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

Radiation OncologyRadiation OncologyRobert S. Gold, MDRobert 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 readmissions?

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://tinyurl.com/6nccdoc) includes a complete list of the 13 measures.

Goals of Implementation – Prove You Are Value Based

• Excellence in severity adjusted data

• Reasonable occurrence of PSIs

• Lower than average Readmissions for Pneumonia, Heart Failure, AMI

• Cooperation with quality initiatives

• Patient satisfaction

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

Adjustments• Severity adjusted data leads to morbidity and

mortality rates

• 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

World Health Organization and ICD Codes

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/Plan82 YO F patient presented to ER with:

1. Sepsis,2. Septic Shock, 3. Acute Hypercapnic Respiratory Failure, 4. Acute Renal Failure due to #2, (don’t 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 pneumonia

CC time 1hr 45 minutes John Smith MD

So What’s the Difference?Principal Diagnosis Chills and Fever Sepsis

Secondary Diagnoses Altered Mental Status Septic Shock

Acute Respiratory Failure

Aspiration PneumoniaAcute Renal Failure (or AKI)Respiratory AcidosisMetabolic Encephalopathy

Medicare MS-DRG 864 Fever w/o CC/MCC 871 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

=1

Profiles Come from Severity Adjusted

Statistics

Observed mortalityExpected mortalityFrom severity adjusted DRGs

=1; as good as the next guy

<1; preferred provider – significantly better

>1; excessive mortality; find another provider -

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Respiratory Diseases

Pneumonia

Hosp plus 6 months

COPD

Hosp plus 6 monthsCritical Care

Respiratory Failure

Hosp plus 6 months

Sepsis

Hosp plus 6 monthsCardiac Diseases

Heart Failure

Hosp plus 6 months

Acute MI

Hosp plus 6 monthsCardiac Surgery

CABG

Hosp plus 6 months

Interv Cardiology

Hosp plus 6 months

Heart Valve

Hosp plus 6 monthsSurgery

ORIF Hip Maj Compl

GI Surgery

Hosp plus 6 months

THA Maj Compl

Cholecystectomy Maj C

Clinical Documentation Clinical Documentation ImprovementImprovement

What is this all for?

Patient SafetyWorse than

Better than

Average Average

Death in procedures where mortality is usually very low ●Pressure sores or bed sores acquired in the hospital ●Death following a serious complication after surgery ●Collapsed lung due to a procedure or surgery in or around the chest ●Catheter-related bloodstream infections acquired at the hospital ●Hip fracture following surgery ●Excessive bruising or bleeding as a consequence of a procedure or surgery ●Electrolyte and fluid imbalance following surgery ●Respiratory failure following surgery ●Deep blood clots in the lungs or legs following surgery ●Bloodstream infection following surgery ●Breakdown of abdominal incision site ●Accidental cut, puncture, perforation or hemorrhage during medical care ●

Foreign objects left in body during a surgery or procedure

Average

0 Events

Examples• Differentiate tracheoesophageal fistula

due to the cancer from TEF due to the radiation

• Fluid losses from gastrointestinal mucositis vs other causes of fluid losses

• Lymphedema from the radiation vs from the superior vena cava syndrome

• Radiation pneumonitis vs aspiration pneumonitis in esophageal cancer pt

Complication?• Access site injury

– Pseudoaneurysm or significant hematoma?– Incidental, insignificant ecchymosis?

• Hepatic artery injury– Specific obstruction, perforation, dissection

• Infection– Distinguish hepatic abscess from procedure or was it

already there, procedural blood stream infection vs incidental bacteremia

• Nontarget embolization• Pulmonary embolism/air embolism• Iatrogenic pneumothorax – clinically significant or

just minimal apical cap?

Clinical Integration• CMS proposes to pay separately for complex chronic

care management services starting in 2015. • "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.

Change in the Entire System

ICD-9

ICD-10

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)

How Close Are We Now?

Anesthesiology 87% Ophthalmology 69%Cardiology 65% Orthopedic 73%Dermatology 86% Otorhinolaryngology (ENT) 74%Emergency Medicine 71% Pathology 75%Endocrinology 63% Pediatrics 53%Family Practice 68% Plastic Surgery 98%Gastroenterology 48% PMR 65%General Surgery 86% Primary Care 63%Hospital Medicine 73% Psychiatry 61%Infectious Disease 78% Psychology 81%Internal Medicine 58% Pulmonary 56%Nephrology 64% Rheumatology 71%Neurology 70% Sleep Medicine 68%Neurosurgery 75% Urgent Care 56%Obstetrics & Gynecology 84% Urology 80%Oncology 63% Overall 63%

AAPC AUDIT RESULTSData compiled from results of 20,000 medical charts audited the First half of 2013

% Documentation Sufficient to Transition To ICD-10CLIENT SERVICES

Example - Specificity

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

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 I

(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 digits1 – right2 – left9 - unspecified

Principal Diagnosis – Describe It!

16 year old female with acute myelogenous leukemia diagnosed in 2004 who underwent consolidation chemotherapy and went into successful remission. She was doing well until she was hospitalized with syncope from severe anemia and bruising from thrombocytopenia found to be due to relapse in November 2013 and is now admitted for allogeneic bone marrow transplantation.

80 year old WF with episode of syncope in March led to findings of iron deficiency anemia and positive stool guaiac, probably due to chronic blood loss. Colonoscopy late March revealed right colon exophytic lesion with erosions. Biopsy adenoca colon. Abdominal CT showed possible evidence of solitary lesion in left lobe of liver. Right hemicolectomy performed two weeks ago with benign postoperative course. Liver biopsy positive for adenocarcinoma of colon. In now for percutaneous embolization of metastatic colon cancer in left lobe of liver.

Consider Issues That Make it Tough

Do other conditions of the patient make the route, positioning, choice of therapies more complex?

• Kyphoscoliosis?• Chronic respiratory failure?

– Hypoxemic? Hypercapnic?– What’s the cause? Pleural effusion? Ascites?

• Morbid obesity?• Coagulopathies?

Primary and Metastatic Cancer

• Tell where the primary is (was) and if it was previously removed or treated and treatment is over or currently under treatment

• State where the metastatic sites are and if they (any) are symptomatic and if they are currently under treatment

• State if new site is found and if it led to the symptoms that required admission – ALWAYS LINK SYMPTOMS TO THE CANCER, when you can

Lung Cancer I-9

162 Malignant neoplasm of trachea, bronchus, and lung162.0 Trachea162.2 Main bronchus162.3 Upper lobe, bronchus or lung162.4 Middle lobe, bronchus or lung162.5 Lower lobe, bronchus or lung162.8 Other parts of bronchus or lung162.9 Bronchus and lung, unspecified

Laterality of Lung Cancer I-10

C34.0 Malignant neoplasm of main bronchusC34.00 Malignant neoplasm of unspec main bronchusC34.01 Malignant neoplasm of right main bronchusC34.02 Malignant neoplasm of left main bronchus

C34.1 Malignant neoplasm of upper lobe, bronchus or lungC34.10 Malignant neoplasm of upper lobe, unspec bronchus or lungC34.11 Malignant neoplasm of upper lobe, right bronchus or lungC34.12 Malignant neoplasm of upper lobe, left bronchus or lung

C34.2 Malignant neoplasm of middle lobe, bronchus or lungC34.3 Malignant neoplasm of lower lobe, bronchus or lung

C34.30 Malignant neoplasm of lower lobe, unspec bronchus or lungC34.31 Malignant neoplasm of lower lobe, right bronchus or lungC34.32 Malignant neoplasm of lower lobe, left bronchus or lung

C34.8 Malignant neoplasm of overlapping sites of bronchus and lungC34.80 Malignant neoplasm of overlapping sites of unspec bronchus and lungC34.81 Malignant neoplasm of overlapping sites of right bronchus and lungC34.82 Malignant neoplasm of overlapping sites of left bronchus and lung

Adrenal Gland Malignancy I-9

194.0 Adrenal gland

Adrenal cortex

Adrenal medulla

Suprarenal gland

All in one

Laterality/Specificity I-10

C74.0 Malignant neoplasm of cortex of adrenal glandC74.00 Malignant neoplasm of cortex of unspecified adrenal glandC74.01 Malignant neoplasm of cortex of right adrenal glandC74.02 Malignant neoplasm of cortex of left adrenal gland

C74.1 Malignant neoplasm of medulla of adrenal glandC74.10 Malignant neoplasm of medulla of unspecified adrenal glandC74.11 Malignant neoplasm of medulla of right adrenal glandC74.12 Malignant neoplasm of medulla of left adrenal gland

Colon Cancer I-9153 Malignant neoplasm of colon

153.0 Hepatic flexure153.1 Transverse colon153.2 Descending colon153.3 Sigmoid colon153.4 Cecum153.5 Appendix153.6 Ascending colon153.7 Splenic flexure153.8 Other specified sites of large intestine153.9 Colon, unspecified

154 Malignant neoplasm of rectum, rectosigmoid junction, and anus154.0 Rectosigmoid junction154.1 Rectum154.2 Anal canal

Colon Cancer I-10C18 Malignant neoplasm of colon

C18.0 Malignant neoplasm of cecumC18.1 Malignant neoplasm of appendixC18.2 Malignant neoplasm of ascending colonC18.3 Malignant neoplasm of hepatic flexureC18.4 Malignant neoplasm of transverse colonC18.5 Malignant neoplasm of splenic flexureC18.6 Malignant neoplasm of descending colonC18.7 Malignant neoplasm of sigmoid colonC18.8 Malignant neoplasm of overlapping sites of colonC18.9 Malignant neoplasm of colon, unspecifiedMalignant neoplasm of large intestine NOS

C19 Malignant neoplasm of rectosigmoid junctionMalignant neoplasm of colon with rectumMalignant neoplasm of rectosigmoid (colon)

Mets to Bone

ICD-9

198.5 Bone and bone marrow

ICD-10

C79.51 Bone

C79.52 Bone marrow

Pathologic FracturePathologic Fracture• Medical TextbookA fracture involving

abnormal bone is a pathologic fracture. The abnormality may be due to disuse, a surgical defect, infection, a metabolic disorder, a primary benign tumor, a primary malignant tumor or metastatic carcinoma. The fracture occurs spontaneously or with minimal trauma

• Coding GuidelinesA break in a diseased bone

due to weakness of the bone structure by pathologic process (such as osteoporosis or bone tumors) without identifiable trauma or following only minor trauma. Only the physician can make the determination that the fracture is out of proportion to the degree of trauma

Pathologic FracturePathologic Fracture• If a patient with severe osteoporosis or

myeloma falls from the second story of her home and suffers a compression fracture of the spine, that’s a traumatic fracture.

• If a patient gets the same fracture setting the table – or raising a window - with the bone weakened by SOME pathologic process, that’s a pathologic fracture

• Pediatric orthopedic textbooks describe over 100 causes of pathologic fracture that are not malignancies.

• Be sure pathologic fracture in a cancer patient is not due to another cause.

Osteoporosis and Pathologic Fx I-9

733.0 OsteoporosisUse additional code for history of pathologic (healed) fracture (V13.51)733.00 Osteoporosis, unspecified733.01 Senile osteoporosis733.02 Idiopathic osteoporosis733.03 Disuse osteoporosis733.09 Other Drug-induced osteoporosis

733.1 Pathologic fractureExcludes: stress fracture (733.93-733.95), traumatic fractures (800-829)

733.10 Pathologic fracture, unspecified site733.11 Pathologic fracture of humerus733.12 Pathologic fracture of distal radius and ulna733.13 Pathologic fracture of vertebrae733.14 Pathologic fracture of neck of femur733.15 Pathologic fracture of other specified part of femur733.16 Pathologic fracture of tibia and fibula733.19 Pathologic fracture of other specified site

Osteoporosis ICD-10

M81 Osteoporosis without current pathological fracture

personal history of (healed) osteoporosis fracture, if applicable (Z87.310)

M81.0 Age-related osteoporosis without current pathological fracture

M81.6 Localized osteoporosis [Lequesne]

Excludes1: Sudeck's atrophy (M89.0)

M81.8 Other osteoporosis without current pathological fracture

Osteoporosis with Pathologic Fx I-10

M80 Osteoporosis with current pathological fractureExcludes1: collapsed vertebra NOS (M48.5)

pathological fracture NOS (M84.4)

wedging of vertebra NOS (M48.5)

Excludes2: personal history of (healed) osteoporosis fracture (Z87.310)

M80.0 Age-related osteoporosis with current pathological fracture

M80.8 Other osteoporosis with pathological fracture

drug induced, idiopathic, disuse,

Osteoporosis with Pathologic Fx ICD-10

1 Shoulder2 Humerus3 Forearm4 Hand5 Femur6 Lower leg7 Ankle/foot8 Vertebra

Sixth digit1 = right2 = left

Add 7th digit for episode of care

Traumatic Fracture vs Pathologic

• M84.3 Stress fracture

• M84.4 Pathologic fracture NEC

• M84.5 Pathologic fracture in neoplastic disease

• M84.6 Pathologic fracture in other specified disease – name the disease, too (excludes, osteoporosis M80.x)

Neoplastic and Other Pathologic Fx ICD-10

1 Shoulder2 Humerus3 Ulna or Radius 4 Hand5 Pelvis or Femur6 Tibia or Fibula7 Ankle or foot8 Other site

Add 7th digit for episode of care

And Then There Were Seven (Digits) … for

Injuries

Anemia Designations

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.)

D62

D50.0

D63.1

D63.0

D63.8

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 cancer284.11 D61.810 pancytopenia from chemo284.12 D61.811 pancytopenia from other drugs284.2 D61.82 pancytopenia from cancer taking over bone

marrow (myelophthisis) – code the cancer causing it284.89 D61.1 aplastic anemia due to chemo, other drugs284.89 D61.2 radiation induced aplastic anemia285.22 D63.0 anemia due to neoplastic disease – code

the cancer causing it285.3 D64.81 antineoplastic chemotherapy induced

anemia

Lymphoma Subdivisions in ICD-9

• Hodgkins cell types• Small Cell• Mantle zone• Large cell

lymphoma• Lymphoblastic• Burkitt• Non-follicular

• Unspecified site• Head, face, neck nodes• Intrathoracic nodes• Intraabdominal nodes• Nodes axilla, upper limb• Inguinal, lower limb• Pelvic nodes• Spleen• Multiple sites• Extranodal and solid

organ sites

Lymphoma ICD-10C81 Hodgkin’s Lymphoma

C81.0 Nodular lymphocyticC81.1 Nodular sclerosingC81.2 Mixed cellularityC81.3 Lymphocyte depletedC81.4 Follicular grade IIIB C81.5 Diffuse follicular centerC81.6 Cutaneous follicle centerC81.8 Other specified

Fifth Digit0 – unspecified site1 – head, face neck nodes2 – intrathoracic nodes3 – intraabdominal nodes4 – axilla, upper limb5 – inguinal, lower limb6 – pelvic nodes7 – spleen8 – multiple sites9 – unspecified site

C83.0 Small B cellC83.1 MantleC83.3 Diffuse large B cellC83.5 Lymphoblastic diffuseC83.7 BurkittC83.8 Other nonfollicularC84.0 Mycosis fungoidesC84.1 Sezary diseaseC84.4 Peripheral T-cellC84.6 Anaplastic large cell (ALK pos)C84.7 Anaplastic large cell (ALK neg)C84A Cutaneous T-cellC84.9 Mature T/NK cellC85 B-cell lymphomas

Fifth Digit0 – unspecified site1 – head, face neck nodes2 – intrathoracic nodes3 – intraabdominal nodes4 – axilla, upper limb5 – inguinal, lower limb6 – pelvic nodes7 – spleen8 – multiple sites9 – unspecified site

Lymphoma ICD-10

Status of Leukemias

• All leukemia codes are divided into subdivisions to demonstrate the patient’s status NOW:– Never having achieved remission– In remission– In relapse

If you don’t specify, it defaults to never having achieved remissionYour success in treatment depends on

accuracy.

What is Your Definition ofRemission?

• Is it immediate reduction of blasts in bone marrow with patient still to continue ongoing chemo or radiation therapy?

• Or is it completion of therapeutic regimen with evaluation demonstrating that patient’s malignancy is evidently gone?

• Which does the statistics mean?

Side Effects/Complications

• “Mucositis” due to chemo

• Bleeding by severity – chronic? Acute with hypovolemia, hemorrhagic shock?

• During neutropenic phase, specify:– Probable bacterial infection in

immunocompromised host– Sepsis in neutropenic patient when septic– “Neutropenic fever” does not indicate

concern that there is an infection

Side Effects/Complications

• Veno-occlusive disease– Identify when patient comes through the

door with it (POA)– Identify what vein involved – sural veins,

deep femoral vein subclavian vein

• Organ failures from GVHD or from another source– Insufficiency isn’t failure– Azotemia isn’t failure– Transaminasemia isn’t disease

• Link and differentiate pulmonary disease to the disease, the drug, the radiation or the BMT– Pneumonitis– Recurrent pneumonia– Obliterative bronchiolitis– Cryptogenic organizing pneumonia– Diffuse alveolar hemorrhage– CMV or PCP pneumonia

Side Effects/Complications

Risks to Therapeutic Treatment of the Cancer

Patient• Malnutrition

• Immunosuppression

• Decreased function of organs– Respiratory dysfunction– Cardiac dysfunction– Renal dysfunction– Hepatic dysfunction

• Lack of support – physical, emotional, financial

Nutrition in the Cancer Patient

• Cachexia, inanition is an appearance• When the patient needs nutritional support,

it may be because of one of three reasons:– Chronic malnutrition due to malignancy– Acute malnutrition due to surgery or

infection– Prevention of malnutrition when patient who

is not malnourished now is at risk• State if malnutrition DUE TO tumor, DUE

TO side effects of chemo, DUE TO … what?

Malnutrition• Be wary of BMI in patients with ascites,

pleural effusions, anasarca from hypoproteinenia

• Work with dietary to use ASPEN eval of pt to stratify malnutrition when it exists

• Malnutrition quick estimates – Mild - < 10% body mass loss– Moderate – 10 – 20% body mass loss– Severe - > 20% body mass loss

Malnutrition• One third of hospital patients are affected by

moderate or severe malnutrition• Capability to tolerate tests, treatments,

surgeries significantly impaired with moderate to severe malnutrition

• What we see:– Cachexia– 20 lb wt loss in past month– Poor nutrition due to dysphagia

Infectious Disease

• Although sepsis and septicemia determined to be two different entities (local infection with systemic impact through release of kinins from macrophages vs infection of the blood stream), both have same code now - A41

• Bacteremia R78.81, viremia B34.9, fungemia B49 have specific codes, none of which carry severity

Specific “Sepsis/Septicemia”• Anthrax sepsis A22.7• Septicemia of plague A20.9• Salmonella sepsis A02.1• Listeria sepsis A32.7• Meningococcemia

– Acute A39.2– Chronic A39.3

• Streptococcal sepsis – specify group• Toxic shock syndrome A48.3• Sepsis not specified A41

The Future Must Be Started Now

ICD-9-CM995.91 Sepsis (SIRS due

to infection without organ dysfunction

995.92 Severe sepsis (SIRS due to infection with organ dysfunction

995.93 SIRS due to noninfection without organ dysfunction

995.94 SIRS due to noninfection with organ dysfunction

ICD-10-CM*****

R65.20 Severe sepsis without septic shock

R65.21 Severe sepsis with septic shock

R65.10 SIRS due to noninfection without organ dysfunction

R65.11 SIRS due to noninfection with organ dysfunction

Conditions Related to …

Sepsis due to: UTI

Pneumonia

Ascending cholangitis

Infected decubitus

Osteomyelitis

Infected vascular cath

Subphrenic abscess

All are infections!

SIRS due to:Hemorrh pancreatitisBurns (not infected)Pulmonary embolism (clot, fat, amniotic fluid)Multiple traumaAllergy

None are infections!

Severe Sepsis

Intent is to identify sepsis with distant organ failure. Organs may include:– Acute renal failure (due to sepsis)– ARDS/acute respiratory failure– Shock liver/ acute hepatic necrosis– Demand NSTEMI– Disseminated intravascular coagulopathy– Encephalopathy (metabolic – due to

sepsis)– Critical care myopathy– Circulatory system failure – inability to

perfuse vital organs

Indwelling Device Infections

• Specific code sets apply when infection or “septicemia” is related to indwelling:– Vascular access catheter for dialysis– Urinary tract catheter or device– Orthopedic appliance– Artificial heart valve– Prosthesis for vascular bypass or for

hernia supportMAKE THE LINK

Confusing TerminologyMust Differentiate After Study …

• Neutropenic fever - fever in a patient with low white count but no infection found– Fever of at least 38.3° C occurring on several occasions

in a patient whose neutrophil level is lower than 500/mm3 or is expected to fall below that level within 1 or 2 days, the cause of which cannot be determined after 3 days of investigation, including 2 days of incubation of cultures

– Or is there a specific infectious process identified• Neutropenic sepsis

– Sepsis in a patient with low white count from cancer or chemo

– Severe sepsis with bone marrow dysfunction due to infection

• Fever because of destruction of white cells

Fever in an Immunocompromised

HostQuestion: A patient undergoing chemotherapy presents with

acute onset of fever and chills. His WBC is 800. Chest x-ray and cultures do not reveal any etiology. The patient is placed on antibiotic therapy and improves over the 72 next hours. The physician states the principal diagnosis to be fever in an immunocompromised host and documents in the medical record that he suspects a culture-negative bacterial infection. Is this coded as fever of undetermined origin?

Answer: No. This is an immunocompromised host who is very

susceptible to opportunistic bacterial infection as the physician has delineated. The clinical situation, the selection of the therapy, and the response to that treatment support the physician's clinical suspicion. The appropriate diagnosis code would be 041.9 (A49.9), Bacterial infection, unspecified.

Cardiomyopathy

“CMP” – Vanilla Is it hypertensive?Is it ischemic?Is it alcoholic, viral?Is it toxicity due to chemotherapy?Is it due to valvular disease?Is it due to congenital disease?Describe the pathogenesis! Name the

disease!

Chemotherapy Related Cardiac Dysfunction

• CRCD can be classified into two types. – Type I exemplified by anthracyline-induced

dysfunction– Type II exemplified by trastuzumab-induced

dysfunction.• Establish an early diagnosis and initiating early

treatment to prevent irreversible damage • No guidelines developed specifically for the

treatment of chemotherapy induced cardiomyopathy (CIC)

• Follow American College of Cardiology/ American Heart Association (ACC/AHA) guidelines.

Criteria for CRCD

1) decrease in cardiac left ventricular ejection fraction (LVEF), either global or more severe in the septum;

2) symptoms of heart failure (HF) ; 3) associated signs of HF, including but not

limited to S3 gallop, tachycardia, or both; and 4) decline in LVEF of at least 5% to less than

55% with accompanying signs or symptoms of HF, or a decline in LVEF of at least 10% to below 55% without accompanying signs or symptoms. The presence of any one of the four criteria is sufficient to confirm a diagnosis of CRCD

Premier Quality Demonstration

HEART FAILURE

• Left Ventricular function assessment• ACEI or ARB for LVSD

– Angiotensin Converting Enzyme Inhibitor– Angiotensin Receptor Blocker– Change as of 1 January 2005

• Smoking cessation counseling• Detailed DC instructions

Do You Use 428/L50 for Your Billing?

428.1 L50.1 Acute pulmonary edema from acute left heart failure428.20 L50.20 Unspecified systolic heart failure

428.21 L50.21 Acute systolic heart failure428.22 L50.22 Chronic systolic heart failure428.23 L50.23 Acute on chronic systolic heart failure428.30 L50.30 Unspecified diastolic heart failure428.31 L50.31 Acute diastolic heart failure428.32 L50.32 Chronic diastolic heart failure428.33 L50.33 Acute on chronic diastolic heart failure428.40 L50.40 Unspecified combined systolic and diastolic heart

failure428.41 L50.41 Acute combined systolic and diastolic heart failure428.42 L50.42 Chronic combined systolic and diastolic heart failure428.43 L50.43 Acute on chronic combined systolic and diastolic

heart failure

CardiomyopathyThe Causes

• Hypertensive• Infectious

myocarditis• Collagen vascular

diseases• Transplant rejection• Sarcoidosis• Brugada’s disease• Chemotherapeutic

agents• Lead poisoning• Cocaine or

amphetamine use

• Ischemic• Alcoholic• Nutritional deficiencies• Thyroid disease• Diabetic CMP• Obesity• Amyloidosis• Hemochromatosis• Scleroderma• Radiation myocarditis• Septal hypertrophy• IHSS

49

“Chronic Renal Failure”

and Complexity of Medical Decision MakingNon Specific

formerly CRF or CRI, now CKD

SpecificCKD DUE TO Hypertensive

nephrosclerosisCKD DUE TO Diabetic

glomerulosclerosisCKD DUE TO Intrinsic glomerular

diseaseCKD DUE TO Tubulointerstitial

diseaseCKD DUE TO LupusCKD DUE TO Polycystic diseaseCKD DUE TO Multiple myeloma

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.

Stages of AKIStg 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

AKI Caveat

• It is imperative to NOT CALL changes in creatinine AKI until the patient has been volume repleted for at least six hours. If creatinine bump persists after fluid resuscitation, there was likely AKI. If not, there was NOT AKI.

• “Acute kidney injury should be both abrupt (within 1–7 days) and sustained (more than 24 hours).”

Respiratory Failure in ICD-10

• Document acute or chronic or both

• Specify if hypoxemic or hypercapnic respiratory failure for either acute or chronic

• Without specificity,

defaults to unspecified,

with least severity

Acute Respiratory Failure

Definitions by chemistries agreed upon by coding guidelines and by Medical textbooks:

• Hypoxemic – inability to maintain O2 sats of 90% on 6 liters

• pO2 10 - 15% lower than expected for that patient

• Hypercapnic - pH < 7.30 and pCO2 > 55 regardless of pO2

• Clinical – patient tiring and need respiratory support immediately, tubed or not

Chronic Respiratory Failure

• Adds to severity of any admission

• Adds to expected morbidity and mortality of any admission

• Allows for immediate approval of home oxygen and other medications

• Can be identified by pH=7.4 and pCO2

over 50 – 60 or pO2 under 50

• May consider CO2 over 35 on BMP in absence of other acid-base issue

AMS is not Encephalopathy

When a patient is determined to have one of the following as cause of AMS, specify as:– Alcoholic encephalopathy– Ischemic (anoxic) encephalopathy– Hepatic encephalopathy– Hypertensive encephalopathy– Metabolic (internal source) encephalopathy– Toxic (external source) encephalopathy– Traumatic (post-concussive) encephalopathy

Aspiration Pneumonitis, Aspiration Bronchitis

• Microaspiration of gastric acid can lead to acute aspiration bronchitis or aspiration pneumonitis

• Pneumonia due to anaerobes or gram negatives - likely outcome if– Aspirated material large in volume– Contains virulent components of the anaerobic

microbial flora if patient has teeth or– Foreign bodies such as aspirated food or necrotic

tissue

DNR vs Palliative Care V66.7 Z51.5

DNR – patient desires some limitations in case of perception of death (no code, slow code, no vent, etc.)

Comfort measures only – patient and family and physician and chaplain all agree that treating measures will be stopped or not instituted with exception of pain management, fluids – comfort

Palliative care consult is NOT the same

Lab Result vs Disease?

Symbols and directions for abnormalities do not translate into disease processes from a

severity standpoint.• Troponin • Na+ = 124• EtOH (+)• Hb

… do not translate into the economic language of health care!

Handling the Problem List

It’s an Epic Task

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, lyman@virginia.edu

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 electronic 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 others

• 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.

Paint the picture of Paint the picture of the patient properly the patient properly

with WORDSwith WORDS

So the coder can paint the same picture with codes.

What you want…

what you might get.

may notbe…

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