-9-CM coding and the lack of higher specificity/documentation they will continue to lose money under ICD-10-CM/PCS

Payers have not stated they will remain budget neutral Payer market is very active and ahead of provider market in preparing for ICD-

10-CM/PCS

50

Impact on Hospitals

Hospitals and Physicians will be required to undertake significant planning efforts for ICD-10 implementation, budgeting for capital and anticipated operational expenses, a complete systems inventory and development of educational activities to prepare staff.

The implementation of ICD-10 will impact every:

Paper and software system Information system Functional department

Scheduling – preauthorization & medical necessity Admission Physician/Clinical Care Case Management Lab, Radiology and other Ancillary areas Transcription Performance management HIM Department & HIM system Billing and Accounting Contract management Payer relationships Data warehouse

51

Impact on Clinical Providers

Clinical provider documentation is the foundation of ICD-10 specificity; incomplete documentation will impede ability to code accurately.

Physicians and other Clinicians will need to undergo training to learn about the

detailed documentation that ICD-10 requires of them. Training will need to be general awareness as well as specialty-based.

Clinical providers will need to collaborate closely with the HIM Coding and the Clinical Documentation Improvement teams.

Changes may need to be made to existing systems and processes such as clinical documentation, practice management systems, electronic billing systems, and encounter forms/superbills.

52

Impact to Clinical Documentation Improvement Team

If your hospital has a Clinical Documentation Improvement Team, the CDI specialists (CDIS) will need to be trained on the detailed documentation requirements for ICD-10.

A CDI team can be instrumental in working with clinicians/physicians to ensure

the specificity and level of detail needed to support ICD-10 is captured in the clinicians’ medical record documentation.

Existing CDI program may only touch Medicare; ICD-10 is across all payers.

53

Impact on Coding Staff

Coding Staff will need to be extensively trained to become fully proficient in ICD-10 coding. Educational requirements will differ based on the coder’s responsibility.

Coding Staff will need to have a deeper knowledge of the biomedical sciences than was required under ICD-9-CM. Specifically in the areas of: anatomy and physiology pathophysiology pharmacology medical terminology

In addition, staff need better comprehension of operative and procedure reports.

Contrast for radiology or cardiology services Some ICD-10-PCS code descriptions for imaging procedures include the type of

contrast utilized. Example: Arteriogram of left vertebral artery

54

Summary

Physician offices and ambulatory care will continue to use CPT for procedural codes.

Hospitals will team with physicians to query when more documentation is

needed. Physician engagement and responsiveness to queries will assist in

capturing the most accurate coding of the patient’s acuity and outcomes.

ICD-10 will require further documentation of specificity of diseases by all entities (inpatient, extended care facilities, physician offices or clinics). Physician offices will be impacted most in the area of medical necessity

and need to provide specified diagnoses, diagnostics, and care.

55

Summary continued

Case Management, Social Services and Utilization Management will be impacted in the area of medical necessity and the process to authorize/precert services, (OR case boarded with use of CPT code or ICD10-PCS?) obtaining readmission data, tracking avoidable day data, facilitating transfer to post discharge care providers, evaluating patients for transfer to another facility with awareness of reimbursement impacted by transfer, and tracking quality indicators.

CM/SW/UM can benefit from more specific data to establish screening priority

for discharge planning, assess outlier trends, quality issues, readmission drivers, medical necessity roadblocks.

56

Questions?

Queries?

Confabulation?

Wishful thinking?

Hopeful outcomes?

57