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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