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Clinical Documentation Improvement

Medical Staff Transition to ICD-10

DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

Conflict of Interest Disclosure

Robert S. Gold, MD

Has no real or apparent

conflicts of interest to report.

© 2012 HIMSS

Session Objectives

Learn what your facility needs to know in order to attract the cooperation of the medical staff in the

transition to ICD-10 ... and what to avoid.

Learning Objectives:

1. Evaluate the needs of the members of the medical staff

2. Discuss how to effectively market ICD-10 to

doctors and their midlevels

3. Describe how CDI can get you there with universal acceptance by the medical staff and avoid alienating them

• Cost per patient

• Resource utilization

• Length of stay

• Complications

• Morbidity

• Mortality

• Outcomes

• Fraud and abuse

Medicine Under the Microscope

• Documentation leads to identification of

diagnoses and procedures

• Recognition of diagnoses and procedures lead to ICD codes – THE TRUE KEY

• ICD codes lead to DRG assignment

• DRG assignment massaged to “Severity

Adjusted DRGs”

• Severity adjusted data leads to morbidity and mortality rates

Where Does Data Come From?

• The DRG – hospital reimbursement

• APR-DRGs – physician/hospital profiles

• Documentation’s relationship to code assignments

• Codes and APR-DRGs

• Codes and profiles

ICD-9-10-CM

Relationship Between the Medical

Record and the ―Data‖

7

Issues of Concern

• Severity of illness – conditions that make the principal diagnosis more costly – ALL diagnoses, ALL procedures

• Risk of mortality – conditions that add to the likelihood that a patient will die – ALL diagnoses, ALL procedures

• Patient safety – identification of risk issues that can be minimized or controlled

• Teaching your medical staff the important facts of the business of medicine – things that will affect them the rest of their professional careers

What is an Index?

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• 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

What is an Index?

• HealthGrades.com tells everyone about the reputation of the hospital and the medical staff with no input from the physicians.

• Patients can access this data to determine where they will seek care.

Hospital Report Card

Observed mortality

Expected mortalityFrom severity adjusted DRGs

=1; as good as the next guy

<1; preferred provider – significantly better

>1; excessive mortality; find another provider -

Profiles Come from

Severity Adjusted Statistics

S t F ra n c is S o u th e a s t H e a r t la n d S S M M is s o u r i S t. M a ry 's M id d le s e x

M e d C e n H o s p ita l R e g io n a l S t C la re D e lta C e n tra lia H o s p ita l

R e s p ira to ry D is e a s e s

C O P D

H o s p p lu s 6 m o n th s

P n e u m o n ia


R e s p ira to ry F a ilu re


S e p s is


C a rd io v a s c u la r D is e a s e s

H e a r t F a ilu re


A c u te M I


S tro k e


In te rv C a rd io lo g y N R N R N R

H o s p p lu s 6 m o n th s N R N R N R

C A B G N R N R N R

H o s p p lu s 6 m o n th s N R N R N R

S u rg e ry

O R IF H ip M a j C o m p l N R

P ro s ta te M a j C o m p

C h o le c ys te c to m y M a j C

• Physician quality profiles (M&M)

• Physician utilization profiles (efficiency of treating patients)

• Physician E&M levels now

• Physician E&M levels in the future including P4P

• Interference of daily smooth work flow by needs of Utilization Review

• HOW I LOOK TO THE WORLD

How Does This Affect Me?

• The sicker your patient is…

• The higher the complexity of

medical decision making…

• Justifying an appropriately higher level of E&M

Documentation’s Effect on E&M Coding and Physician Income

Effect on Quality of Care

• Identifying a condition with the proper words permits retrieval of mortality data

• Identifying a condition by your thoughts permits others who treat your patients and follow you to know what you’re thinking

• Identifying a condition specifically permits quality indicators to be extracted retrospectively

• Hierarchical condition category risk adjustment – the more complex the disease, the higher the risk, the higher your reimbursement

• Billing only vanilla codes reaps least rewards– 250.00 is diabetes type 2, not stated as

uncontrolled – is this ALL of your patients?

– 428.0 is CHF with no additional risk – is this ALL of your patients?

HCC RAs - Here Since 2004

HCC Cat # Description Weight

15 DM with renal (250.4x) or circulatory manif (250.7x)

.508

16 DM with neurol (250.6x) or other spec manif (250.8x)

.408

17 DM with acute complications (250.1x, 250.2x, 250.3x)

.339

18 DM with retinopathy (250.5x) or unspecified manif (250.9x)

.259

19 DM uncomplicated (250.00) .162

The More Complex the Diabetic, the Higher the Payments

Provider Members Risk Score PMPM

Average 5,011 0.963 $688.22

Providers

A 14 0.650 $508.77

B 11 0.820 $594.48

C 9 1.080 $760.94

D 14 1.220 $803.54

E 14 1.380 $866.56

F 12 1.750 $1,127.34

IDEAL 1.08-1.10

Risk Adjusted Capitation

Disclosed May 16, 2008

Acute Care Episode project

Combine Part B payments with Part A

“Value Based Centers” to be identified trial

starting with Texas, Oklahoma, New

Mexico and Colorado

Value based purchasing

28 cardiac and 9 orthopedic inpatient

surgical services

Gainsharing also permitted here

ACEs Are Wild

September 2, 2011

Bundles physician and hospital payment into one lump sum could represent a long-term, revolutionary solution to that age-old question.

Testing four new bundled payment plans, according to a Fact Sheet released August 23

Three models involve retrospective payment, one a prospective payment determined by MS-DRG

Aggregate Medicare payment for the episode will be reconciled against the target price. Savings beyond the discount reflected in the target price will be paid to the participants to share among the participating providers.

News: CMS releases bundled payment information

A s s o c ia te d P re s s

B y R IC A R D O A L O N S O -Z A L D IV A R

F e d s to a l lo w u s e o f M e d ic a re d a ta to r a te d o c to r s

W A S H IN G T O N —

P ic k in g a s p e c ia lis t fo r a d e lic a te m e d ic a l p ro c e d u re lik e a h e a rt

b y p a s s c o u ld g e t a lo t e a s ie r in th e n o t - to o -d is ta n t fu tu re .

T h e g o v e rn m e n t a n n o u n c e d M o n d a y th a t M e d ic a re w ill f in a lly a llo w

its e x te n s iv e c la im s d a ta b a s e to b e u s e d b y e m p lo y e rs , in s u ra n c e

c o m p a n ie s a n d c o n s u m e r g ro u p s to p ro d u c e re p o rt c a rd s o n lo c a l

d o c to rs — a n d im p ro v e c u rre n t ra t in g s o f h o s p ita ls .

B y a n a ly z in g m a s s e s o f b illin g re c o rd s , e x p e rts c a n g le a n s u c h

c r it ic a l in fo rm a tio n a s h o w o f te n a d o c to r h a s p e rfo rm e d a p a rt ic u la r

p ro c e d u re a n d g e t a g e n e ra l s e n s e o f p ro b le m s s u c h a s

p re v e n ta b le c o m p lic a t io n s .

D o c to rs w ill b e in d iv id u a lly id e n t if ia b le th ro u g h th e M e d ic a re f ile s ,

b u t p e rs o n a l d a ta o n th e ir p a t ie n ts w ill re m a in c o n f id e n t ia l.

C o m p ile d in a n e a s ily u n d e rs to o d fo rm a t a n d re le a s e d to th e p u b lic ,

m e d ic a l re p o rt c a rd s c o u ld b e c o m e a p o w e rfu l to o l fo r p ro m o tin g q u a lity c a re .

M e d ic a re a c t in g a d m in is tra to r M a r ily n T a v e n n e r c a lle d th e n e w p o lic y "a g ia n t s te p fo rw a rd in

m a k in g o u r h e a lth c a re s y s te m m o re tra n s p a re n t a n d p ro m o tin g in c re a s e d c o m p e tit io n ,

a c c o u n ta b ility , q u a lity a n d lo w e r c o s ts ."

• 1662: London Bills of Mortality–attempt to define mortality rate and causes under age 6 in England; no particular classification

• “Having premised these general Advertisements, our first observations upon the Casualties shall be, that in twenty years there dying of all Diseases and Casualties, 229,150 that 71,124 dyed of the Thrush, Convulsions, Rickets, Teeth, and Worms; and as Abortives, Chrysomes, Infants, Livergrowns, and Overlaids; that is to say, that about 1/3 of the whole dies of those Diseases, which we guess did all light upon children under four or five years old”

Origins

• 1853–1855: Uniform Classification of Causes of Death–England and France– first divided diseases by anatomic site

• 1855: Revision added; England, Germany and Switzerland distinguished between general diseases and those specified by anatomic site

Advancements

• 1898: American Public Health Association

recommended adoption of “Bertillon

Classification of Causes of Death” for all North America

• 1899: Agreement to update system every

ten years

• 1900: First international conference for

Revision of the Bertillon or “International List of Causes of Death” – 26 nations met in

Paris; next three revisions held there

Progress

• 1900: New parallel list of nonfatal diseases proposed and adopted in 1909

• Changed title to International Classification of Causes of Sickness and Death

• 1928: League of Nations “Mixed Commission” drafted proposals for the 4th

and 5th revisions of the International List of Causes of Death – became WHO

• 1929: U.S. government volunteered to spearhead further statistical tabulations

• 1938: Update added causes of stillbirth

More Growth

• Uniform list containing both causes of

mortality and causes of morbidity initiated

• 1946: Sixth Revision formally adopted need for a single listing International Classification

of Diseases, Injuries and Causes of Death

• 1955: Seventh Revision – amended errors

and inconsistencies

• 1965: Eighth Revision – classified by etiology rather than particular manifestation

Toward the Present

• 1975: Ninth Revision updated, added detail with 4th and 5th digit specificity, reclassified where appropriate; added impairments, handicaps, and procedures for the first time –implemented 1979

• The world adopted ICD-10 in 1999–except…

Back to the Future

Prep for the EHR Mandate

Is It Y2K All Over Again?

• State that the programs are ready for ICD-9, ICD-10 and SnoMED

• State that they provide “meaningful use”

• State that they aid with “pick lists”

• State that they help with “problem lists”

• State that they help with physician professional billing because you can cut and paste

Is the EHR a Friend or Foe?

ICD-9

ICD-10

Change in the Entire System

• 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 7

alphanumeric places

• ICD-9 14,000 codes; ICD-10 68,000 codes

• ICD-9 has no specificity as to which side of

the body (eg., percent burn on right or left arm or leg – side of paralysis after stroke)

Notable Changes

Example - Fracture

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

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

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 digits

1 – right

2 – left

9 - unspecified

Example Specificity - Location

It’s a retrospective system –NOT a concurrent help!

Enter diagnosis

_______________

Ella McPherson 1323 Jefferson St.112233445 OtowannaJan 22, 1934

I50Heart failureI50.1 Left ventricular failureI50.2 Systolic (congestive) heart

failureI50.20 Unspecified systolic (congestive) heart failure

I50.21 Acute systolic (congestive) heart failure

I50.22 Chronic systolic (congestive) heart failure

I50.23 Acute on chronic systolic (congestive) heart failure

I50.3Diastolic (congestive) heart failure

I50.30 Unspecified diastolic (congestive) heart failure

I50.31 Acute diastolic (congestive) heart failure

I50.32 Chronic diastolic (congestive) heart failure

Enter diagnosis

___CHF______


Enter diagnosis

____________


Enter diagnosis

___CHF_________


Is it:

Acute now?

Chronic heart

failure patient?

Chronic heart

failure with acute

exacerbation?

Enter diagnosis

___CHF______


Is it:

Acute now?

X Chronic heart

failure patient?

Chronic heart

failure with acute

exacerbation?

Enter diagnosis

___CHF_________


Is it

Right heart failure

Left heart failure

Biventricular

Shunt

hyperperfusion

Don’t know

Enter diagnosis

___CHF_______

Chronic heart failure

patient


Is it

Right heart failure

X Left heart failure

Biventricular

Shunt

hyperperfusion

Don’t know

Enter diagnosis

___CHF______

Chronic heart failure

patient


Is it due to:

Systolic dysfunction

(EF<40)

Diastolic

dysfunction

(normal EF)

Combination

Don’t know

Enter diagnosis

___CHF_______

Chronic left heart

failure patient


Is it due to:

X Systolic dysfunction

(EF<40)

Diastolic

dysfunction

(normal EF)

Combination

Don’t know

Enter diagnosis

___CHF_______

Chronic left heart

failure patient


As best you know, what is the cause?

Ischemic CMP

Alcoholic CMP

Hypertensive CMP

Valvular CMP

Hypertrophic CMP

Amyloid CMP

Other __________

Unknown

Enter diagnosis

___CHF_____

Chronic systolic left

heart failure

patient


As best you know,

what is the cause?

X Ischemic CMP

Alcoholic CMP

Hypertensive CMP

Valvular CMP

Hypertrophic CMP

Amyloid CMP

Other __________

Unknown

Enter diagnosis

___CHF______

Chronic systolic left

heart failure

patient


Enter diagnosis

___CHF_________

I50.22 Chronic systolic left heart failure

I50.9 Congestive heart

failure

I25.5 Ischemic cardiomyopathy


Remember …

Recent Progression

• ICD-9 has had a flurry of activity over past 4 years– Added specificity

– Added E codes

– Added pediatric diseases, dental, eye

• Docs must be fluent in ICD-9 needs to make an easy transition

• Docs who can’t speak 9 will be lost with 10

52

So the coder can paint the same

picture with codes.

What you want…

what you might get.

may not

be…

Paint the picture of the patient properly with WORDS

Res Ipsa Loquiter

• The physician’s pen leads to all data

• The physician’s pen leads to all payments for healthcare

• No EHR product in the inpatient setting provides help to the practicing physician

• If the docs don’t know how to fill the gaps in the data, how to document diagnostic entities properly …

So What’s GOING to Happen?

Our Mandate – Meaningful Use

How can there be meaningful use of a medical record if nobody knows what’s wrong with the patient?

Frustration in the Field

• “Since we went live, we can’t code anything anymore. There are no useful diagnoses anywhere.”

• “If you have any influence with our EHR people, please ask them to provide a textbox in the Critical Care Nursing Notes. As it is now, we have no idea what’s wrong with our patients.”

• “I’m not going to waste time picking from these lists – my patients are sick.”

What We SORELY Need

• An EHR in the cloud that can be accessed by all healthcare givers with patient authorization

• A common pathway of interaction with the cloud

• An app for the physician’s smart phone/ tablet/computer that communicates with the cloud, the hospital, the office that provides algorithms for diagnoses and procedures in doc-speak

There are various views

regarding the President

Obama’s ability to ensure that

all medical records in the

United States are converted

into the electronic format by

2014 but there is no denying

the fact that an increased

adoption of EMR or electronic

medical records by

physicians, healthcare

organizations and their

related business associates

is now a gradually-

progressing certainty.

Set Your Benchmarks

Share Data with the Med Staff

• Severity adjusted mortality rate by:– Whole hospital

– Medical DRGs whole hospital

– Surgical DRGs whole hospital

– Service line

– Individual physician or groups

• Severity adjusted LOS

• Severity adjusted complication rate

• Severity adjusted costs/patient

“If you don’t look good, we don’t

look good” Vidal sassoon, ca 1985

Father of modern medical economics

Motto For The Age

Questionsand Answers

Your Ideas and Comments

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