the impact of physician and icd-10 terminology on obamacare initiatives august, 2015 ·...
TRANSCRIPT
The Impact of Physician and ICD-10
Terminology On ObamaCare Initiatives
August, 2015
James S. Kennedy, MD, CCS
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Disclaimer The materials utilized in this presentation are intended solely for use in
conjunction with today’s seminar. Although great efforts have been taken in the preparation of today’s
material, the speaker and his employer does not assume responsibility for errors or omissions or for damages resulting from the use of the information contained therein.
Advice is general, thus participants should consult professional counsel for specific legal, ethical, technical and clinical questions prior to claim submission.
This lecture was prepared with information that was publicly available on August 6, 2015
ICD-9-CM, ICD-10 and MS-DRGs are constantly evolving. Please consult official guidance prior to code preparation or submission.
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Speaker Information
• James S. Kennedy MD CCS President, CDIMD Engaged in Clinical Documentation and Coding Integrity (CDCI)
physician/CDS/coder education, training, and process development • Education and Certifications Medical School – UT Memphis, 1979 Board Certified – Internal Medicine, 1983 AHIMA CCS Certification – 2001 • Publications
– 2007 – AHIMA – Severity Adjusted DRGs, an MS-DRG Primer – 2009 – ACDIS – Physician Query Handbook – Ongoing – “Minute for the Medical Staff” in HcPRO’s Medical Records Briefings – Ongoing – “Coding Clinic Update” – HcPRO’s CDI Journal (ACDIS)
• Contact (615) 479-7021 – Cellular [email protected]
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Objectives • Have a firm understanding of how CMS and the state of
California evaluate physician/hospital quality
• Know the differences between the CDC’s ICD-9-CM and ICD-10-CM/PCS terminology
• Master challenging definitions impacting severity and risk adjustment
• Devise a plan to assure the integrity of their ICD-10-CM/PCS data measuring patient outcomes
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Like the Phone Book Interesting Characters – Terrible Plot
Dictionary without
Definitions
ICD-10-CM/PCS Basics
• ICD-10-CM/PCS (and ICD-9-CM) are NOT clinical languages (like SNOMED) – ICD-9-CM and ICD-10-CM/PCS are useful for classifying
healthcare data for administrative purposes, including reimbursement claims, health statistics, and other uses where data aggregation is advantageous
• ICD-10-CM/PCS is based ONLY on provider documentation of clinical language, not on a patient’s clinical characteristics that are abstracted by a data analyst (e.g. like STS, NCDR, or ATS databases) – The provider must use the magic words that drive ICD-10-
CM/PCS code assignment based upon patient circumstances
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ICD-10 Implementation Date October 1, 2015
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Diagnoses Procedures
ICD-10-CM (Clinical Modification)
All entities - providers and facilities for diagnoses in all settings: – Hospital inpatients – Hospital outpatients – Physicians offices – Emergency department – Home health – Long-term care – Rehabilitation facilities
ICD-10-PCS (Procedure Coding System)
Used by inpatient facilities ONLY • Includes outpatient facility services
rendered within the prior 72 hours of writing the inpatient order
• Very different than ICD-9-CM or CPT
CPT • Physician and outpatient/observation
facility services still utilize CPT • CPT does not change!!
US Modifications – ICD-10-CM and PCS The Cooperating Parties
• CDC • Responsible for diagnoses
• CMS • Responsible for inpatient
procedures
• American Hospital Assn. • Responsible for interpreting
ICD-9 or ICD-10 (Coding Clinic)
• American HIM Assn. • Provides input from coding
community
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What’s Old? ICD-9-CM
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What’s New ICD-10-CM
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Overall Changes
• 34,250 (50%) are related to the musculoskeletal system
• 17,045 (25%) are related to fractures
• 10,582 (62%) of fracture codes to distinguish ‘right’ vs. ‘left’
• ~25,000 (36%) of all ICD-10 codes to distinguish ‘right’ vs. ‘left’
Clinical Changes Expansions and Deletions
• Marked expansion of codes – Trauma, overdoses, or complications
treatment phases – Office encounters – Asthma – Diabetes mellitus – Obstetrics (trimesters) – Non-pressure ulcer staging – Myocardial infarction timing and vessel
involvement – Open fractures staging – Cerebral hemorrhage location – Ischemic stroke vessel involvement – Coma (Glasgow Coma Scale) – Atrial flutter and fibrillation – Drug underdosing
• Deletion of MD language, such as: – Urosepsis
• Must say “sepsis due to UTI”
– SIRS due to infection • Must say “sepsis” or
“severe sepsis”
– Accelerated or malignant hypertension
• Must describe the organ dysfunction caused by hypertension to measure severity
MD progress notes and DC summaries must use ICD-10-CM’s language (Index or Table) as to defend the assigned code
Differences from ICD-9-CM to ICD-10-CM
ICD-9-CM
Diagnosis Codes ICD-10-CM
Diagnosis Codes
Laterality No Laterality
Laterality –
Right or Left account for 35-40% of codes
Code Construction
3-5 digits 7 digits
First digit is alpha (E or V) or numeric
Digit 1 is alpha; Digit 2 is numeric
Digits 2-5 are numeric Digits 3–7 are alpha or numeric
Decimal is placed after the third character
Decimal is placed after the third character
Placeholders No placeholder characters “X” placeholders
# of Codes 14,000 codes 69,000 codes
Severity Limited Severity Parameters Extensive Severity Parameters
Combination Limited Combination Codes Extensive Combination Codes
Excludes Notes
1 type of Excludes Notes 2 types of Excludes Notes
New Changes Excludes Notes
Excludes1 - A type 1 Excludes note is a pure excludes. – It means 'NOT CODED HERE!' – An Excludes1 note indicates that the code excluded should
never be used at the same time as the code above the Excludes1 note.
– An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.
Excludes2 - A type 2 excludes note represents 'Not included here'. – An excludes2 note indicates that the condition excluded is not
part of the condition it is excluded from but a patient may have both conditions at the same time.
– When an Excludes2 note appears under a code it is acceptable to use both the code and the excluded code together.
Excludes1 Example
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Excludes1 Example
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Requirement for Documentation on Each Record
• Each encounter’s codes must be based on the physician’s documentation (not the problem list) for that encounter
– Coders are prohibited from using previous documentation to support the specificity of a code from the current encounter
Put the MEAT in your Documentation At Least Once A Year
• Monitor—signs, symptoms, disease progression, disease regression – “Diabetes, well controlled w/diet”; “Alcohol dependence in
remission, got 20 year chip”; “Toe amputation status, no evidence of complications”
• Evaluate—test results, medication effectiveness, response to treatment – “Hypertension, well controlled w/Rx”
• Assess/Address—ordering tests, discussion, review records, counseling – “HIV Disease w/lymphadenopathy, check CD4 count”
• Treat—medications, therapies, other modalities – “Thrush, treat with oral nystatin”
Conditions Interdependencies (M.U.S.I.C.)
• Manifestation – Aphasia, right sided weakness, amarosis fugax
• Underlying cause or pathology – Ischemic cerebral infarction
• Severity or specificity – Weakness involves right dominant side – Stroke involves left middle cerebral infarction
• Instigating or precipitating cause – Cerebral embolus in the setting of persistent atrial fibrillation – Underdosing of the patient’s warfarin due to financial difficulty in
obtaining medication • Complications or consequences
– Vasogenic edema requiring expectant intensive care monitoring – Hemorrhage within stroke due to heparin – Midline shift due to edema resulting in subfalcine herniation
When given a diagnosis, place it one of these categories and then look for
the other four, linking them with terms such as “due to,” “resulting in,” and
the like
General Coding Rules for Physicians (Even Inpatient Physicians)
• ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit – List first the ICD-10-CM code for the diagnosis, condition, problem, or
other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided.
• In some cases the first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician
– List additional codes that describe any coexisting conditions..
• H. Uncertain diagnosis – Do not code diagnoses documented as “probable”, “suspected,”
“questionable,” “rule out,” or “working diagnosis” or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.
– Please note: This differs from the coding practices used by short-term, acute care, long-term care and psychiatric hospitals.
Coding Rules for Hospitals Only Uncertain Diagnoses
• If the diagnosis documented at the time of discharge is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out”, or other similar terms indicating uncertainty, code the condition as if it existed or was established. – The bases for these guidelines are the diagnostic workup,
arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.
• Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.
• Inpatient coders cannot code from EKG, Echocardiogram, laboratory, X-ray or pathology reports – Even if interpreted by a board-certified cardiologist
– Results must be documented as diagnoses in the PN
• Arrow up (h) or down (i) with labs cannot be interpreted as abnormal – Document: “hyponatremia”
• i Na of 120 meq/liter ≠ hyponatremia – Document: “anemia”
• i Hct ≠ Anemia
• Physicians must completely describe and document conditions as to be coded
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ICD-10 Coding Rules
Personal and Family History
History (of) • There are two types of history Z codes, personal and family.
– Personal history codes explain a patient’s past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require continued monitoring.
– Family history codes are for use when a patient has a family member(s) who has had a particular disease that causes the patient to be at higher risk of also contracting the disease.
• A history of an illness, even if no longer present, is important information that may alter the type of treatment ordered. – Consequently, important to document and code whenever
present
Send Your Own Questions to
Coding Clinic Advisor
Anyone can send in questions and do it online – They are now accepting ICD-10-CM/PCS questions
http://www.codingclinicadvisor.com It’s FREE, so physicians should ask questions!
• Inpatient coders cannot code from EKG, laboratory, X-ray or pathology reports, even if interpreted by a board-certified physician – Results must be documented as diagnoses in the
physician’s notes
• Arrow up (h) or down (i) with labs cannot be interpreted as abnormal i Na of 120 meq/liter ≠ hyponatremia i Hct ≠ Anemia
• Physicians must completely describe and document conditions as to be coded
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ICD-10 Coding Rules
Federal Government - PPACA
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CMS’s Vision for Population Payment
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http://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD-10-guidance.pdf
“Family of Codes”
• “Family of codes” is the same as the ICD-10 three-character category. – Codes within a category are clinically related and provide
differences in capturing specific information on the type of condition.
– For instance, category H25 (Age-related cataract) contains a number of specific codes that capture information on the type of cataract as well as information on the eye involved.
• Examples include: H25.031 (Anterior subcapsular polar age-related cataract, right eye), which has six characters; H25.22 (Age-related cataract, morgagnian type, left eye), which has five characters; and H25.9 (Unspecified age-related cataract), which has four characters.
• One must report a valid code and not a category number. In many instances, the code will require more than 3 characters in order to be valid.
Medi-Cal ICD-10 Medical Necessity - Crosswalk
• Medi-Cal implementation of ICD-10 – Medi-Cal will be using a crosswalk solution in the legacy
California Medicaid Management Information System (CA-MMIS).
• Medi-Cal has mapped all ICD-10 codes to corresponding ICD-9 codes by starting with the General Equivalence Mappings (GEMs) provided by the Centers for Medicare & Medicaid Services (CMS) and modifying the mappings to align with existing Medi-Cal policy.
• Claims will be run against the crosswalk to determine the ICD-9 value to process through the system.
• Will an ICD-10 to ICD-9 crosswalk be published? – Medi-Cal will not publish the crosswalk. – However, the provider manuals will be updated with the
ICD-10 codes as appropriate.
Mapping Tool Provided by SJHS to You
Note how ICD-10-CM combined benign, malignant, and unspecified HTN into one code, I10 - HTN http://www.stjhs.org/documents/ICD-10/2014-ICD-9-CM-to-ICD-10-CM-GEMS.pdf
Emergency Department Billing
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Code NPP (Severity) History Physical MDM
99281 Self-limited PF PF SF
99282 Low-moderate EPF EPF Low
99283 Moderate EPF EPF Moderate
99284 High-urgent Detailed Detailed Moderate
99285 Life-threatening Comp Comp High
99291 Over 30 minutes of dedicated care for a critical illness
99219 99235
Moderate Comp Comp Moderate
99220 99236
High Comp Comp High
99217 Discharge services on any day subsequent to placing the patient in observation services
Abbreviations: NPP – Nature of the Presenting Problem; MDM – Medical Decision Making PF – Problem focused; EPF – Expanded problem focused; Comp - Comprehensive
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Medical Decision Making Quantity & Quality
High Extensive Extensive High
Moderate Moderate Multiple Medium
Low
Limited Limited Low
Minimal Minimal Minimal
Straight
forward
Patient Risk Amount
of Data No. of
Diagnoses/
Management
Options
Type
Need 2 out of 3 of these to qualify
CMS’s Definition of Critical Care Billing
• Critical care is defined as a physician’s (or physicians’) direct delivery of medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.
• Critical care involves high complexity decision making to assess, manipulate, and support vital system functions to treat single, or multiple, vital organ system failure; and/or to prevent further life threatening deterioration of the patient’s condition. Examples of vital organ system failure include (but are not limited to): – Central nervous system failure; – Circulatory failure; – Shock; – Renal, hepatic, metabolic, and/or respiratory failure
• Although it typically requires interpretation of multiple physiologic parameters and/or application of advanced technology(s), critical care may be provided in life threatening situations when these elements are not present. 35
Case Example ED History
• Patient presents with: – Nasal Congestion
– Cold
– Poor Feeding
– Decreased Urine Output - only 2 wet diapers today
– Crying
• HPI Comments: Pt is a 2 week female presenting to ED with rhinorrhea and cough x 3 days. Mom states that she has been having fevers at home, however Tmax 99.7 axillary. While in ER temp rectal= temp was 100.8. She has been taking decreased PO for the past day or so as well. Decreased wet diapers and decreased BMs.
Case Example ED Physical
• Note the prolonged capillary refill, mottled appearance, and dusky color • 70 cc saline fluid bolus administered • Lactate level was not drawn due to patient’s age
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Case Example Impressions
• ED Resident
– 2 week female with cough, rhinnorhea and neonatal fever. RSV +
– S/p LP with clear fluid.
• ED Attending
– 2 week female with RSV bronchiolitis presents with fever, tachycardia, respiratory distress
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Definitions of Shock
http://tinyurl.com/2006ShockConsensus
Recommendation 1
• We recommend that shock be defined as a life-threatening, generalized maldistribution of blood flow resulting in failure to deliver and/or utilize adequate amounts of oxygen, leading to tissue dysoxia
– Inadequate oxygen delivery typically results from poor tissue perfusion but occasionally may also be caused by an increase in metabolic demand
– Signs of inadequate tissue perfusion on physical examination are required to define shock
Recommendation 2
• We recommend that hypotension [SBP < 90 mmHg, SBP decrease of 40 mmHg from baseline, or mean arterial pressure (MAP) < 65 mmHg], while commonly present, should not be required to define shock
– Signs of inadequate tissue perfusion on physical examination are required to define shock
Recommendations 3 and 4
• In the absence of hypotension, when shock is suggested by history and physical examination, we recommend that a marker of inadequate perfusion be measured (decreased ScvO2, SvO2, increased blood lactate, increased base deficit, perfusion related low pH) – Apart from lactate and base deficit, current
evidence does not support the routine use of bio-markers for diagnosis or staging of shock
• Eligibility criteria – a suspected or confirmed infection, two or more
criteria for a systemic inflammatory response, and – evidence of refractory hypotension OR hypoperfusion.
• Refractory hypotension was defined as a systolic blood pressure of < 90 mm Hg or a mean arterial pressure of < 65 mm Hg after an intravenous fluid challenge of 1000 ml or more administered within a 60-minute period.
• Hypoperfusion was defined as a blood lactate level of 4.0 mmol per liter or more.
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N Engl J Med 2014; 371:1496-1506 October 16, 2014
Hypoxemic Respiratory Failure
• Hypoxemic – Classical definition:
pO2 < 60 mm Hg
– Critical care definition: pO2 divided by FiO2
< 200–250
• Chronic – Requires chronic oxygen
to maintain oxygenation
• Acute – Requires intensive care
(even if transient), such
as BiPAP, high-flow O2
or mechanical
ventilation
pO2 < 60 corresponds to O2 sat < 88%–90%
Hypercapnic Respiratory Failure
• Classically defined as pCO2 > 45 to 50
• pH value dependent upon chronicity and renal effects – Acute - < 7.33 – Chronic - >7.33
CRF
ARF
pCO2
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Renal Disease Options
• Azotemia (not a CC) – A medical condition characterized
by abnormally high levels of nitrogen-containing compounds, such as urea (BUN), creatinine, various body waste compounds, and other nitrogen-rich compounds in the blood
• Acute kidney insufficiency (not a CC) – A reduction of renal function
characterized by a rise of creatinine or fall of urine output fails to meet the criteria for acute renal failure or acute renal injury
• Acute kidney injury (a CC)
Acute kidney failure (a CC) – A common clinical syndrome
defined as a sudden onset of reduced kidney function manifested by increased serum creatinine or a reduction in urine output
• It is NOT the underlying renal pathology
• Uremia (not a CC) – A term used to loosely describe
the illness accompanying kidney failure, in particular the nitrogenous waste products associated with the failure of this organ
Clinical Criteria of Acute Kidney Injury
http://www.kdigo.org/clinical_practice_guidelines/pdf/KDIGO%20AKI%20Guideline.pdf
Published 2012
http://circ.ahajournals.org/content/early/2012/08/23/CIR.0b013e31826e1058.citation
Published online on August 24, 2012
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Third Universal Definition of MI Types of MI
SEPAS - January 2013 50
Third Universal Definitions of MI Etiologies of Myocardial Necrosis (Injury)
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Clinical Example for “Denominator Management”
• A 65 year old white male with known NYHA Class 4 systolic heart failure due to ischemic cardiomyopathy is admitted for acutely worse orthopnea and edema. – Past Hx: HTN, multiple
myocardial infarctions – Baseline creatinine 1.0 mg/dl,
last troponin <0.04
• PE: – SBP 100/palp; Pulse 90 &
regular; RR 32; – Reduced capillary refill – JVD & rales; – 3+ edema
• Current labs: Creatinine 1.6 mg/dl, BUN 40, troponin 0.16. ECG with subtle but new ST-depression inferiorly. Lactate 5.0. CXR with pulmonary edema
• Admitting Dx: – Decompensated HF – Prerenal azotemia – Hypotension – Lactatemia – Troponin “leak”
• Rx: ICU admission, increased diuretics, inotropic agents, IV TNG
Risk of Mortality Determinants Secondary Diagnoses (APR-DRG ROM)
Decompensated heart failure With + troponins, EKG Δs, and Cr rise of >0.5 mg/dl from baseline
Lactate level elevated; Rx with inotropic support
4
3
2
1
0
Acute renal failure Explains the creatinine rise
“Demand ischemia” Explains the troponin rise & ECG
Acute NSTEMI
Consistent with 3rd Universal Definition of Myocardial Infarction
Cardiogenic shock Supported by elevated lactate level and renal hypoperfusion
CMS’s Vision for Population Payment
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Alternative Payment Models Bundled Payment Care Initiative
• Hospitals and physicians paid out of the same payment for current admissions and all care within 30 days of discharge
• Places physicians at risk for efficient hospital resource utilization.
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Impact of BPCI on Readmission Rates
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Impact on Cost Orthopaedics
• Costs in BPCI group fell below comparison group with intervention period
http://innovation.cms.gov/Files/slides/Bundled-Payments-Episode-Definition-Slides-01-05-12.pdf
Bundled Payments – Appendicitis
MS-DRG
MS-DRG title Weights GM LOS
Bundled payment
338 APPENDECTOMY W COMPLICATED PDx w MCC 3.2008 8.3 $32,008
339 APPENDECTOMY W COMPLICATED PDx w CC 1.8675 5.4 $18,675
340 APPENDECTOMY W COMPLICATED PDx w/o CC/MCC 1.2024 3.0 $12,024
341 APPENDECTOMY W/O COMPLICATED PDx w MCC 2.3116 4.8 $23,116
342 APPENDECTOMY W/O COMPLICATED PDx w CC 1.3516 2.9 $13,516
343 APPENDECTOMY W/O COMPLICATED PDx w/o CC/MCC 0.9547 1.6 $9,547
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“caused by,” “due to,” “resulting in”
“Peritoneal signs” ≠ “localized peritonitis”
• Localized or generalized peritonitis with appendicitis counts as a
“complicated principal diagnosis.”
• K353 Acute appendicitis with localized peritonitis MCC, SOI 3,
ROM 1
These are the rules that have been prepared for us to use.
Sepsis due to appendicitis is weighted higher.
Appendicitis What’s new in ICD-10
• K35.2 Acute appendicitis with generalized peritonitis – Appendicitis (acute) with generalized (diffuse) peritonitis
following rupture or perforation of appendix – Perforated or ruptured appendix NOS
• K35.3 Acute appendicitis with localized peritonitis – Acute appendicitis with or without perforation or rupture
with localized peritonitis – Acute appendicitis with peritoneal abscess
• K35.8 Other and unspecified acute appendicitis – K35.80 Unspecified acute appendicitis
• Acute appendicitis NOS • Acute appendicitis without (localized) (generalized) peritonitis
MS-DRG Pneumonia Classifications Simple pneumonia and pleurisy
MS-DRG 193, 194, 195 (RW 1.0)
Respiratory infections and inflammations
MS-DRG 177, 178, 179 (RW 1.6)
• Viral pneumonia (adenovirus, RSV,
parainfluenza, SARS-associated
coronavirus, influenza)
• Pneumonia due to pneumococcus,
streptococcus, H. flu, mycoplasma,
and chlamydia
• CAP, HAP, lobar, or
bronchopneumonia for which an
etiologic organism in the complex
pneumonia category is not explicitly
documented
• Mycoplasma, chlamydia pneumonia
• Pleurisy: adhesions lung or pleura,
calcification pleura, acute, sterile,
diaphragmatic, fibrous, interlobar,
thickening of pleura
• Gram-negative pneumonia
• Salmonella, Proteus, Serratia, Klebsiella, E.
coli, Pseudomonas, or GNR nonspecified
• Legionella
• Staph aureus (MSSA or MRSA)
• Pulmonary tuberculosis
• Fungus (specified) and other odd organisms
• Histoplasmosis, blastomycosis, candidiasis,
coccidiomycosis, tularemia
• Aspiration PNA, lipoid PNA
• Empyema with/without fistula, infected bacterial
pleural effusions, pleurisy w/effusions
• Lung abscess, gangrenous or necrotic
pneumonia
• Mediastinitis
Pneumonia must be the PDx Source: ICD-10 MS-DRG Definitions Manual
Note that CAP, HCAP, HAP, or nosocomial pneumonia group to MS-DRG 193, 194, 195.
Expected costs Pneumonia
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Multiple relative weight by base rate (e.g., $15,000) to get reimbursement
MS-DRG
MDC MS-DRG Title Wgts Bundle
871 18 SEPTICEMIA OR SEVERE SEPSIS W/O MV 96+ HOURS
1.8527 $27,791
177 04 RESPIRATORY INFECTIONS & INFLAMMATIONS
W MCC 1.9934 $29,901
178 04 W CC 1.3955 $20,933
179 04 W/O CC/MCC 0.9741 $14,612
193 04 SIMPLE PNEUMONIA & PLEURISY
W MCC 1.4550 $21,825
194 04 W CC 0.9771 $14,657
195 04 W/O CC/MCC 0.6997 $10,496
HCAP groups to
Simple Pneumonia
DRG
63
Infection with “some” criteria
with documentation that the patient is toxic,
sick or “septic” appearing
Intensive Care Med (2003) 29:530–538
MS-DRG Pneumonia Classifications Simple pneumonia and pleurisy
MS-DRG 193, 194, 195 (RW 1.0)
Respiratory infections and inflammations
MS-DRG 177, 178, 179 (RW 1.6)
• Viral pneumonia (adenovirus, RSV,
parainfluenza, SARS-associated
coronavirus, influenza)
• Pneumonia due to pneumococcus,
streptococcus, H. flu, mycoplasma,
and chlamydia
• CAP, HAP, lobar, or
bronchopneumonia for which an
etiologic organism in the complex
pneumonia category is not explicitly
documented
• Mycoplasma, chlamydia pneumonia
• Pleurisy: adhesions lung or pleura,
calcification pleura, acute, sterile,
diaphragmatic, fibrous, interlobar,
thickening of pleura
• Gram-negative pneumonia
• Salmonella, Proteus, Serratia, Klebsiella, E.
coli, Pseudomonas, or GNR nonspecified
• Legionella
• Staph aureus (MSSA or MRSA)
• Pulmonary tuberculosis
• Fungus (specified) and other odd organisms
• Histoplasmosis, blastomycosis, candidiasis,
coccidiomycosis, tularemia
• Aspiration PNA, lipoid PNA
• Empyema with/without fistula, infected bacterial
pleural effusions, pleurisy w/effusions
• Lung abscess, gangrenous or necrotic
pneumonia
• Mediastinitis
Pneumonia must be the PDx Source: ICD-10 MS-DRG Definitions Manual
Note that CAP, HCAP, HAP, or nosocomial pneumonia group to MS-DRG 193, 194, 195.
Expected costs “Complex” vs. “Simple” Pneumonia
65
Multiple relative weight by base rate (e.g., $15,000) to get reimbursement
MS-DRG
MDC MS-DRG Title Wgts Bundle
871 18 SEPTICEMIA OR SEVERE SEPSIS W/O MV 96+ HOURS
1.8527 $27,791
177 04 RESPIRATORY INFECTIONS & INFLAMMATIONS
W MCC 1.9934 $29,901
178 04 W CC 1.3955 $20,933
179 04 W/O CC/MCC 0.9741 $14,612
193 04 SIMPLE PNEUMONIA & PLEURISY
W MCC 1.4550 $21,825
194 04 W CC 0.9771 $14,657
195 04 W/O CC/MCC 0.6997 $10,496
HCAP groups to
Simple Pneumonia
DRG
ICD-9-CM/ICD-10-CM Coding Rule for Inpatient Facility Admissions
• If the diagnosis documented at the time of discharge is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out” or other similar terms indicating uncertainty, code the condition as if it existed or was established. – The bases for these guidelines are:
• the diagnostic workup
• arrangements for further workup or observation, and
• initial therapeutic approach that correspond most closely with the established diagnosis.
66
Source: ICD-10-CM Official Guidelines for Coding and Reporting - 2014
Pneumonia Antibiotic Utilization Rules of Thumb for >3 days use
• 193–195 Simple pneumonia “Community-acquired pneumonia”
– Levaquin – or other fluroquinolone – Claforan®/Rocephin® + Zithromax® combo – Oselatmivir – Influenza w/o bacterial infection
• 177–179 Respiratory infections & inflammations – Doxycycline – Legionnaire’s disease – Clindamycin = anaerobes or staph aureus – Ceftaroline (Teflaro®) – MRSA – Daptomycin – specified gram-positive organisms – Zosyn®/Unasyn® = Gram-negative rods, aspiration – Zyvox® = MRSA, other specified Gram-positives – Aminoglycosides – Gram-negative rods – Fortaz® or Maxipime® – Pseudomonas – Carbepenams – aspiration, pseudomonas, other GNRs – Vancomycin – MRSA or enterococcus (rare) – Amphotericin or fluconazole – Fungus – INH, Rifampin, Ethambutol – Possible TB
Just because a
physician chooses
these antibiotics does
not mean he or she
does not suspect a
more serious cause
Uncertain diagnoses may be coded if documented at the time of discharge
Usually administered
for more than three
days after admission
Empiric vs. definitive
treatment
Expected costs “Complex” vs. “Simple” Pneumonia
68
Multiple relative weight by base rate (e.g., $15,000) to get reimbursement
MS-DRG
MDC MS-DRG Title Wgts Bundle
871 18 SEPTICEMIA OR SEVERE SEPSIS W/O MV 96+ HOURS
1.8527 $27,791
177 04 RESPIRATORY INFECTIONS & INFLAMMATIONS
W MCC 1.9934 $29,901
178 04 W CC 1.3955 $20,933
179 04 W/O CC/MCC 0.9741 $14,612
193 04 SIMPLE PNEUMONIA & PLEURISY
W MCC 1.4550 $21,825
194 04 W CC 0.9771 $14,657
195 04 W/O CC/MCC 0.6997 $10,496
HCAP groups to
Simple Pneumonia
DRG
MS-DRG CC/MCC Table
Not a CC CC MCC
AMS or acute delirium
Unresponsive
Delirium due to a
“medical condition” or
postprocedural state
Toxic or metabolic
encephalopathy
Unconscious or coma
Oxygen dependency
Chronic
respiratory failure
Acute on chronic
respiratory failure
Cystitis
Urosepsis (no code)
UTI or acute cystitis
Bacteremia Sepsis due to UTI
CAD
Stable angina
Demand ischemia
AS of CABG graft
NSTEMI
STEMI
HFpEF
HFrEF
Systolic CHF
Diastolic CHF
Acute systolic CHF
Acute diastolic CHF
DSM-5 Diagnostic Criteria
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Alternatives to “Altered Mental Status”
DSM-5 Brief Acute Psychosis
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Alternatives to “Altered Mental Status”
Delirium Underlying Causes
http://www.tinyurl.com/TMEncephalopathy
Toxic/Metabolic Encephalopathies Definitions
• Toxic and metabolic encephalopathies are a group of neurological disorders characterized by an altered mental status – A delirium, defined as a disturbance of
consciousness characterized by a reduced ability to focus, sustain, or shift attention
that cannot be accounted for by preexisting or evolving dementia and that is caused by the direct physiological consequences of a general medical condition.
• Causes – Medications – Drug overdose – Uremia – Liver failure – Hypercalcemia – Pancreatitis – Hyponatremia – Sepsis – Hypercapnia
Encephalopathy can be the Underlying Cause of Delirium
Hypoxemic Respiratory Failure
• Hypoxemic – Classical definition:
pO2 < 60 mm Hg
– Critical care definition: pO2 divided by FiO2
< 200–250
• Chronic – Requires chronic oxygen
to maintain oxygenation
• Acute – Requires intensive care
(even if transient), such
as BiPAP, high-flow O2
or mechanical
ventilation
pO2 < 60 corresponds to O2 sat < 88%–90%
Hypercapnic Respiratory Failure
• Classically defined as pCO2 > 45 to 50
• pH value dependent upon chronicity and renal effects – Acute - < 7.33 – Chronic - >7.33
CRF
ARF
pCO2
50
Hypoxemia & Hypercapnia Respiratory Insufficiency/Failure
Always list the underlying cause, such as
status asthmaticus, drug overdose, CHF
Entity MS-DRG
Hypoxemia No CC
Hypercapnia No CC
Respiratory insufficiency or distress
No CC
Acute respiratory insufficiency or distress
Not a CC
Acute resp. failure MCC
Chronic resp. failure CC
Systolic and Diastolic Heart Failure
• As above, not codeable in ICD-9-CM as diastolic or systolic HF • Physician must state “diastolic” or “systolic” or both to get CC or
MCC
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Decompensated = Acute Systolic/Diastolic Heart Failure
To get the MS-DRG MCC, physicians must document acute or decompensated “systolic”, “diastolic”, or both “systolic/diastolic” heart failure
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MS-DRG CC/MCC Table
Not a CC CC MCC
Diabetes Mellitus
Uncontrolled -
Hyperosmolar state
DKA
Blood loss anemia
Acute blood loss
anemia
Toxic anemia
(x chemotherapy)
+ HIV AIDS or +HIV with
previous Hx of AIDS
Ranson’s criteria
(w/pancreatitis)
SIRS
(due to pancreatitis)
SIRS w/organ
dysfunction
Stool with
+ occult blood GI bleeding
GI bleeding from
defined site
(e.g., PUD)
Diabetes
• History of Diabetes – BS controlled and on no Rx
• Uncontrolled Diabetes – HgbA1C > 7 – Mulitple plasma glucoses over 250-300 mg/dl
80
Metric
DKA (plasma glucose >250 mg/dl) Hyperosmolar Hyperglycemic Syndrome
(plasma glucose >600 mg/dl) Mild Moderate Severe
Arterial pH 7.25–7.30 7.00 - 7.24 <7.00 >7.30 Serum bicarbonate (mEq/l) 15–18 10 to <15 <10 >18 Urine ketone* Positive Positive Positive Small Serum ketone* Positive Positive Positive Small Effective serum osmolality Variable Variable Variable >320 mOsm/kg Anion gap‡ >10 >12 >12 Variable Mental status Alert Alert/drowsy Stupor/coma Stupor/coma
If these are not diagnosed as
“present on admission”, they are
complications of care or not
considered as MCCs
Kitabchi, AE, et. al. Diabetes Care July 2009 vol. 32 no. 7 1335-1343
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Acute Blood Loss Anemia (not ↓ Hct)
• “Acute blood loss anemia” - CC • Major Bleeding Definition
– Clinically overt – Associated with a fall of the hemoglobin level of 2.0 g/dL (e.g. Hct
drop of 6) or required transfusion of at least 2 units of red cells, or involved a critical organ or was fatal
MS-DRG MS-DRG Title Weights Payment 377 G.I. HEMORRHAGE W MCC 1.7775 $14,220 378 G.I. HEMORRHAGE W CC (e.g. acute blood loss anemia) 1.0021 $8,017
379 G.I. HEMORRHAGE W/O CC/MCC 0.6776 $5,421
+HIV vs. HIV Disease (MCC)
• +HIV (no code)
– Includes HIV-infected individual who never had exhibited symptoms
– Based on documentation of +HIV only
• HIV-disease (MCC)
– Currently having acute HIV symptoms
– + HIV with previous HIV-related symptoms
– + HIV with current or previous HIV-related disease
– Current AIDS or previous history of AIDS
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Must Be Documented on Each Admission
MS-DRG CC/MCC Table
Not a CC CC MCC
Acute renal
insufficiency
Toxic nephropathy
Acute renal failure
Acute kidney injury
Acute tubular necrosis
Acute cortical necrosis
CRI or CKD CKD Stage 4 or 5 ESRD
Chronic/persistent
atrial fibrillation
Persistent
atrial fibrillation
Acute systolic/diastolic
HF due to rapid afib
Past Hx of multiple
DVT on warfarin
Hypercoagulable
state -
Peripheral neuropathy Autonomic peripheral
neuropathy -
Underweight with
anorexia
Cachexia
Malnutrition Severe malnutrition
MDC 5 – DVTs With Hypercoagulable State
MS-DRG MS-DRG title Weights
294 DEEP VEIN THROMBOPHLEBITIS W CC/MCC 1.0373
295 DEEP VEIN THROMBOPHLEBITIS W/O CC/MCC 0.6403
• Primary hypercoagulable states (CC) Initial Recurrent
– Factor V Leiden – 12%–20% / 40%–50%
– Protein C def – 2%–5% / 5%–10%
– Protein S def – 1%–3% / 5%–10%
– AT3 deficiency – 1%–2% / 2%– 5%
• Secondary hypercoagulable states (CC) – Active cancer, chemotherapy (L-asparaginase, thalidomide,
anti-angiogenesis therapy), myeloproliferative disorders, HIT, nephrotic syndrome, intravascular coagulation and fibrinolysis/DIC, TTP, sickle cell disease, oral contraceptives or estrogen, pregnancy/postpartum state, selective estrogen receptor modulator therapy (tamoxifen and raloxifene), antiphospholipid antibodies, PNH, Wegener granulomatosis
Thrombophilia now
has a code
“Still to be ruled out”
MS-DRG CC/MCC Table
Not a CC CC MCC
Anemia – neutropenia
Thrombocytopenia Pancytopenia
Pancytopenia due to
any pharmaceutical
Bedridden state “Functional
quadriplegia”
Seizure disorder
Poorly controlled
seizures
Poorly controlled
seizure disorder Status epilepticus
Syncope
Ventricular pause
Ventricular
tachycardia
Ventricular fibrillation
or asystole
TIA Stroke
Chemo Rx Drug-Induced Complications
• Bone marrow suppression – no code – Anemia, thrombocytopenia, and/or neutropenia
• MS-DRG 846 – Chemotherapy w/o acute leukemia w/o CC/MCC – 0.8635
– Pancytopenia • MS-DRG 845 – Chemotherapy w/o acute leukemia
w/CC/MCC – 1.1062
– Pancytopenia due to drug or chemotherapy • MS-DRG 844 – Chemotherapy w/o acute leukemia
w/MCC – 2.4344
Ventricular Pause vs. Ventricular Asystole
Stroke Differentiation from TIA
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Stroke Consequences
• Hemiparesis or monoparesis (CC)
– Not weakness
• Aphasias (CC)
– Not just “altered mental status”
• SIADH as a cause of hyponatremia
• Mechanisms of death
– Significant cerebral edema
– Sulfalcine herniations
– Acute respiratory failure
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CDI’s Impact on Bundled Payments
Clinical scenario
requiring query
Query
response
MS-
DRG Title
Bundled
payment
70 yo male with
previous Hx of
AIDS undergoes
TJR for DJD. MD
only documents
“+HIV.”
AIDS or + HIV
with previous
Hx of AIDS
469
Major Joint Replacement or
Reattachment of Lower
Extremity W/ MCC
$51,627
+ HIV only or
“unable to
determine”
470
Major Joint Replacement or
Reattachment of Lower
Extremity W/O MCC
$31,299
65 yo male
undergoes
cardiac cath and
CABG.
Documented with
postoperative
acute renal
failure.
Acute renal
failure is “likely”
due to ATN due
to contrast
233 Coronary Bypass With
Cardiac Cath W/MCC $107,127
Cause of acute
renal failure is
“undetermined”
234 Coronary Bypass With
Cardiac Cath W/O MCC $72,471
Notes: MS-DRG version 30; base rate $15,000
Bottom Line
• ICD-9-CM (and ICD-10) codes are crucial – Definitions are critical – Documentation infrastructure must support the
higher specificity
• Physicians are be incentivized to document and code completely in their offices – Especially important if they form Accountable Care
Organizations or participate in other entities emphasizing cost efficiency and outcomes.
• This lecture will orient the healthcare provider of what is needed now and what we can expect in the future
91