Kansas City ACDIS ChapterKansas City CDI Group

ACDIS CHAPTER

POST ICD 10

November 10, 2015

Agenda• Introductions• Housekeeping Issues: • ·       CCDS request for CE credit form• Sign in Sheet• ·       Please complete the online membership roster• ·       There has been some discussion on tricky

ICD-10 items via CDI Talk if that helps your presentation• ·         We are seeking donations of ICD-10 query forms for

our Forms & Tools Library. They can email me at mvarnavas@acdis.org to contribute

• ·         ACDIS recently updated its Code of Ethics. It’s free and open to the public. We encourage everyone to read it.

• Study Group

How Did ICD 10 Go?• ICD 10….41 Days Post GO-LIVE• How did everything go? Coding, CDI, Staffing, Auditing,

Training physicians• Challenges?• Documentation Issues• Tips for Queries for ICD 10 • Specific Examples• To update your information on ACDIS website for our group go

to:

• http://www.keysurvey.com/votingmodule/s180/f/617822/c7f0/

CORONARY ARTERY INTERVENTION SITE (ICD-10-PCS)

• With ICD-10-PCS, the treatment of coronary arteries has changed. Coronary arteries are classified as a single body part that is further specified by number of sites treated, not by name or number of arteries (B4.4).

• So the question remains, what is a “site”? A coronary intervention “site” refers to each distinct lesion treated, unless a single lesion extends into more than one artery. (CC 2Q2015 p.3)

CORONARY ARTERY INTERVENTION SITE (ICD-10-PCS)

• Coding Clinic has received multiple questions about what constitutes a “site”, and they posted five examples of what a “site” is. Here is the breakdown:

• 1. Multiple drug-eluting stents placed in multiple coronary artery lesions. In this example, the patient had DES placed in three separate arteries, and this is considered three coronary artery sites. (CC 2Q2015 p.3)

• 2. Multiple stents to treat single coronary artery lesion. In this example, the patient had one long lesion of an artery, and had two stents placed. Since it was the same lesion, it is considered ONE site. (CC 2Q2015 p.3-4)

CORONARY ARTERY INTERVENTION SITE (ICD-10-PCS)

• 3. PTCA of one coronary artery with more than one lesion, DES. In this example, the patient had two lesions, both in the same artery, but one was at the proximal left anterior descending, and one was at the distal left anterior descending artery. Since they were two separate lesions, this is considered two coronary sites. (CC 2Q2015 p.4)

• 4. Treatment for coronary artery lesion extending into bifurcation. In this example, the lesion that was within the left anterior descending coronary artery extended into the branch artery of the LAD at the bifurcation, and two stents were placed. This is coded as one site, bifurcation, with DES, since it was one lesion that extended to the branch.(CC 2Q2015 p.4-5)

CORONARY ARTERY INTERVENTION SITE (ICD-10-PCS)

• Treatment for two distinct lesions in the same coronary artery. In this example, the patient had PTCA of the right coronary artery (RCA) with placement of two drug-eluting stents, and also had PTCA of the proximal and mid-portion of the left anterior descending (LAD) coronary artery. Three drug-eluting stents overlapping from the proximal to the mid- LAD were inserted. This is coded to two sites, because they treated the site in the RCA with two stents, and the site in the proximal-mid LAD with three stents. These are considered “long lesions” or a single site each (one site RCA one site LAD).(CC 2Q2015 p.5)

CORONARY ARTERY INTERVENTION SITE (ICD-10-PCS)

ICD 10 PCSInterventional Radiology

• This patient had a thrombomechanical thrombolysis of the ileofemoral popliteal viens.  But there isn’t specificity as to which iliel vein, femoral vein was treated.

• Femoral vein does include the popliteal vein, but the iliac is the true problem, do we just assume that it would be in the external iliac vein?  

• http://www.healthline.com/human-body-maps/common-iliac-vein.

 

ICD 10 PCS Interventional Radiology

ICD 10 PCS Interventional Radiology

ARTIFICIAL RUPTURE OF MEMBRANES (ICD-10-PCS)

• In ICD-9, coders were instructed to only code artificial rupture of membranes (AROM) if it was performed to induce labor. It was not to be coded if it was performed to augment labor.

• The instruction in ICD-10-PCS has changed. Artificial rupture of membranes should be coded when it is performed to induce or augment labor. The following information is from Coding Clinic:

• There is also a 3m Nosology Help Message

Leadless pacemaker insertion

• Coding Clinic, Second Quarter ICD-10 2015 Pages: 31-32 Effective with discharges: July 6, 2015

• Question: • A 70-year-old male with first and second degree atrioventricular (AV)

blocks as well as right bundle branch block presents for insertion of a leadless pacemaker. A leadless pacemaker was inserted via catheter under fluoroscopic guidance into the right ventricle. The ICD-10-PCS does not provide a value for leadless pacemaker. How should this procedure be coded?

• Answer: • The ICD-10-PCS does not provide a specific device value for

leadless pacemaker. Intraluminal device is the closest available equivalent. Assign the following ICD-10-PCS code for this new technology:

• 02HK3DZ • Insertion of intraluminal device into right ventricle, percutaneous

approach

Excludes1

• The Centers for Disease Control (CDC) has received many inquires regarding interpretation of the Excludes1 note regarding diagnoses unrelated to one another where an Excludes1 note is included in the tabular list. Below is the interim guidance by the CDC to help with interpreting the Excludes1 Notes:

• If the two conditions are not related to one another, it is permissible to report both codes despite the presence of an Excludes1 note.

Excludes

The Excludes1 note at code range R40-R46, states that symptoms and signs constituting part of a pattern of mental disorder (F01-F99) cannot be assigned with the R40-R46 codes. However, if dizziness (R42) is not a component of the mental health condition (e.g., dizziness is unrelated to bipolar disorder), then separate codes may be assigned for both dizziness and bipolar disorder.

• In another example, code range I60-I69 (Cerebrovascular Diseases) has an Excludes1 note for traumatic intracranial hemorrhage (S06.-). Codes in I60-I69 should not be used for a diagnosis of traumatic intracranial hemorrhage. However, if the patient has both a current traumatic intracranial hemorrhage and sequela from a previous stroke, then it would be appropriate to assign both a code from S06- and I69-.

• This information can also be found at: • http://www.cdc.gov/nchs/data/icd/

Interim_Coding_advice_on_Excludes_1_note.pdf

Problem solving Scenarios

• Case Study #1– St Elsewhere’s Compliance

Department analyzed accounts for Oct-Dec 2015 and determined 50% of their principal diagnoses were submitted as “unspecified”. • What would the internal audit objective be?• What data elements would be most useful

to determine problem resolution?

Problem solving Scenarios

Case Study 2: Your facility has an increased of Observed vs. Expected Mortality on patients with Sepsis? Your CFO wants an analysis and a plan for improvement.

What data would you gather? What would you want to look at.

Who would you include on your team?

What data would you get from CDI?

Problem solving Scenarios

CASE Study #2 cont.

Is Severe Sepsis Present• In order to say yes by CMS specs, it has to be either

documented by physician preferably in the ED record OR 3 criteria has to be met within 6 hours each other.– Documentation of suspected source of clinical infection– 2 or more of SIRS criteria: Temp .38.3 C or <36.0 C,

HR>90, RR>20 and WBC>12,000 or <4,000 or >10% bands– Organ dysfunction evidenced by any one of the following:

SBP<90 or MAP<65 or SBP decrease of more than 40 points

Crt >2.0 or urine output <0.5ml/kg/hr for 2 hours

Bili >2 mg/dl

Plt <100,00

INR > 1.5 or aPTT >60 sec

Lactate > 2mmol/L

Problem solving Scenarios

CASE Study #2 cont.• 45 y/o female arrived to ED on 3/17 at 1330,

complaining about SOA for the last 2 weeks. History of DM, CAD, valvular disease, Hypertension, ESRD with Hemodialysis on M/W/F, and diabetic foot ulcers.

• ER physician exam revealed black/necrotic toes with foul odor. CXR unrevealing. Clinical impression dyspnea on exertion and necrotic toes.

• Labs essentially normal with baseline elevated Crt of 7.2, WBC was 8.49. Initial vitals 98.6 F, HR 97, RR 16, and BP 98/52. Admitted to Med/Obs.

Problem solving ScenariosCASE Study #2 cont.

• On morning of 3/18 pt began having decreasing blood pressures with SBP below 90 several times. Blood cultures obtained along with UA micro. 500 cc NS bolus given.

• Pt officially met severe sepsis criteria 3/18 @ 1219 with vital of: HR=109, RR=22, and BP 86/42. Rest of day stayed in Med/Obs, no abx ordered, again received some fluid boluses.

DRG ChangesTwo new Endovascular Cardiac Valve Replacement

DRGs are carved out from the current DRGs 216-221 to distinguish such patients from Open Valve Replacement:

• DRG 266 - Endovascular Cardiac Valve Replacement with MCC

• DRG 267 - Endovascular Cardiac Valve Replacement without MCC

DRGs 483 and 484 - Major Joint/Limb Reattachment of Upper Extremity with and without CC/MCC are combined into a single DRG:

• DRG 483 - Major Joint/Limb Reattachment of Upper Extremity

Aneurysm Repair

• For this aneurysm repair, we would go with the root operation “repair”, which is “restoring to the extent possible, a body part, to its normal anatomical structure and function.  They did not put in graft material. 

• So the best code for the repair of the aneurysm would be 04QF0ZZ, repair left internal iliac artery, open approach.

 • You would also have B41G1ZZ for the fluroscopy of the

left lower extremity arteries using low osmolar contrast-for the angiography that was done on 9/29

Open or Percutaneous?

The valve was placed transcatheter, not open.  It's not a full blown sternotomy with rib spreaders, etc.  They would not jam the catheter with the valve through the skin and ribs; they need to make a percutaneous incision to assist getting the materials through. Going back to the definition of open: cutting through skin...to expose the site of the procedure. 

TAVRs do not expose the site of the procedure.

MEDIASTINAL LYMPH NODE LEVELS

MEDIASTINAL LYMPH NODE LEVELS

• CONTINUED: MEDIASTINAL LYMPH NODE LEVELS

• Definition of nodal zone and nodal station: A nodal zone is an anatomical area that includes one or several neighboring nodal stations.

• The supraclavicular and the subcrainal zones include one nodal station each (station 1 & station 7). The other nodal zones include two, three or six nodal stations. It is important to realize that, in theory, a single N2 zone may have from one to multiple nodes involved in one or several nodal stations, and the nodes may be small or large.

MEDIASTINAL LYMPH NODE LEVELS

• The concept of nodal zones is of special value for those patients who will not undergo surgical treatment. For those receiving chemotherapy, radiotherapy or the combination of the two, the precise anatomical location of the nodes involved is not so important. The nodal zones help locate nodal involvement without having to define the exact anatomical location of the nodes.

MEDIASTINAL LYMPH NODE LEVELS

• However, nodal stations are important for those patients in whom surgical treatment is required. Precise nodal location is important preoperatively to guide surgical treatment, and also intra- and postoperatively to indicate further treatment. This is especially relevant in the upper mediastinal zone. Whether the right or the left paratracheal nodes are involved or not is important to confirm or rule out N2 or N3 disease and to select patients for surgical (multimodality) treatment.

• If a physician removes all nodes in a zone, the root operation is resection. If a physician does not remove all nodes in a zone, the root operation is excision.

Debridement•  Debridement documentation for ICD-9

required the depth of tissue debrided and to specify, by using the word “excisional,” if the procedure was excisional.  According to Coding Clinic 1st quarter of 2008, this was needed even when the description of “sharply debrided” was used.  Though depth into tissue is still required, thankfully, ICD-10-PCS documentation requirements of use of the word “excisional” have relaxed somewhat.Over the years there was much Coding Clinic advice given.

Debridement Among their most recent, first quarter 2013, stated that the coder cannot assume that debridement is excisional so documentation of the type is necessary.  ICD-10-PCS requests the type of procedure or technique used to be stated.  If the procedure is described as a “cutting out” or “cutting off” and there is no replacement, then the actual word “excisional” is no longer required. ICD-10-PCS documentation requirements are more closely aligned to CPT documentation needs so that the Clinical Documentation Specialist (CDS) and coder should attain increased provider cooperation with ICD-10-PCS of debridement documentation needs.

• CPT; Type of debridement:• Excision-Surgical removal of tissue at

wound margin or at the wound base until viable tissue is achieved.Explaining the technique used and by naming the instrument used will help support any questionable documentation and would be defendable from overzealous auditors. If the technique is not excisional, the method used likewise needs to be mentioned. The coder should be able to discern the root operation performed by the procedure note and not simply dependent upon a certain word used. 

Debridement• ICD-10 PCS Official Guidelines, Section

A11 • “Many of the terms used to construct PCS

codes are defined within the system. It is the coder’s responsibility to determine what the documentation in the medical record equates to in the PCS definitions. The physician is not expected to use the terms used in PCS code descriptions, nor is the coder required to query the physician when the correlation between the documentation and the defined PCS terms is clear.  

Hepatic Encephalopathy

• Is hepatic encephalopathy and hepatic coma one in the same? It seems as if we will need the physician to specifically document "hepatic coma" when applicable as the encephalopathy terminology alone does not get us there. The difference between these two codes will be an MCC versus No MCC. The potential difference here for DRG payers is massive if the coding changes and we cannot assume that encephalopathy always means coma.

Hepatic Encephalopathy Due to Viral Hepatitis

Coding Clinic, Second Quarter 2007 Page: 6Effective with Discharges: June 30, 2007Question:When assigning the code for viral hepatitis with encephalopathy, is code 572.2, Hepatic coma, assigned as an additional code, or is this information captured in category 070, Viral hepatitis at the fourth digit level, which describes "with hepatic coma"?What is the correct code assignment for hepatic encephalopathy due to a specific type of viral hepatitis?

Hepatic Encephalopathy

• Answer:Assign the appropriate code from category 070, Viral hepatitis, with the fourth digit indicating hepatic coma, for the viral hepatitis with hepatic encephalopathy. The hepatic encephalopathy (coma) is included in the code assignment at the fourth digit level, so it is not necessary to report 572.2, Hepatic coma, as an additional code assignment.

If you look at the descriptors in the K72 series, it includes the term hepatic encephalopathy with the coma term. All is well, MCC or not. The docs don't have to change anything.

Encephalopathy• Encephalopathy and coma are synonyms in ICD

(9 or 10) as stated...". Is there something in ICD 10, that states they are synonymous? And/or CAN we use Coding Clinics from ICD 9 until the topics are addressed in ICD 10?

Also your statement - "If you look at the descriptors in the K72 series, it includes the term hepatic encephalopathy with the coma term ... The docs don't have to change anything". Again, I am not sure where that comes from. My resources state:

Encephalopathy• K72- Hepatic failure, not elsewhere classified

Includes:acute hepatitis NEC, with hepatic failurefulminant hepatitis NEC, with hepatic failurehepatic encephalopathy NOSliver (cell) necrosis with hepatic failuremalignant hepatitis NEC, with hepatic failureyellow liver atrophy or dystrophy

K72.91 Hepatic failure, unspecified with comaInclusion Term:Hepatic coma NOS

• K72.0 Acute and subacute hepatic failureK72.00 Acute and subacute hepatic failure without comaK72.01 Acute and subacute hepatic failure with comaK72.1 Chronic hepatic failureK72.10 Chronic hepatic failure without comaK72.11 Chronic hepatic failure with coma

So, basically you add your inclusions to get the specifics of the acute or subacute process and you have the with and without coma.

With the acute hepatitis codes, we have:B15 Acute hepatitis AB15.0 Hepatitis A with hepatic comaB15.9 Hepatitis A without hepatic comaHepatitis A (acute)(viral) NOSB16 Acute hepatitis BB16.0 Acute hepatitis B with delta-agent with hepatic comaB16.1 Acute hepatitis B with delta-agent without hepatic comaB16.2 Acute hepatitis B without delta-agent with hepatic comaB16.9 Acute hepatitis B without delta-agent and without hepatic coma

So it's the same thing - with and without "hepatic coma."

Now, is hepatic coma the same as hepatic encephalopathy? Whether it says it now in Coding Clinic for ICD-10 or not, that is the definition. Hepatic coma is a metabolic encephalopathy caused by elevated bilirubin levels.

Lessons Learned

• 3M Encoder had some issues• Interface Issues• Didn ‘t anticipate challenges with new coding

tables• Increase in query for specificity• Some of the procedural pathways lead to

different codes. Careful on the choices you pick in the encoder.

• Codes may put some cases into a HAC depending on the documentation.

• New challenges for documentation

Post Implementation Issues

• Coder productivity• Number of concurrent queries• Number of concurrent queries• Days to final bill• Pre-authorization• Claim edits and denials• Days to payment• Coder questions• Coding quality• Revenue cycle flow

. Number of concurrent queries. Most of us can assume queries will increase due to the more specific nature of ICD-10, especially with ICD-10-PCS. The worst-case scenario is that queries will double or even triple in volume.  Hopefully, organizations have already begun to ask for clinical details necessary in ICD-10, thereby mitigating the increase in queries post go-live. Regardless, it's important to monitor the concurrent query volume and compare it with your baseline. Following are three questions to ask:  • Are queries increasing significantly? If so, are these

queries related to a particular service line or provider • Can you work with a physician advisor to perform physician

education in those areas causing query spikes • Can you use templates to collect additional documentation

electronically or automatically?

Coder productivity Many experts agree that coder productivity will take an initial hit by as much as 50 percent. Organizations should know exact coder productivity in ICD-9 in order to monitor their decrease. The productivity drop will likely vary from institution to institution, depending on the quality of coder training and physician documentation.  HIM directors should expect an initial dip followed by a gradual increase. If a gradual increase isn't apparent, take corrective steps immediately by asking three critical questions: • Is additional coder education necessary? In what specific

areas? • Are documentation gaps causing productivity lags? What

CDI interventions can be immediately performed?  • What are the factors that slow coders down, and how can

you address those factors to put coder productivity back on the upswing?

Number of concurrent queries. For retrospective queries, it is important to know your baseline in ICD-9 and then compare the volume of retrospective queries in ICD-10. An increased number of retrospective queries could indicate a breakdown in communication between CDI or coders and physicians.   Another reason for lackluster physician response to retrospective queries may be ICD-10 overload and the surge in queries. Be attuned to process and workflow improvements that may help alleviate query overload for physicians. In addition, consider implementing a process to prioritize queries.

Days to final bill

What is the organization's average discharged not final billed (DNFB) in ICD-9, and what does the DNFB look like immediately following ICD-10? A rising DNFB could indicate a problem with insufficient physician documentation, a lack of physician responses to queries, coder problems with ICD-10 code assignment, technological glitches, and more. The goal is to identify the cause of coding delays so coders don't fall further and further behind during a time when productivity is already compromised.

. Pre-authorization Obtaining prior authorization for services is often a necessary prerequisite for payment, which makes it a high-risk area in ICD-10. In particular, organizations must ensure that orders and referrals from physician practices include ICD-10 codes. These codes must also be as specific as possible. 

Be prepared to provide additional support for staff members who obtain prior authorizations from physician practices. Many HIM professionals fear that physician practices will continue to submit ICD-9 codes even though the industry has—for the most part—transitioned to ICD-10. Reach out to practices proactively to ensure they have a plan in place to submit correct ICD-10 information.

Claim edits and denials

Be on the lookout for payment impacts sometime in mid to late October, depending on your organization's accounts receivable cycle. Track and trend payer responses, including specific edits and medical necessity denials. What types of edits occur and how often? Incorporate this information into a go-forward mitigation strategy.

Coding quality

Select high-risk cases to audit as well as cases for which there is a diagnosis-related group (DRG) shift between ICD-9 and ICD-10. Ideally, coding educators can audit these cases prior to submission, although even retrospective audits are helpful. The idea is to identify a pattern of incorrect coding before third-party auditors do.

Coder questions. Although the American Hospital Association's Coding Clinic continues to provide ICD-10 guidance, many coder questions are expected immediately following go-live. Organizations must establish a method whereby coders can submit questions internally to a dedicated individual for compilation of concerns to Coding Clinic and tracking of responses. Failure to monitor this information will create rework and inconsistent coding within the department.

Revenue cycle flowFollow the entire flow for each record type—inpatient, outpatient, same-day surgery, emergency department, and recurring accounts—including Medicare and commercial cases. Did the record move through scheduling and pre-authorization to coding/billing and then to the payer? This information can be tracked within the first ten days following go-live.

On-going Monitoring• Perhaps the greatest indicator of organization-wide

performance is the case mix index (CMI). Barring any seasonal changes, clinical personnel changes, or service line changes, the CMI shouldn't increase or decrease significantly after go-live. Monitor the CMI closely, as a change could indicate a deeper problem with coding and/or documentation. 

• As with all performance metrics, the goal is to identify problems when they're still relatively small and manageable. The metrics discussed in this article are those that require close monitoring in the days immediately following implementation; however, there are many more metrics to monitor on an ongoing basis. HIM can help drive process improvement by keeping tabs on this information and regularly sharing it with hospital executives

• We have tested hospital ICD-10 claims processes with our clearinghouse and the following payors with no issues:

RelayHealth Medicare

MO Medicaid TriCare

Cigna BCBS – Kansas City

Humana BCBS – Kansas

• Our workers compensation payors will also accept ICD-10

• Clinics completed claims submission testing in the Epic environment (live in the clinics 8/1/15)

Claims Operations Testing

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Resource Prioritization & Contingency Plans

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Contract Coding Support• Participated in evaluation and selection of two coding vendors. We

have contracted with TrustHCS and are using 15 – 17 coders, mitigating AR increases.– This represents a 50% increase in coding resources over internal staff– That amount represents the projection for coder productivity loss immediately after go-

live.

Epic Tools• We have leveraged Epic implementation to include activation of

“Diagnosis Calculator” technology to assist physicians with a decision tree to arrive at ICD-10 required documentation specificity of diagnosis codes.

• Facility based coders went through over 50 hours of education.

• Facility based coders began double-coding accounts in June 2015.

• Our metro hospital revenue cycle system is successfully passing both ICD-9 and ICD-10 codes to downstream applications including Quality and Decision Support.

HIM/Coding

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• Facility based coders went through over 50 hours of education.

• Facility based coders began double-coding accounts in June 2015.

• Our metro hospital revenue cycle system is successfully passing both ICD-9 and ICD-10 codes to downstream applications including Quality and Decision Support.

HIM/Coding

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Education Key Audiences

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• Providers: Provider education has been occurring since 2012 when CDI was expanded. It has continued through Kaizen events, Epic Best Practice Alerts, and Epic Diagnosis Calculator. Formal on-line ICD-10 training is offerred.

• Coders: Hospital coders had ICD-10 training in 2013-2014 with refreshers & quizzes in 2015. Double coding has been reinforcing that education and providing real-time opportunities for on the job training. Clinics organized ICD-10 “boot camp” coder training.

Education

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This is an example of a disease-specific ICD-10 tip sheet. We have 125 of these available.

Note that it discusses the documentation that is needed and not the codes themselves.

Our CDI staff are utilizing these same educational documents with physicians as well as asking the same question content in queries to the physicians that are concurrent with patient stay.

The ICD-10 Steering Committee continues to function as the vehicle to communicate, discuss, and resolve issues and barriers post go-live.

“SWAT” Teams are in place to address potential issues such as:Increase in unbilled claims

Increased denials

Gaps in payments vs. expected payments

Changes in claims processing cycle times

IT system issues

Other unfavorable trends in KPIs

Post Go-Live SWAT Team Organization

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– Denials– Case mix index– Coding quality and productivity– Unbilled account days and dollars– Average time from claim to payment– Expected payment variances– Education completion

Monitoring: Key Performance Indicators

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Saint Luke’s

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“SWAT” Teams have been in place since 10/01/15

No significant variances from the norm in the key performance indicators

A handful of minor application and/or interface issues, most remediated already

Claim payments received to date are appropriate

2184 total staff have been trained7312 courses have been takenOf those, 418 were Medical Staff, who have taken 1170

courses

THANK YOU!