ahima game of documentation - dance with the icd10 dragon

PowerPoint Presentation

Nick van Terheyden, MD (aka @drnic1)Chief Medical OfficerDell Health and Life Sciences

Game of Documentation:Dance with the ICD-10 Dragon

@DrNic1 #DrHIT Dell - Internal Use - Confidential

Spoiler alertThis presentation may contain details from the Game of Thrones series and may spoil your enjoyment


You too can tame the ICD-10 Dragon like Daenerys Targaryen


Like Daenerys Targaryen3 Dell - Internal Use - Confidential

Agenda

A quick recapSo its happening reallyBasic changes from ICD9 to ICD10What it means to youThe impact to patientsTips on survivingWhats next


4 Dell - Internal Use - Confidential

AgendaA quick recapSo its happening reallyBasic changes from ICD9 to ICD10What it means to youThe impact to patientsTips on survivingWhats next



ICD-10 history

ICD-10 adopted by the World Health Organization in 1990United Kingdom: 1995Australian Mods: 1998Canadian: 2001U.S. development began in 1994Multiple versions final implantation date October 1, 2014SGR Bill signed April 1, 2014Final implementation deadline October 1, 2015ICD-11 not likely until 2017, earliest2 years for U.S. to consider, 2 year review, 2 year mandated waitICD-11-CM not before 2023 (with the same structure as ICD-10)



Survey questionWhere are you on the continuum of preparing your office for ICD-10?

Were readyWe have a plan and are on our way to being readyWe might be ready becauseWeve talked about itUh, when do we have to start?No need to prepare... it will be delayed again


Dont end up like Ned Stark.7 Dell - Internal Use - Confidential




Jon SnowExpect the unexpected

It aint over till its over


High level messageICD-10 implementation will improve patient careICD-10 is not being imposed on physicians by the hospitalThe hospital is collaborating to reduce impact on physicians by building knowledgeable infrastructureIndependent physicians need to focus now on their practice, specifically their systems and staffFurther education will be coming at the appropriate time for every specialty and subspecialty





Should we really replace ICD-9?ICD-9-CM is 35 years old when it was put in use:Margaret Thatcher, Ronald Reagan, and Mikhail Gorbachev were the leaders of that time and Russian Olympics were boycotted but the U.S. Won the Miracle on IceRubiks Cube was all the rageJohn Lennon was shot deadCNN went worldwideMusic: Celebration/ Another One Bites the DustSmallPox was declared eradicatedAnd doctors could still smoke in room with patients



Should we really replace ICD-9?Much of the terminology and classification of conditions are outdated and even obsoleteIncreasingly demonstrates lack of specificity especially for EHR and population data trackingProblematic for international comparison



IntakeSelect chief complaint Enter vitalsReview of symptomsReview past medical and social historyReview medications and allergiesExamReview IntakeDocument patient examSelect diagnosisEnter ordersReview quality measures

Sign-offReview assessment and planSign off on ordersComplete billing slipGenerate lettersReview chargesClose the patient encounter

Check-inVerify appointment, demographic, insurance informationCollect patient paymentsPrint billing slipFormsCheck-outSchedule follow up appointmentsCollect outstanding balancesDistribute patient education materialsEnter charges

The ICD-10 transition broadly affects the patient visit



CodersPhysiciansThe Coder / Physician dichotomyICD-9 is 35 years old with outdated terminologyCoders must learn current anatomy, pathophysiology, terminology, etc.Coders must understand the entire ICD-10 systemCoders must think expansively of all possible code optionsThe burden on coders is tremendousICD-10 includes modern terminologyPhysician practice has evolved even though the coding system was stagnantPhysicians need to learn what is applicable to their specialtyPhysicians tend to be linear and hierarchicalThe burden on physicians is manageable


Some ICD-10 new featuresCombination codes (etiology and manifestation)Type 1 diabetes with diabetic nephropathyLateralityLeft, right, bilateral, unspecified (4)Episode of careInitial (open, closed), subsequent (routine, delayed, nonunion, malunion), treatment of sequelaTrimesters for obstetrical careClinical changesTime frames for acute myocardial infarctions


Changes to the codesCondensation of codesExpansion of codesChanges to terminology


Largest expansion is the Injury, poisoning and other consequencesSports medicine with about 39,000 codes in chapterSpecificity required for nature of injury


ICD-9-CM ICD-10-CMAcute Myocardial InfarctionAcute Myocardial Infarction (30 codes)Primary axis: Site involved (10)Anterolateral, other anterior wall, inferior wall, inferoposterior wall, other inferior, other lateral, true posterior, subendocardial, other, unspecifiedSecondary axis: episode of care (3)initial, subsequent, unspecifiedAcute Myocardial Infarction (14 codes)Axes of classification: Initial MI (9)STEMI (8) (by site)Anterior (3)L main, L anterior descending, other coronary arteryInferior (2)Right coronary artery, other Other (2)Left circumflex, other sitesUnspecified (1)NSTEMI (1)Subsequent MI (5)Anterior wallInferior wallNon-STEMIOther sitesUnspecified

Subsequent AMI AMI occurring within 4 weeks of previous AMI, regardless of site


New terminology STEMI, NSTEMI (new to ICD-10 and coders, but has been in clinical use for at least the last two decades)New terminology for subsequent AMI important for risk and outcomes

Also true for Hypertension (33 codes to 14)


Changes to terminology


Asthma classificationAsthma 14 codesType/etiology/cause (12 types)ExtrinsicIntrinsicChronic obstructiveAsthma, UnspecifiedSeverity (for above types)UnspecifiedWith (acute) exacerbationWith status asthmaticusOther forms of asthma (2 types)Exercise induced bronchospasmCough variant asthmaAsthma 18 codesSeverity / typeMild intermittent (3)Mild persistent (3)Moderate persistent (3)Severe persistent (3)Presentation (for each above)UncomplicatedWith acute exacerbationWith status asthmaticusOther and unspecified asthmaUnspecified (3)With 3 presentations aboveOther asthma (3)Exercise induced bronchospasmCough variant asthmaOther asthmaICD-9-CM ICD-10-CM


New terminology is new to coding been in use in clinical practice for many yearsAlso Diabetes change to terminology and expansion





Benefits of ICD-10

The new, up-to-date classification system will provide much better data needed to:Measure the quality, safety, and efficacy of careImprove quality reporting and scoringReduce the need for additional documentation to explain the patients conditionDesign payment systems and process claims for reimbursementConduct research, epidemiological studies, and clinical trialsSet health policySupport operational and strategic planningDesign healthcare delivery systemsMonitor resource utilizationImprove clinical, financial, and administrative performancePrevent and detect healthcare fraud and abuseTrack public health and risks



Why physicians are liking ICD-10Codes are more specificThey link etiology to disease (staph pneumonia)They link manifestation to etiology (hypertensive heart disease)They make more clinical senseInjuries grouped by anatomical site rather than type of injuryLaterality has been added to relevant codesThey are up to dateCode titles reflect new technology & recent terminologyCodes have been added to describe postoperative or post-procedural conditionsICD-10 is essential for clinical research and epidemiology


329 major small and large bowel procedure W MCCRel wtExp mortExp LOSExp costExp readmitExp paymentSecondary DX acute systolic failure5.269.51%13.59$30,30218.69%$34,716

330 major small and large bowel procedure W CCRel wtExp mortExp LOSExp costExp readmitExp paymentSecondary DX chronic systolic failure2.570.73%7.79$1668112.25%$16,962

*Exp outcome values based on specific population with proprietary analysis of severity may vary with different population and assessment methods for illustrative purposes only based on real data331 major small and large bowel procedure WO CC/MCCRel wtExp mortExp LOSExp costExp readmitExp paymentSecondary DX CHF1.640.13%5.67$128518.93%$10,824

Effect of accurate documentation on outcomes



PhilosophyPhysicians do not need to learn codingPhysicians need to work in a collaborative process to achieve accurate documentation on every patientThe process must increase efficiencyThe documentation process should be owned by physicians


Basic conceptsCoding solutions, alone, cannot resolve the issue of inadequate physician documentation

Physician leaders must be able to engage their colleagues in a proactive manner, establishing the appropriate motivation & sharing necessary knowledge to achieve success under Coding and Continuous Documentation Improvement ProgramsInadequate physician documentation has been a challenge for accurate coding under ICD-9If uncorrected, that challenge continues to increase


Clinical documentation is everything


Clinical documentation is everything, document findings, communication to the care team about patient and treatment, used for reimbursement, MU reporting (quality reports MU 2menu item for Acute), quality reporting (HAC/POA indicators) VBP.27 Dell - Internal Use - Confidential




Feds to allow use of Medicare data to rate doctors USA Today 12/5/11The federal government announced that Medicare will now allow use of its extensive medical claims database by employers, insurance companies and consumer groups to produce report cards on local doctors and hospitals.

By analyzing masses of billing records, experts can glean such critical information as how often a doctor has performed a particular procedure and get a general sense of problems such as preventable complications.

Compiled in an easily understood format and released to the public, medical report cards could become a very powerful tool for promoting quality care and reducing wasteAnnounced by Marilyn Tavenner Acting Administrator of CMS



30



MCOs ALSO measure MD PerformanceUnitedH Physician Locator Website



MCOs ALSO measure MD Performance

UnitedH Physician Locator Website



UnitedH Physician Locator WebsiteQuality and cost efficiencyCost efficiency and not enough data to assess qualityQuality and not enough data to assess cost efficiency Quality and did NOT meet cost efficiencyDid NOT meet quality and cost efficiency

Members in health plans that offer tiered benefits may pay lower copays and coinsurance amounts for services provided by UnitedHealth Premium Tier 1 physicians.

UnitedHealth Premium Tier 1 physicians have received the premium designation for quality and cost efficiency


We believe our networks will continue to exceed accessibility standards right down to the county level," McElrath-Jones said.

We have conducted outreach to area providers that will remain in network to confirm their capacity to take on additional patients."


The risk to providersThe only way clinical performance is adjudicated is through billing dataIf you do not get the billing data correct then your performance will be adjudicated incorrectly


This will be vital in the changing healthcare environmentMy patients are sicker is no longer an acceptable excuse for less than expected performance because severity adjustment is built into the coding systemBut only if you get it right In a population based payment system those that have less than expected performance in quality and cost will be marginalizedIt would be a shame for your hospital and clinicians were to be affected just because you didnt understand the Documentation, Regulatory, and Compliance environment we live in today





Post implementation

Review documentation and coding quality post-October 1, 2015

Provide team member, clinician, and physician education, as needed

Conduct financial impact analysis

Update risk and monitoring planSupport accounts receivable billing and collection backlog and activity, as needed



Conduct 3, 5, 6, 9 and 12-month post-conversion optimization assessments

Reassess/ update training for coding personnel

Validate future state workflows

Perform post-implementation project training and documentation auditsDevelop medical coding tests for Health System new hire screening

Post implementation



RisksEducation/documentation gapsProductivity lossesLack of resourcesChanges in reimbursementLimited immediate but as ICD10 data arrives at CMS they will likely refine MS-DRGNot limited to this: patient care outcomes, quality of care, profiling providers, P4P, medical necessityExpect audits to focus on clinical documentation to determine if it supports the specificity of ICD-10 codesUnspecified = unpaid

!


International lessonsAustralians love ICD-10 because not working with so many dump codes or unspecified Coders were back to old output rates w/in 3 monthsEducation is keyProviders still adjusting billing because of what they are learning from their ICD-10 dataSee ICD-10 as a must do and a benefit





Value-based paymentTwo shiftsIncreasing accountability for quality and total cost of careTimeline:30% of Medicare payments in alternative payment models (categories 3 & 4) by the end of 201650% of Medicare payments in alternative payment models (categories 3 & 4) by the end of 2018Overall, 85% of payments in categories 2 through 4 by 2016 and 90% by 2018



PrinciplesEducation, particularly on clinical issues, must be peer-to-peer

Physicians are interested in their specialty, not material unrelated to their practicePhysicians will commit minimal timePhysicians should learn the documentation principles and specific changes relevant to their specialtyPhysicians should never attempt to memorize ICD-10-CM codes there are simply too manySpecific examples should be utilized






Nick van Terheyden, MDCMO, Dell Health and Life SciencesAboutMehttp://about.me/obiwanTwitterhttp://twitter.com/drnic1LinkedInhttp://www.linkedin.com/in/nickvtBloghttp://drnick.vanterheyden.com/FaceBookhttp://www.facebook.com/[email protected], [email protected] Voice(301) 355-0877

Where you can find me


Dell - Internal Use - Confidential

ResourcesCMS ICD10 Websitehttp://www.cms.gov/Medicare/Coding/ICD10/index.html

ICD10 MS-DRG Conversion Project (GEMS)http://www.cms.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html

Updated ICD10 Implementation Information (MLN)http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1239.pdf

ICD10 Myths and Factshttp://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD-10MythsandFacts.pdf

Medicare Fee-For-Service Provider Resourceshttp://www.cms.gov/Medicare/Coding/ICD10/Medicare-Fee-for-Service-Provider-Resources.html

Provider Resourceshttp://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html

The Road to ICD10www.RoadTo10.org


Game of Thrones Theme SongGame of Thrones (HBO)2011Other100416.68

ahima game of documentation - dance with the icd10 dragon

Healthcare