value based purchasing, changes for icd-10 and the future of radiation oncology robert s. gold, md
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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 -
Univ VA VCU Retreat Augusta Culpeper Rockingham Henrico2013 2013 Doctors Health Regional Memorial Doctors
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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