Download Compliance in Documentation and Clarification: Honesty Is the

7th Annual
Association for Clinical Documentation
Improvement Specialists
Conference
Compliance in Documentation and
Clarification: Honesty Is the ValueBased Policy
Robert S. Gold, MD
CEO
DCBA, Inc.
Atlanta, Ga.
2
Learning Objectives
• At the completion of this educational activity,
learners will be able to:
– Distinguish the vision of the future of CDI
– Identify errors made by themselves and others
– Recognize “the intent of the code”
– Describe how to measure success
– Initiate intercommunication toward the big picture
3
Medicine Under the Microscope
•
•
•
•
•
•
•
•
Morbidity
Mortality
Cost per patient
Resource utilization
Length of stay
Complications
Outcomes
ARE YOU SAFE –
avoiding harm, avoidable
readmissions?
4
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
5
Goals of Implementation –
Prove You Are Value Based
• Excellence in severity-adjusted data
• Reasonable occurrence of PSIs
• Lower than average readmissions for
– AMI
– Heart failure
– Pneumonia
• Cooperation with quality initiatives
• Patient satisfaction
6
CMS Bundled Payment Plans
September 2, 2011
• Bundling 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.
7
Avoidable Readmissions
Initiative
• Identify hospitals with excess readmissions for certain
selected conditions beginning in FY 2013 for discharges on
or after October 1, 2012
– Acute myocardial infarction (i.e., heart attack)
– Heart failure
– Pneumonia
• Definition of readmission: “occurring when a patient is
discharged from the applicable hospital and then is admitted
to the same or another acute care hospital within a specified
time period from the time of discharge from the index
hospitalization”
• The specified time period would be 30 days
8
Excellence in Heart Attack Care
Reduces Readmissions
•
Memorial Hermann Memorial City Medical Center in Houston, Texas
– Achieved superior readmission rates. Its readmission rate for patients with
AMI and pneumonia surpassed the best 10% of hospitals in the country for
the selection period.
Performance improvement strategies
• Planning for discharge begins upon admission, with staff actively
educating patients about their disease and connecting patients with a
source of ongoing care, even if they lack insurance coverage
• The hospital offers a community-based disease management program
for uninsured patients with chronic illness
• Pharmacists are located in high-risk units to provide medication
education to patients and help simplify home medication regimens
9
Participation and Success in
Reporting of Core Measures
•
•
•
•
AMI
Heart failure
Pneumonia
Postoperative wound
infections
• Venous
thromboembolism
• Stroke
• Asthma in children’s
hospitals
10
Where Does This Data Come
From?
• Documentation leads to identification of diagnoses and
procedures
• Recognition of diagnoses and procedures leads to ICD
codes – THE TRUE KEY
• ICD codes lead to risk of mortality computations and
estimates of expenditures
• APR or other methodology relative weight assignment
massaged to “severity” adjustments
• Severity-adjusted data leads to mortality profiles
• Complication rate comes from ICD codes
11
What Is an Index?
12
Where You Are Compared to 1?
•
•
•
•
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
13
Profiles Come From SeverityAdjusted Statistics
<1; preferred
provider – 
significantly better
Observed mortality
Expected mortality
From severity-adjusted DRGs
= 1; as good as
the next guy

> 1; excessive
mortality; find
another provider – 
14
Patient Safety
Worse
than
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
Average
Better
than
Average
●
●
●
●
●
●
●
●
●
●
Foreign objects left in body during a surgery or procedure
●
●
●
0 Events
15
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
All of the above depend on
ICD coding accuracy
• Patient satisfaction
16
Where We See People
Hurting the Data
1. Concentrating on Medicare patients only
2. Dwelling on CCs and MCCs only
3. Teaching docs to document complications of
care for DRG shifts and Medicare dollars
4. Making up definitions of diseases and
conditions for Medicare dollars
5. Misinterpreting Coding Clinic and definitions of
ICD codes for Medicare dollars
6. Putting today’s bottom line ahead of tomorrow,
hurting the health system’s value basis
17
The Result
18
Where We See People
Hurting the Data
1. Concentrating on Medicare patients only
2. Dwelling on CCs and MCCs only
3. Teaching docs to document complications of
care for DRG shifts and Medicare dollars
4. Making up definitions of diseases and
conditions for Medicare dollars
5. Misinterpreting Coding Clinic and definitions of
ICD codes for Medicare dollars
6. Putting today’s bottom line ahead of tomorrow,
hurting the health system’s value basis
19
Florida Blue and Holy Cross Create
Accountable Care Arrangement
Jacksonville and Fort Lauderdale, Fla. – Florida Blue,
Florida’s Blue Cross and Blue Shield Company, and Holy Cross
Physician Partners are pleased to announce that effective
January 1, 2013, Holy Cross Physician Partners will participate
in the Florida Blue Accountable Care Program.
“Florida Blue is excited to expand our relationship with Holy
Cross surrounding this exciting new partnership,” said Dr.
Jonathan Gavras, chief medical officer and senior vice
president for Florida Blue. “In the age of reform, both
organizations realize the importance of moving away from the
fee-for-service model to one that focuses on quality outcomes
that will benefit our members in South Florida.”
20
Aetna, Baptist Memorial Health Care
Announce Collaborative Care Agreement
Thursday, April 25, 2013 4:11 pm EDT
MEMPHIS, Tenn. – (BUSINESS WIRE) – Aetna (NYSE: AET) and
Baptist Memorial Health Care today announced a collaborative care
agreement to bring a new health care model to Aetna members and
introduce Aetna Whole HealthSM, a commercial health care product.
This collaboration will give employers and their workers access to
highly coordinated care from physicians and facilities in the Baptist
Select Health Alliance. The Baptist Select Health Alliance is a
clinically integrated group of physicians focused on tracking
outcomes, sharing data and measuring clinical standards to improve
quality and efficiency.
In collaborative care models, a group of health care providers
delivers more coordinated care for patients to drive better quality and
lower overall costs. Through Baptist Memorial Health Care, Aetna
members will receive an enhanced level of coordinated care in
addition to the member benefits of their current Aetna plan.
21
Orthopedics Service Line Success:
Physician Engagement, Efficiency, and Quality
Dr. Marshall Steele of Stryker and Dr. James D. Holstine of
PeaceHealth St. Joseph Medical Center reveal evidence-based
strategies for improving orthopedic efficiency, quality, and
performance while also increasing collaboration, cost savings, and
market share within the service line.
You’ll get lessons learned and best practices on how to:
•
Identify and leverage the six primary influencers of orthopedic service line success
•
Implement physician leadership models that address value-based incentives and
enhance workplace culture
•
Improve the orthopedic structure for better collaboration, performance, data evaluation,
and efficiency
•
Identify and evaluate key alignment tools
22
Care Coordination & Population Health:
Primary Care Redesign, Closing Care Gaps, and HIT
Thursday, March 27, 2014
12:00–3:00 pm (ET)
Attend Live or Virtually From Your Office!
The leaders of Geisinger Health System understood that to
drive costs out of the care continuum, they had to be able to
navigate patients effectively among the appropriate
healthcare providers. Join them live as they share proven
strategies that combine evidence-based best practices,
electronic health records, and quality and accountability
metrics to standardize care processes.
Register for HealthLeaders Media LIVE From Geisinger:
Care Coordination & Population Health for solutions,
interactive Q&A, and lessons learned. Participants will:
• Discover how to redesign primary care through patient
engagement and a team approach
• Learn how to close gaps in care transitions with
outpatient care managers
• Find out how to build an effective population health
management system through data mining, risk
stratification, and disease registries
• Learn how Geisinger’s ProvenHealth Navigator™
model promotes best practices and sustainable
systems of care
23
Conclusion
•
•
•
•
Aetna cares about Aetna patients
MetLife cares about MetLife patients
Blue Cross cares about Blue Cross patients
All managed care organizations are keeping
data on THEIR patients
• If you concentrate on Medicare patients, you will
lose as a value-based organization
24
Where We See People
Hurting the Data
1. Concentrating on Medicare patients only
2. Dwelling on CCs and MCCs only
3. Teaching docs to document complications of
care for DRG shifts and Medicare dollars
4. Making up definitions of diseases and
conditions for Medicare dollars
5. Misinterpreting Coding Clinic and definitions of
ICD codes for Medicare dollars
6. Putting today’s bottom line ahead of tomorrow,
hurting the health system’s value basis
25
Complexity of Diagnoses Influence
MD and Hospital Outpatient Billing
• HCCs have been used for physician billing in 5
states for over 5 years
• New Medicare G-codes depend on complexity of
diseases for complex management services in
the absence of face-to-face interactions
• Many diagnoses are not CCs or MCCs in
Medicare, and none are CCs or MCCs in
managed care contracts
26
Risk-Adjusted Outpatient Billing
• 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?
27
The More Complex the Diabetic,
the Higher the Payments
HCC cat #
Description
Weight
15
DM2 with renal (250.4x) or circulatory manif
(250.7x)
.508
16
DM2 with neurol (250.6x) or other spec
manif (250.8x)
.408
17
DM2 with acute complications (250.1x,
250.2x, 250.3x)
.339
18
DM2 with retinopathy (250.5x) or
unspecified manif (250.9x)
.259
19
DM2 uncomplicated (250.00)
.162
28
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
– That the beneficiary consent to this arrangement over a oneyear period
29
Patient Centered/Family
Centered Medical Home
• A medical home is an approach to providing comprehensive
primary care that facilitates partnership between patients,
physicians, and families. The American Academy of Pediatrics
(AAP), American Academy of Family Physicians (AAFP), ACP,
and AOA created the Joint Principles in 2007.
Access to care
Group visits
Care team & staffing
Patient-centered care
Chronic disease care
Practice efficiency
EHRs
Quality & safety
30
Will Physicians Be Dropped From
Managed Care Networks?
Greg Freeman, January 22, 2014
Insurers are dropping thousands of physicians from their managed
care networks in response to growing pressures from the Affordable
Care Act (ACA), leaving many doctors to wonder what plans they will
still participate in for 2014 and beyond. But that's not all.
UnitedHealth Group confirmed recently that it sent discontinuation
letters to thousands of physicians in 10 states that cited “significant
changes and pressures in the healthcare environment” as the cause.
The company issued a statement saying that it expected its Medicare
Advantage network, which covers about 27% of people on Medicare,
to remain at about 85% of its 2013 size through the rest of 2014. The
insurer currently has more than 350,000 providers in the Advantage
network.
Humana, Aetna, and WellPoint have confirmed publicly that they may
trim their provider networks as well.
31
Conclusion
• Excluding obstetrics, neonatology, pediatrics,
and family practice, non-Medicare patients will
lead to overall reduction in SOI and ROM scores
overall, and it’s overall payer data that drives
VBP
• Stopping at an MCC or CC regardless of payer
will ensure lack of complexity of your cases,
regardless of the impact on MS-DRGs
• Your docs, your hospital will be excluded from
preferred provider status by private insurers
32
Where We See People
Hurting the Data
1. Concentrating on Medicare patients only
2. Dwelling on CCs and MCCs only
3. Teaching docs to document complications of care for DRG shifts and Medicare
dollars
4. Making up definitions of diseases and
conditions for Medicare dollars
5. Misinterpreting Coding Clinic and definitions of
ICD codes for Medicare dollars
6. Putting today’s bottom line ahead of tomorrow,
hurting the health system’s value basis
33
CC = Complication (or Comorbidity)
• Origin of IPPS with Medicare
• “Postop” – adjective or adverb?
• Original definition and application of processes
in tracking CCs
• Coding Clinic perspective changes day to day
“as previously stated”
• Change of beloved MCCs to PSIs, HACs
34
Postoperative Ileus
Coding Clinic, First Quarter 2012 p. 6; Effective With Discharges: April 1, 2012
Question:
The patient who underwent surgical repair of small bowel obstruction one week ago is
now admitted for treatment of an ileus with vomiting. The patient previously had lysis of
adhesions secondary to small bowel obstruction. Would it be appropriate to assign code
997.49, Digestive system complication, Other digestive system complications, as the
principal diagnosis, or must the provider explicitly document “postoperative ileus”?
Answer:
Assign code 997.49, Digestive system complication, Other digestive system
complications, as the principal diagnosis. Code 560.1, Paralytic ileus, should also be
assigned to describe the specific complication. The Alphabetic Index provides direction
and leads the coder to assign 997.49. This code assignment may be located in ICD-9CM’s Alphabetic Index as follows:
Ileus
following gastrointestinal surgery 997.49
Although in the past Coding Clinic has advised that a causal relationship between the
surgery and the condition should be documented, in this case the ICD-9-CM’s
Alphabetic Index takes precedence.
35
More “Postop” Issues
• Postop urinary retention – not urinary complication
of surgery when patient has BPH with LUTS
• Postop ileus – not GI complication of surgery when
physiologic ileus for up to 3 days post-opening
abdomen – not GI complication when caused by
process for which surgery was performed
• Postop atelectasis – not codable if only incentive
spirometry and ambulating when EVERYONE gets
incentive spirometry and ambulating
36
Postoperative Respiratory Failure
New code 518.51 Acute respiratory failure
following trauma and surgery
Respiratory failure, not otherwise specified,
following trauma and surgery
Excludes: acute respiratory failure in other
conditions (518.81)
37
Situation
• Acute respiratory failure is an MCC
• Acute postoperative respiratory failure is an MCC
• Acute postop resp insufficiency is BOGUS and is to
be AVOIDED – it’s immeasurable, irreproducible and
unethical – it’s a travesty based on lack of
knowledge
• 518.81 is due to a disease
• 518.51 is caused by the surgery
• BOTH are PSIs by Healthgrades and AHRQ
• Both indicate poor care at your hospital
• Both state your surgeons are to be avoided
38
NOT Acute Respiratory Failure
• Patients being purposely maintained on the ventilator
after surgery because of weakness, chronic lung
disease, massive trauma are NOT in acute respiratory
failure
• Abdominal compartment syndrome is a well-known
complication after abdominal trauma and is increasingly
recognized as a potential risk factor for renal failure and
mortality after adult orthotopic liver transplantation
(OLT)
• These data consistently show that maintaining the open
abdomen protocol in high-risk groups has been effective
in reducing mortality in a clinical setting
39
“Everyone on a Vent Has ARF (VDRF)”
• “Well, if we turn off the
ventilator, the patient will die”
• “Patient on vent for a day or two
has VDRF”
www.nhlbi.nih.gov/health/health-topics/topics/vent/while.html
40
ARF vs. Airway Protection
Question:
A patient presents to the Emergency Department (ED) due to an overdose of
Ambien and is intubated and placed on mechanical ventilation. The attending
physician admits the patient to the intensive care unit (ICU) and documents that
the patient was intubated for airway protection because of the drug overdose.
There was no documentation of respiratory failure and the patient was weaned
from the ventilator the next day. Can the coder assume that the patient was in
respiratory failure and report code 518.81, Acute respiratory failure, based on
the fact that the patient was intubated and placed on mechanical ventilation for
airway protection?
Answer:
Do not assign code 518.81, Acute respiratory failure,
simply because the patient was intubated and received
ventilatory assistance. Documentation of intubation and mechanical
ventilation is not enough to support assignment of a code for respiratory failure.
The condition being treated (e.g., respiratory failure) needs to be clearly
documented by the provider.
41
Preventive Maintenance
on Respirator
• Postop issues in the morbidly obese patient.
• Patients who have obesity-related comorbidities
carry a dramatically greater risk of perioperative
complications. Therefore, any obese patient
undergoing major surgery, or those with a history
of comorbidities, should be treated in an
appropriate level 2 or level 3 facility.
42
AHRQ PSI Reported on
HealthGrades
Worse
than
Average
Excessive bruising or bleeding as a consequence
of a procedure or surgery
Electrolyte and fluid imbalance following surgery
Better
than
Average
•
•
Respiratory failure following surgery
•
•
•
Deep blood clots in the lungs or legs following
surgery
Bloodstream infection following surgery
Breakdown of abdominal incision site
Average
•
43
Patient Safety Indicator #11
AHRQ QI, Technical Specifications,
Postoperative Respiratory Failure Rate
Postoperative respiratory failure rate
Patient Safety Indicator #11
Technical specifications
Provider-level indicator
ICD-9-CM codes as follows:
ICD-9-CM acute respiratory failure diagnosis codes
518.51
518.53
518.81
518.84
AC RESP FLR FOL TRMA/SRG
AC/CHR RSP FLR FOL TR/SG
ACUTE RESPIRATORY FAILURE
ACUTE & CHRONIC RESP FAIL
44
How Value Based Do You Look?
Some
University
Another
Hosp Ctr
Any Oid
Hospital
Pneumonia
Hosp plus 6 months
COPD
Hosp plus 6 months
Respiratory Failure
Hosp plus 6 months
“Don’t go to Some University – they’ll kill you.”
45
Conclusion
• Events in postop period not caused by the
surgical procedure are not complications of
surgery
• Inappropriate coding of integral parts of an
operation are not complications (“enterotomy
was made to insert the GIA stapler”)
• The things that happen because of the disease
are not complications of surgery
• If you’re counting CCs, these codes still are
without the complication code
46
Where We See People
Hurting the Data
1. Concentrating on Medicare patients only
2. Dwelling on CCs and MCCs only
3. Teaching docs to document complications of
care for DRG shifts and Medicare dollars
4. Making up definitions of diseases and
conditions for Medicare dollars
5. Misinterpreting Coding Clinic and definitions of
ICD codes for Medicare dollars
6. Putting today’s bottom line ahead of tomorrow,
hurting the health system’s value basis
47
Encephalopathy
• Post-ictal state after a seizure is NOT
encephalopathy
• An abnormality on EEG is NOT encephalopathy
• Being sedated by Haldol is NOT encephalopathy
• Being unconscious after trauma is NOT
encephalopathy
• Being drunk is NOT encephalopathy
• There is NO SUCH THING as toxic-metabolic
encephalopathy
48
Encephalopathy
• Nontraumatic conditions with delivery to the
brain of toxic substances that interfere with
normal brain function and have the potential for
permanent damage
49
Encephalopathy ICD-9
349.82 Toxic encephalopathy
348.31 Metabolic encephalopathy
348.39 Other encephalopathy
291.2 Alcoholic
437.2 Hypertensive
50
Encephalopathy ICD-10
G93.41
Metabolic encephalopathy
– Includes due to sepsis, hyper and hyponatremia,
uremic encephalopathy
G92
Toxic encephalopathy
– Lead encephalopathy, bromidism
– Polypharmacy over prolonged periods leading to
CNS damage
G93.1
K72
Anoxic encephalopathy
(brain damage)
Hepatic encephalopathy
51
Encephalopathy
I67.4
E51.2
F10.26
P91.6x
Hypertensive encephalopathy
Wiernicke’s nutritional encephalopathy
Alcoholic encephalopathy
Hypoxic ischemic encephalopathy
– P91.61 mild, P91.62 moderate, P91.63 severe
J09.x9 Novel influenza A virus with
encephalopathy
J10.81, J11.81 other flu with encephalopathy
G93.49 Other encephalopathy
Lyme encephalopathy + A69.21 Lyme disease
52
Nicotine Withdrawal
• Use of a patch is NOT nicotine withdrawal
“because it’s a CC”
• Most people use a patch for elective cessation of
smoking
• Symptoms must be clinically evident enough to
require identification and treatment in order for it
to meet UHDDS criteria as a valid diagnosis
53
Cardiomyopathy
• “Cardiomyopathy” is NOT to be sought for
documentation “because it’s a CC”
• Cardiomyopathy is a disease of heart muscle
that may or may not have clinical impact
• “Cardiomyopathy” in ICD-9 is NOT automatically
425.4 – NOT the intent of the code – error in
coding advice over and over
• Specific CAUSES of heart muscle damage
SHOULD be sought
54
Stages of Left Heart Failure – A
Those at high risk for
developing heart failure
without structural
changes or symptoms
NOT chronic heart failure
This is “cardiomyopathy” –
the disease that CAN
progress
• Hypertension
• Diabetes mellitus
• Coronary artery disease
(including heart attack)
• History of cardiotoxic drug
therapy
• History of alcohol abuse
• History of rheumatic fever
• Family history of cardiomyopathy
55
Stages of Left Heart Failure – B
Those diagnosed with
structural disease by a
condition but who have
never had symptoms of
heart failure (usually by
finding systolic or diastolic
dysfunction on
echocardiogram)
This is dysfunction, but not
chronic heart failure
Patients with:
• Previous MI
• LV systolic dysfunction or
diastolic dysfunction
• Asymptomatic valvular disease
56
Stages of Left Heart Failure – C
Patients with structural
disease caused by a
condition AND past or
current symptoms of
heart failure due to that
disease and structural
abnormality
Symptoms include:
• Shortness of breath
• Fatigue
• Reduced exercise intolerance
These are chronic heart
failure patients!
57
Stages of Left Heart Failure – D
Refractory heart failure
requiring more than
medical support
END-STAGE heart failure
• Marked symptoms at rest despite
maximal medical therapy
• Recurrent hospitalizations or
cannot be discharged from
hospital without mechanical
intervention
• End-of-life care
58
Primary Cardiomyopathies ICD-9
425.0
425.1
Endomyocardial fibrosis
Hypertrophic cardiomyopathy
Excludes: ventricular hypertrophy (429.3)
425.11 Hypertrophic obstructive cardiomyopathy
425.18 Other hypertrophic cardiomyopathy
425.2 Obscure cardiomyopathy of Africa
425.3 Endocardial fibroelastosis
425.4 Other primary cardiomyopathies:
NOS
congestive
constrictive
familial
idiopathic
obstructive
restrictive
cardiovascular collagenosis
59
Secondary Cardiomyopathies ICD-9
425.5 Alcoholic cardiomyopathy
425.7 Nutritional and metabolic cardiomyopathy
Code first underlying disease, as:
amyloidosis (277.30–277.39), beriberi (265.0), cardiac
glycogenosis (271.0), mucopolysaccharidosis (277.5),
thyrotoxicosis (242.0–242.9)
Excludes: gouty tophi of heart (274.82)
425.8 Cardiomyopathy in other diseases classified
elsewhere
Code first underlying disease, as:
Friedreich's ataxia (334.0), myotonia atrophica (359.21),
progressive muscular dystrophy (359.1), sarcoidosis (135)
425.9 Secondary cardiomyopathy, unspecified
60
More Cardiomyopathies – Really
402.9x Hypertensive heart disease with or without heart
failure PLUS 428.8 (hypertensive cardiomyopathy)
414.8
Ischemic heart disease PLUS 428.8 (not told
anyone in coding advice) (ischemic cardiomyopathy)
424.0, 424.1 Mitral or aortic valvular cardiomyopathy
PLUS 428.8 (it is NOT “valvular heart disease
endocarditis” 424.90)
074.23 Viral myocarditis PLUS 428.8 Coxsackie viral
cardiomyopathy
674.5x Peripartum cardiomyopathy (distinguish from
648.64 other CMP going into pregnancy)
61
ICD-10: A Significant Step
Backwards
I42.0 Dilated cardiomyopathy (congestive CMP)
I42.1 Obstructive hypertrophic cardiomyopathy (IHSS)
I42.2 Other hypertrophic cardiomyopathy (nonobs.)
I42.3 Endomyocardial (eosinophilic) disease (fibrosis,
Loffler’s endocarditis)
I42.4 Endocardial fibroelastosis (congenital CMP)
I42.5 Other restrictive cardiomyopathy
I42.6 Alcoholic cardiomyopathy
I42.7 Cardiomyopathy due to drug and external agent
I42.8 Other cardiomyopathies
I42.9 Cardiomyopathy, unspecified
62
ICD-10: More Cardiomyopathies
I43 Cardiomyopathy in diseases classified elsewhere
Code first underlying disease, such as:
amyloidosis (E85.-), glycogen storage disease (E74.0),
gout (M10.0-), thyrotoxicosis (E05.0-E05.9-)
Excludes1: cardiomyopathy (in):
coxsackie (virus) (B33.24), diphtheria (A36.81),
sarcoidosis (D86.85), tuberculosis (A18.84)
I25.5 Ischemic cardiomyopathy (now stands alone)
I11.x Hypertensive heart disease PLUS I42.8 – both
O90.3 Peripartum cardiomyopathy (different from
patient going into pregnancy with sick heart O99.4)
63
Post-Transplant ESRD
• Inappropriate advice: “A patient who has had a
renal transplant should always be identified as
an ESRD patient” (because it’s an MCC)
• A patient who has had a renal transplant is
identified as V42.0 plus the stage of CKD of the
transplant kidney
• If that transplant kidney has failed and the
patient is back on dialysis, then it’s V42.0 plus
ESRD 585.6 for the transplant kidney plus the
reason for the failure 996.81 complication of
transplant kidney
64
Respiratory Failure Codes ICD-9
518.81 Acute respiratory failure
518.82 Other pulmonary insufficiency, not elsewhere
classified
Acute respiratory distress
Acute respiratory insufficiency
Adult respiratory distress syndrome NEC
518.83 Chronic respiratory failure
518.84 Acute and chronic respiratory failure
65
Erroneous Advice Re: 518.82
(518.52)
Other pulmonary insufficiency, NEC
Other pulmonary insufficiency not elsewhere classified and acute respiratory
insufficiency assigned to code 518.82 are manifestations of another disease
process, somewhat like respiratory failure. However, unlike respiratory
failure, these manifestations do not imply a complete inability of the
respiratory system to supply adequate oxygen to maintain metabolism
and/or eliminate sufficient carbon dioxide to avoid respiratory failure.
Pulmonary (or respiratory) insufficiency is a descriptive manifestation
usually in conjunction with the diagnosis of COPD that reflects the body's
inability to excrete carbon dioxide rather than failure to transport oxygen.
When the terms of pulmonary or respiratory insufficiency are used by the
physician, it is usually not in a setting of impending life-threatening condition
or the need for endotracheal intubation.
Although labeled ARDS, this is NOT ARDS
66
In the Same Issue, It’s RIGHT
Adult respiratory distress syndrome
Adult respiratory distress syndrome (ARDS) is a
descriptive term that applies to an acute clinicalpathological state characterized by diffuse infiltrative lung
lesions, severe dyspnea, and hypoxemia (deficient
oxygenation of blood) occurring in certain clinical
situations. Another description of ARDS is respiratory
failure due to shock and trauma occurring in the
presence of previously normal lungs.
67
Both Sides of the Advice Mouth
Question:
There seems to be some confusion in the field about the use of 518.82,
Acute respiratory insufficiency, not elsewhere classified, when it is
associated with COPD. Is it assigned as the principal diagnosis with the
code for COPD assigned as a secondary code? Is respiratory
insufficiency a separate condition or is it an integral part of COPD?
Answer:
Respiratory insufficiency is an integral part of COPD and is included in
any COPD code; including specific types such as chronic obstructive
bronchitis (491.2), emphysema (492.X), and chronic obstructive asthma
(493.2X), as well as COPD, not elsewhere classified (496). Do not
assign 518.82 as an additional code.
If it’s integral to AECB, it’s integral to asthma attack!
68
69
Every Child Admitted With Status Has
Acute Respiratory Distress
• Status asthmaticus has a definition
• Hypoxia has a definition
• Acute hypoxemic respiratory failure has a
definition
• ARDS has a definition
• Acute respiratory distress (respiratory
insufficiency) has NO DEFINITION
• Overassignment of 518.82 in status patients has
massively reduced the SOI of status patients
• And whose fault is that?
70
Acute Respiratory Failure ICD-10
J96.0 Acute respiratory failure
J96.00 Acute respiratory failure, unspecified whether with hypoxia or
hypercapnia
J96.01 Acute respiratory failure with hypoxia
J96.02 Acute respiratory failure with hypercapnia
J96.1 Chronic respiratory failure
J96.10 Chronic respiratory failure, unspecified whether with hypoxia or
hypercapnia
J96.11 Chronic respiratory failure with hypoxia
J96.12 Chronic respiratory failure with hypercapnia
J96.2 Acute and chronic respiratory failure
J96.20 Acute and chronic respiratory failure, unspecified whether with hypoxia
or hypercapnia
J96.21 Acute and chronic respiratory failure with hypoxia
J96.22 Acute and chronic respiratory failure with hypercapnia
J96.9 Respiratory failure, unspecified
J96.90 Respiratory failure, unspecified, unspecified whether with hypoxia or
hypercapnia
J96.91 Respiratory failure, unspecified with hypoxia
J96.92 Respiratory failure, unspecified with hypercapnia
71
ARDS
J80 Acute respiratory distress syndrome (ARDS)
Acute respiratory distress syndrome in adult or child
Adult hyaline membrane disease
R06.89 Respiratory insufficiency – categorized with
snoring
R06.00 Respiratory distress – categorized with dyspnea
Let’s get back the SOI and ROM of status patients
by doing it right!
72
Where We See People
Hurting the Data
1. Concentrating on Medicare patients only
2. Dwelling on CCs and MCCs only
3. Teaching docs to document complications of
care for DRG shifts and Medicare dollars
4. Making up definitions of diseases and
conditions for Medicare dollars
5. Misinterpreting Coding Clinic and
definitions of ICD codes for Medicare
dollars
6. Putting today’s bottom line ahead of tomorrow,
hurting the health system’s value basis
73
Official Coding Guidelines
If the diagnosis documented at the time of discharge is
qualified as “probable,” “suspected,” “likely,”
“questionable,” “possible,” “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.
74
Compliance Supersedes All
• IM-possible, IM-probable, or UN-likely
• Do NOT ask for diagnoses not specifically
supported in the medical record
– Historical aspects of gm neg, mixed bacterial,
aspiration pneumonia
75
Treatment MUST Be Appropriate
• If the usual treatment for all community-acquired
pneumonia is Rocephin and Zithromax and this
patient was treated with Rocephin and
Zithromax, it was NOT
– Gram-negative pneumonia
– Aspiration pneumonia
– Mixed bacterial pneumonia
– “Hypostatic pneumonia”
76
Nursing Home Pneumonia
•
•
•
Most Common Pathogens
Streptococcus pneumoniae
Haemophilus influenza
Moraxella catarrhalis
Uncommon
•
•
Legionella
Chlamydophila pneumoniae
http://emedicine.medscape.com/article/234916 – overview September 13, 2013
• The main controversy is the role of gram-negative aerobic rods and
Staphylococcus aureus as causative agents of nursing home–associated
pneumonia. Muder (54) found that when strict criteria were used to evaluate
the degree of contamination of a sputum culture specimen by
oropharyngeal material in those with nursing home-associated pneumonia,
gram-negative bacilli were isolated in only 0–12% of episodes.
• In a study of nursing home residents with pneumonia who were intubated
and placed on mechanical ventilation and had quantitative bronchoalveolar
lavage cultures, the most commonly isolated organisms were S. aureus
(29%), enteric gram-negative rods (15%), Streptococcus pneumoniae
(9%), and Pseudomonas species (4%) (19).
77
www.ncbi.nlm.nih.gov/pmc/articles/PMC2262163
Compliance Supersedes All
“The patient in 322 is from a
nursing home and is 72 years old
and has COPD. Is this gramnegative pneumonia?”
7/26/05 Barbara told
me to write that this is
possible gram-negative
pneumonia
“I don’t know.”
“Is it possible that it’s gramnegative pneumonia?”
“I don’t know.”
“But is it POSSIBLE?”
“Sure, it’s possible.”
78
Overidentification of “Sepsis”
≠
79
Where It All Started
DOI 10.1378/chest.101.6.1644
Chest 1992;101;1644-1655
80
81
What They Didn’t Say
All of the studies were
done on critically ill
patients on critical
care units – all of
them already had
advanced signs and
symptoms of organ
failure – no WONDER
they displayed the
abnormalities!!
82
Dissatisfaction Goes Back
150 Years
“Dear SIRS, … As many
of the gentlemen and I
have often said, you are
too sensitive. That's
where it is.”
Charles John Huffam Dickens, The
Life and Adventures of Martin
Chuzzlewit, c. 1844
http://en.wikipedia.org/wiki/File:How_The_Valley_of_Eden_Appeared_on_Paper_87.jpg
83
Dear SIRS, I'm Sorry to Say
That I Don't Like You
1. Dear SIRS, you’re too
sensitive
2. Dear SIRS, you don’t
help us understand the
pathophysiology
3. Dear SIRS, you’re not
helping us in our
practice
4. Dear SIRS, I’m afraid
we don’t need you
Jean-Louis Vincent,
Critical Care Med 1997;25:372-374
Photo used with permission.
Dr. Vincent is the editor in chief of "Critical
Care,” "Current Opinion in Critical Care,” and
"ICU Management.” He is a member of the
editorial boards of 30 journals including "Critical
Care Medicine" (senior editor), "American
Journal of Respiratory and Critical Care
Medicine,” "Intensive Care Medicine,” "Lancet
Infectious Diseases,” "Chest,” "Shock,” and
"Journal of Critical Care.” Dr. Vincent is a past
president of the European Society of Intensive
Care Medicine and the European Shock
Society, and the post-chairman of the
International Sepsis Forum.
84
SIRS – Only Beneficial to Identify an
Active Inflammatory Process
Special Articles
2001 SCCM/ESICM/ACCP/ATS/SIS
International Sepsis Definitions Conference
Mitchell M. Levy, MD, FCCP; Mitchell P. Fink, MD, FCCP;
John C. Marshall, MD; Edward Abraham, MD; Derek
Angus, MD, MPH, FCCP; Deborah Cook, MD, FCCP;
Jonathan Cohen, MD; Steven M. Opal, MD; Jean-Louis
Vincent, MD, FCCP, PhD; Graham Ramsay, MD; For the
International Sepsis Definitions Conference
Intensive Care Med (2003) 29:530–538, DOI 10.1007/s00134-003-1662-x
85
Editorial – Increasing Awareness of Sepsis:
World Sepsis Day
Jean-Louis Vincent
Editorial
Sepsis is estimated to affect at least 18 million individuals worldwide,
and with mortality rates of 25% to 30% [1,2], severe sepsis kills more
individuals annually than prostate cancer, breast cancer, and HIV/AIDS
combined, and the numbers of cases are increasing every year.
The confusion related to sepsis definitions and
terminology was amplified some 20 years ago when
participants at a North American consensus conference [6]
confused signs of infection, such as fever and altered
white blood cell count, with signs of sepsis, so that sepsis
became severe sepsis, and so on and so forth. But that debate is now
part of history and we must move on.
Critical Care 2012, 16:152, doi:10.1186/cc11511, 13 September 2012
86
Errors Made
• Abnormalities in VS, white count totally unrelated to
infection are called SIRS – only counts when cascade is
caused by inflammatory process
• Cases with possible sepsis based on SIRS criteria
never identified as “sepsis ruled out”
• Cases of simple infections coded as “sepsis” because
doctors urged to identify SIRS criteria when sepsis is
not present
• 310,000 sepsis cases reported 2004
• 820,000 cases reported 2009 – lower LOS, lower
mortality – 280% increase in US, 13.5% in rest of world
87
LPS
Lysed bacterial
cells
LPS binding
protein
LPS-LPS binding
protein complex
Macrophage
CD14, CD11/CD18,
TLR-2/TLR-4 LPS-Receptors
TNF, IL-1, IL-12, IL-6, IFNgamma
Adult Respiratory
Distress Syndrome
(ARDS)
Activation of
coagulation
cascade
Prostaglandins
leukotrienes
Disseminated Intravascular
Coagulation (DIC)
Multiple Organ
System Failure
Endothelial cell
damage
Activation of
complement
cascade
SIRS in ICD-10
ICD-9-CM
995.91 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
Official Coding Guidelines for ICD-10 no longer
mentions SIRS in relation to infection at all!!!
89
It’s Sepsis or It’s Not Sepsis
Anthrax sepsis A22.7
Septicemia of plague A20.7
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 otherwise specified A41
90
Document Excisional
Debridement
• 86.22 has a definition – the INTENT of the code:
“surgical” excision (which means use of cutting
instruments such as scalpel, cutting curette,
laser, scissors, cutting electrocautery, etc.) of
necrotic tissue, infected tissue or slough down to
healthy tissue that can heal. Use of 86.22 is
limited to “excisional debridement” of skin and
subcutaneous tissue.
91
Errors in Coding Advice
• If the doctor says he did excisional debridement
in a progress note, assign 86.22 (sic)
– The use of the term does not define the tissue
removed
– The use of the term does not define the
instruments used
• The word “excisional” has to be in the note to
differentiate excisional from nonexcisional
– It’s what the surgeon DID that counts, not what it
was called
92
Practice Acts May Exclude 86.22
• Nurse, physical therapist, wound therapist state
practice acts often define limitations of
procedures that may be performed
• Use of forceps and scissors or scalpel and
scissors to perform selective debridement is
NOT “excisional debridement” by the intent of
the code or compliance with law
• You will lose
93
Where We See People
Hurting the Data
1. Concentrating on Medicare patients only
2. Dwelling on CCs and MCCs only
3. Teaching docs to document complications of
care for DRG shifts and Medicare dollars
4. Making up definitions of diseases and
conditions for Medicare dollars
5. Misinterpreting Coding Clinic and definitions of
ICD codes for Medicare dollars
6. Putting today’s bottom line ahead of tomorrow,
hurting the health system’s value basis
94
What Else From Over-Reporting
• Acute renal failure (AKI) only acute organ failure
no longer significant (MCC)
• Malignant hypertension gone in ICD-10 even
though it kills thousands of patients a year
• Uncontrolled diabetes is gone with ICD-10
because no increased financial risk (when
patients don’t have it!)
• People are teaching us to destroy the data
95
CDI Is Essential for the Future
Integrity
Honesty
Holistic approach
Directed to the patient
Directed to the physician
Directed to communication for care
I don’t like playing games – and neither
should you!
96
Thank you. Questions?
In order to receive your continuing education certificate(s) for this
program, you must complete the online evaluation. The link can be
found in the continuing education section at the front of the
workbook.
97