Download Plugging the Leaks in Your Reimbursement Caused by ICD-10

Plugging the Leaks in Your
Reimbursement Caused by
ICD-10-CM and PCS for 2017
September 30, 2016
Deborah K. Hale, CCS, CCDS
President-CEO
Objectives
What the end of the I-10 freeze means to you!
I-10 update for Inpatient Services
I-10 update for Outpatient Facility Services
I-10 update for Professional Fees
2
The Code Freeze is Lifted!
Get Ready for Significant ICD-10 Updates
Revisions to Official Guidelines
ICD-10-CM AND ICD-10-PCS
CC,
365
MCC,
82
MS-DRG Mapping Changes
1974 New ICD-10-CM Codes
3827 New ICD-10-PCS Codes
3775 with DRG impact
NonCC,
1527
3
Cleaning Up The MS-DRG Mess!
Repairing Issues From the ICD-10 Transition Year Grouper Logic
“We discovered a replication error…”
CMS
Yes, quite a few!!
4
Annual Updates: From 758 to 757 MS-DRGs
FY17 IPPS Final Rule
FY16
MS-DRG 228-230 Other
Cardiothoracic Procedures w/o
CC, With CC and With MCC
6.9512 – 4.5589 – 4.3018
MS-DRG 884 Organic
Disturbances & Mental
Retardation
FY17
MS-DRG 228-229 Other
Cardiothoracic Procedures w/
w/o MCC
MS-DRG 230 Deleted
7.0869 – 4.7459
MS-DRG 884 Organic
Disturbances & Intellectual
Disability
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Small Bowel Procedures
Until 10/1/16
• Did you remove:
–SOME of the jejunum?
–SOME of the ileum?
–MS-DRG 347-349 Anal /
Stomal Procedures
–SOME of the duodenum?
–MS-DRG 326-328 Stomach
/ Duodenal Procedures
–ALL of the duodenum?
–ALL of the jejunum?
–ALL of the ileum?
–MS-DRG 329-331 Major
Bowel Procedures
Small Bowel Procedures
FY17 IPPS Final Rule
0DBB0ZZ Excision of ileum, open approach and
0DBA0ZZ Excision of jejunum, open approach
FY16
MS-DRG 347-349 Anal & Stomal
Procedures
2.4457 – 1.4486 - 0.9265
FY17
MS-DRG 329-331 Major Bowel
Procedures
4.9612 – 2.5405 – 1.6623
0DB90ZZ Excision of duodenum, open approach still:
 MS-DRG 326-328 Stomach, Esophageal and Duodenal
Procedures
7
Correcting MS-DRG V33 Errors
FY17 IPPS Final Rule
Combinations of procedure codes for the removal and
replacements of knee joints did not group to MS-DRGs
466, 467, and 468 (Revision of Hip or Knee
Replacement with MCC, with CC, and without
CC/MCC, respectively).
Adding the 58 new code combinations that capture
the joint revisions for MS-DRGs 466, 467, and 468.
8
Spacer Problems
FY17 IPPS Final Rule
“We agree that the joint revision cases involving the
removal of a spacer (0SP) and subsequent insertion of
a new knee joint prosthesis (0SR) should be assigned
to MS-DRGs 466, 467, and 468.”
FY16
MS-DRG 469-470 Major Joint
Replacement w/ w/o MCC
3.2962 – 2.0816
FY17
MS-DRG 466-468 Revision of Hip
or Knee Replacement
5.0249 – 3.4412 – 2.7936
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Knee Revisions
Effective 10/1/16
Partial list:
Removal of spacer
Plus
Replacement of
knee
Equals
MS-DRG 466-468
Joint Revisions!
10
Well, not all spacer issues resolved….
Patient presents for removal of existing spacer and
insertion of a new one.
 0SPC08Z Removal of Spacer from Right Knee Joint, Open
Approach
 0SHC08Z Insertion of Spacer into Right Knee Joint, Open
Approach
DRG 560 – Aftercare, musculoskeletal System & Connective
Tissue w/ CC
 Or other MS-DRG based on principal diagnosis.
11
Periprosthetic Fractures
Coordination & Maintenance Committee 9/13
“Fractures around a prosthesis are not complications
of the prosthesis, but the result of the same
conditions as other fractures, that is, trauma or
pathological conditions.”
More codes might be needed!
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Something must be wrong….
The way it was…
1983 – 2007
DRG 468 Major OR Procedure unrelated to the
$$$$$
Principal Diagnosis
2007 – Date
MS-DRG 981-983 Extensive OR Procedure
Unrelated to PDX (6.8917-3.8591-2.5275)
13
Did Your FY16 ST-PEPPER Look Like This?
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398 Codes Removed From MS-DRG 981-983, 987-989
OR Procedures “Unrelated” to PDX
FY17 IPPS Final Rule
ICD-10 replication errors
Revert to ICD-9 MS-DRG
counterparts
Almost all result in lower $$
Will impact CMI
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Replication Issues in MS-DRG 981-983 Extensive OR
Unrelated to PDX (6.8917 – 3.8591 – 2.5275)
FY17 IPPS Final Rule
#
Description
Codes
41
Angioplasty extracranial vessel
34
Aneurysmectomy
To MS-DRG
Result
37-39
various
3.0795-1.5762-1.0818
3
2
1
16
234
356-358
423-425
746-747
228-229
252-254
3.8503-2.0749-1.3550
4.4817-2.3553-1.5207
1.4750-0.9364
7.0869-4.7459
3.3126-2.6441-1.7764
Excision retroperitoneum
Occlusion esophageal varices
Excision vulva
Heart revascularization
Procedures on vascular bodies
(chemoreceptors)
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Replication Issues in MS-DRG 981-983 Extensive OR
Procedures Unrelated to PDX (6.8917 – 3.8591 – 2.5275)
FY17 IPPS Final Rule
#
Description
Codes
41
Angioplasty extracranial vessel
34
Aneurysmectomy
To MS-DRG
Result
37-39
various
3.0795-1.5762-1.0818
3
2
1
16
234
356-358
423-425
746-747
228-229
252-254
3.8503-2.0749-1.3550
4.4817-2.3553-1.5207
1.4750-0.9364
7.0869-4.7459
3.3126-2.6441-1.7764
Excision retroperitoneum
Occlusion esophageal varices
Excision vulva
Heart revascularization
Procedures on vascular bodies
(chemoreceptors)
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Replication Issues in MS-DRG 981-983 Extensive OR
Procedures Unrelated to PDX (6.8917 – 3.8591 – 2.5275)
FY17 IPPS Final Rule
#
Codes
4
16
6
2
4
5
Description
To MS-DRG
Result
Repair intestine
Insertion infusion pump
Procedures on bursa
Shoulder replacement
Reposition of vertebra
Bladder neck repair
329-331
Various
500-502
492-494
515-517
653-655
749-750
4.9612-2.5405-1.6623
3.1228-1.6337-1.2029
3.2145-2.1367-1.6321
3.1355-2.0709-1.7951
5.7501-3.0787-2.1635
2.7550-1.2993
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1,307 Codes From OR to Non-OR Classification
FY17 IPPS Final Rule
Category
Codes
Endoscopic / Transorifice Insertion
72
Endoscopic / Transorifice Removal
155
Tracheostomy Device Removal
5
Endoscopic / Percutaneous Insertion
117
Percutaneous Removal
124
Percutaneous Drainage
519
Percutaneous Inspection
131
Inspection without Incision
40
Dilation of Stomach
6
Endoscopic / Percutaneous Occlusion
6
Insertion of Infusion Device
131
$$$$$$
19
MS-DRG Relative Weight Recalibrations: Biggest Gains
FY17 IPPS Final Rule
RW
MS-DRG Description
Variance
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W/O MCC
1.5101
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W MCC
0.8545
HIV W EXTENSIVE O.R. PROCEDURE W MCC
0.8472
SPINAL FUS EXC CERV W SPINAL CURV/MALIG/INFEC OR EXT FUS W MCC
0.5097
FALSE LABOR
0.4037
WOUND DEBRIDEMENTS FOR INJURIES W MCC
0.3894
OTHER O.R. PROC FOR MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC
0.3570
SPLENECTOMY W MCC
0.3418
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA W MCC
0.3413
O.R. PROCEDURE W PRINCIPAL DIAGNOSES OF MENTAL ILLNESS
0.3352
20
MS-DRG Relative Weight Recalibrations: Biggest Losses
FY17 IPPS Final Rule
RW
MS-DRG Description
Variance
EXT BURNS OR FULL THICKNESS BURNS W MV >96 HRS W SKIN GRAFT
(1.5179)
SKIN GRAFT EXC FOR SKIN ULCER OR CELLULITIS W MCC
(1.0296)
COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC
(0.5845)
FULL THICKNESS BURN W SKIN GRAFT OR INHAL INJ W CC/MCC
(0.5452)
PANCREAS TRANSPLANT
(0.4636)
LIVER TRANSPLANT W MCC OR INTESTINAL TRANSPLANT
(0.4542)
VAGINAL DELIVERY W STERILIZATION &/OR D&C
(0.4060)
INTRACRANIAL VASCULAR PROC W PDX HEMORRHAGE W/O CC/MCC
(0.3882)
HIV W EXTENSIVE O.R. PROCEDURE W/O MCC
(0.3700)
MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R. PROC W MCC (0.3128)
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22
23
24
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Facts of Interest
FY17 IPPS Final Rule
 # Hospitals per FY17 Impact File
3409
 Bedsize Range
1-1942
 CMI Range FY15: Highest
 CMI Median FY15:
 CMI Range FY15: Lowest
3.9898
1.5342
0.5643
 17 Hospitals >1000 beds
 47 Hospitals < 10 beds
26
2014 Top 10 MS-DRGs for Nation
27
28
Sepsis MS-DRGs for 2017
MS-DRG Description
Relative
Weight
GMLOS
870
5.8960
12.6
871
Sepsis with
Mechanical
Ventilation > 96
hours
Sepsis with MCC
1.7660
4.9
872
Sepsis without MCC
1.0283
3.8
29
Impact of CMS Value Based Programs on FFS Payment
FY17 IPPS Final Rule
HVBP, 2%
MS-DRG,
94%
6%
HRRP, 3%
HAC, 1%
30
Importance of Clinical Validation
2016 AHIMA Practice Brief: Clinical Validation: The Next Level of CDI
The importance of accurately capturing the clinical
picture through available codes continues to grow in
importance as CMS revises payment methodologies,
tying quality of care to reimbursement.
31
Patient Safety Indicators
www.healthgrades.com
Hospital ABC
Worse
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
Electrolyte and fluid imbalance following surgery
Respiratory failure following surgery
Bloodstream infection following surgery
Accidental cut, puncture, perforation or hemorrhage
during medical care
Other PSI measures were reported as average.
Better
Wait a Minute…..Hold the Phone!
You want me to code ….
 Severe Sepsis
 Acute Respiratory Failure
 Pneumonia
 Metabolic Encephalopathy
 CLABSI not POA
 AND Query for severe
malnutrition?
 Immunocompromised Dx
 Impacts SOI (from 3 to 4)
 Removes patient from PSI-7 & 13
33
Code Assignment and Clinical Criteria
ICD-10-CM Guidelines Effective 10/1/16
The assignment of a diagnosis code is based
on the provider’s diagnostic statement that the
condition exists.
The provider’s statement that the patient has a
particular condition is sufficient.
Code assignment is not based on clinical criteria used
by the provider to establish the diagnosis.
34
Identification of Clinical Indicators
2016 AHIMA Practice Brief: Clinical Validation: The Next Level of CDI
Subjectivity of clinical validity leads to plethora of
denials
Truly beyond the scope of CDI and / or coding
professionals to define the diagnoses, for example:
 Not appropriate for CDI or coding professionals to omit
malnutrition when it is based on pre-albumin level rather
than ASPEN criteria.
 Must be determined by attending physician.
35
Sepsis-3
The Third International Consensus
Definitions
for Sepsis and Septic Shock
JAMA. 2016;315(8):801-810
You Want Me To Do WHAT?????
The Coder’s Role in Clinical Evaluation & Validation
OK, but when certain
insurance companies audit
us and change Severe Sepsis
to UTI, just remember, It’s
not my fault!
37
WHAT????
Does that mean the coder simply codes whatever is
documented?
Does that mean the coder is not expected to query
the provider?
Or does that mean the ultimate decision about the
application of clinical criteria validate the diagnosis
does not rest with the coder?
38
Escalation Policy
Guidelines for Achieving a Compliant Query Practice AHIMA Updated 2016
CMS recommends that each facility develop an
escalation policy for unanswered queries and to
address staff concerns regarding queries
Policy may include, but is not limited to
 Referral to a physician advisor
 Referral to chief medical officer
 Referral to other administrative personnel
What is the Risk?
Assigning codes for diagnoses without a facility
validation system in place may result in:
 Medicare / payor recoupment
 Incorrect quality scores with impact to quality based
program payments
 Inaccurate hospital / provider profiles
 OIG scrutiny
40
Role of Coder in Reporting Accuracy
ICD-10-CM Official Coding Guidelines
“These guidelines have been developed to assist both
the healthcare provider and the coder in identifying
those diagnoses that are to be reported.
The importance of consistent, complete
documentation in the medical record cannot be
overemphasized.”
41
Impact to CMI?
Absolutely possible
“Sepsis” per previous definition vs localized
infection alone
“Sepsis” vs simple pneumonia w/ CC
“Sepsis” vs complex pneumonia w/ CC
“Sepsis” vs UTI
“Sepsis” vs cellulitis
Initial
MSDRG
871
1.7926
871
1.7926
872
1.0427
Revised Impact
MS-DRG
194
0.9695
178
1.3575
690
0.7828
872
1.0427
603
0.8429
< 0.8231>
< 0.4351>
< 0.2599>
< 0.1998>
42
Concussion…..We Lost Some Detail!
Effective 10/1/16
FROM THIS
TO THIS
43
2014-16 ICD-10-CM
I10 – Hypertension
Benign and Malignant are out!
When documenting hypertension, include the following:
1.Type e.g. essential, secondary, etc.
2.Causal relationship e.g. Renal, pulmonary, etc
Hypertensive Crises
Effective 10/1/16
Hypertensive crises can present as
hypertensive urgency or as a
hypertensive emergency.
45
Hypertensive Crisis
www.heart.org
CC
“Hypertensive crises can present as hypertensive
urgency or as a hypertensive emergency.”
Hypertensive Crisis
 Systolic pressure 180 or higher
OR
 Diastolic pressure 110 or higher
46
Hypertensive Crisis
ICD-10-CM Guidelines Effective 10/1/16
Assign a code from category I16, Hypertensive crisis,
for documented hypertensive urgency, hypertensive
emergency or unspecified hypertensive crisis. Code
also any identified hypertensive disease (I10-I15). The
sequencing is based on the reason for the encounter.
I16.1
I10
Hypertensive emergency
Hypertension
47
Hypertensive Urgency
www.heart.org
Non-CC
Blood pressure is severely elevated
 180 or higher systolic
 110 or higher diastolic
No associated organ damage
Symptoms:
 Severe headache
 Shortness of breath
 Nosebleeds
 Severe anxiety
Treatment
 Readjustment and/or additional dosing of oral medications
 Most often does not necessitate hospitalization
48
Hypertensive Emergency
CC
 Blood pressure reaches levels that are damaging organs.
 The consequences of uncontrolled blood pressure in this range
can be severe and include
 Stroke
 Loss of consciousness
 Memory loss
 Heart attack
 Damage to the eyes and kidneys
 Loss of kidney function
 Aortic dissection
 Angina (unstable chest pain)
 Pulmonary edema (fluid backup in the lungs)
 Eclampsia
49
Potential Documentation Clarification
Accelerated Hypertension
Uncontrolled Hypertension
Meaning Hypertensive
Crisis or Hypertensive
Emergency?
Severe Hypertension
Conflicting documentation with hypertensive urgency,
hypertensive crisis, and/or hypertensive emergency
50
Diabetes With….MORE for FY17
Effective 10/1/16
It’s BACK!!!!!
51
T83 Complications of GU prosthetic devices, implants & grafts
Effective 10/1/16
111 new codes
Breakdown
Displacement
Leakage
Other mechanical compl
 Indwelling urethral
catheter
 Nephrostomy catheter
 Urinary stents
 Implanted testicular
prosthesis
52
Hand Transplants
Effective 10/1/16
53
54
PAPER CUT!
Effective 10/1/16
Contact with edge of stiff paper,
W26.2XXA initial encounter
Contact with edge of stiff paper,
W26.2XXD subsequent encounter
Contact with edge of stiff paper,
W26.2XXS sequela
55
Official Coding Guidelines
Section 1
ICD-10-CM
 “The conventions and instructions of the classification take
precedence over guidelines.”
Classification
(Code Book)
Official Coding
Guidelines
Coding Clinic
Outpatient Services Section IV
ICD-10-CM Guidelines Effective 10/1/16
Guidelines in Section I, Conventions, general coding
guidelines and chapter-specific guidelines, should also be
applied for outpatient services and office visits.
The Uniform Hospital Discharge Data Set (UHDDS)
definition of principal diagnosis does not apply to hospitalbased outpatient services and provider-based office visits
57
Outpatient Services
ICD-10-CM Guidelines Effective 10/1/16
Guidelines in Section I, Conventions, general coding
guidelines and chapter-specific guidelines, should also
be applied for outpatient services and office visits.
58
Official Coding Guidelines 2017
Outpatient Services
IV.
Diagnostic Coding and Reporting Guidelines for
Outpatient Services
The documentation should describe the patient’s
condition, using terminology which includes
specific diagnoses, as well as symptoms, problems,
or reasons for the encounter. There are ICD-10-CM
codes to describe all of these.
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Official Coding Guidelines 2017
Outpatient Services
D. Codes that Describe Signs and Symptoms
Codes that describe symptoms and signs as opposed to
diagnoses are acceptable for reporting purposes when a
diagnosis has not been established (confirmed) by the
provider.
Do not code diagnoses documentation as “possible”,
“probable”, likely” etc.
60
Official Coding Guidelines 2017
Outpatient Services
F 1, F 2
Use of full number of characters required for a code A
three-character code is to be used only if it is not
further subdivided.
A code is invalid if it has not been coded to the full
number of characters required for that code, including
the 7th character, if applicable.
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Official Coding Guidelines 2017
Outpatient Services
I. Chronic Disease
Chronic diseases treated on an ongoing basis may be
coded and reported as many times as the patient
receives treatment and care for the condition(s)
62
Official Coding Guidelines 2017
Outpatient Services
J. Code all documented conditions that coexist
Code all documented conditions that coexist at the time of
the encounter/visit, and require or affect patient care
treatment or management.
Do not code conditions that were previously treated and
no longer exist. However, history codes (categories Z80Z87) may be used as secondary codes if the historical
condition or family history has an impact on current care
or influences treatment
63
Criteria for Reportability of Codes
Face-to-face visit
Documentation must show how chronic condition is
being treated, managed or assessed
Each diagnosis must have an assessment and plan
Risk Adjustment with HCC’s
Hierarchical Condition Categories
Susan Wallace, MEd, RHIA, CCS, CDIP, CCDS
May 30, 2014
HCC Illustration
CAD / Other Chronic Ischemic
Heart Disease
Angina / Old MI
Unstable Angina,
Acute Ischemic
Heart Dz
Acute
MI
How They Are Used
• CMS risk adjustment for Medicare Part C plans
• Determines relative health risk of populations so that CMS
knows how to pay Medicare Advantage plan for coverage of
Medicare patients
• Original purpose for HCC development
• Required per ACA to calculate relative risk of population for
commercial plan on behalf of a state
• CMS and HHS methodologies vary due to expected
variations in populations
How They Are Used
• CMS risk adjustment for quality initiatives such as:
• VBP mortality
• Readmission reduction program
• VBP efficiency: Medicare spending per beneficiary
Get Credit for More Diagnoses!
 National Uniform Claim Committee
 New 1500 paper claim form and electronic 837P developed and
approved
 April 1, 2014 - Medicare will only accept claims with new claim
format
 # Diagnosis code fields from 4 to 12
http://www.nucc.org/images/stories/PDF/1500_claim
form_change_log_2012_02.pdf
Let’s Make An ICD-10-CM Deal 10-01-15
10-01-16
70
CMS Announcement and Guidance Regarding ICD-10
Flexibilities for AMA
https://www.cms.gov/Medicare/Coding/ICD10/Clarify
ing-Questions-and-Answers-Related-to-the-July-62015-CMS-AMA-Joint-Announcement.pdf
71
CMS Announcement and Guidance Regarding ICD-10
Flexibilities for AMA
 Question 5:
What is meant by a family of codes?
 K50.00 Crohn's disease of small intestine without complications
 K50.012 Crohn's disease of small intestine with intestinal obstruction
 K50.90
Crohn's disease, unspecified, without complications
72
CMS Announcement and Guidance Regarding ICD-10
Flexibilities for AMA
 Question 27: (new 08/18/2016) Will unspecified codes be
allowed once ICD-10 flexibilities expire?
 Answer 27: Yes. In ICD-10-CM, unspecified codes have
acceptable, even necessary, uses. Information about
unspecified codes, including an MLN Matters article and
videos, can be found on the CMS website.
73
CMS Announcement and Guidance Regarding ICD-10
Flexibilities for AMA
 While you should report specific diagnosis codes when they are
supported by the available medical record documentation and clinical
knowledge of the patient’s health condition, in some instances
signs/symptoms or unspecified codes are the best choice to
accurately reflect the health care encounter. You should code each
health care encounter to the level of certainty known for that
encounter. When sufficient clinical information is not known or
available about a particular health condition to assign a more specific
code, it is acceptable to report the appropriate unspecified code (for
example, a diagnosis of pneumonia has been determined but the
specific type has not been determined). For ICD-10 coding resources,
visit the Provider Resources section of the CMS ICD-10 website
74
Continued Use of Unspecified Codes May Result In…
Payers questioning “unspecified” diagnosis codes
Medical Necessity Denials for Services Provided:
 Laboratory and imaging tests (LCD and NCDs)
 Elective surgeries
Understating the severity of illness and complexity of
medical decision making
Strategies to Stop the Leaks
Effective Clinical Documentation Improvement for
Inpatient to include Risk Adjustment Factors.
Effective Clinical Documentation Improvement
Strategies for Outpatient and Professional Services
Escalation Policy for Clinical Validation Concerns
Concurrent CDI???
77
Strategies to Stop the Leaks
Persistent appeal of DRG changes inconsistent with Official
Coding Guidelines and Coding Conventions.
 CDI and Coder education for I-10 changes October 1, 2016
 Physician education regarding Risk Adjustment
Bundled Payments
HCC
Quality
PSI
Medical
Necessity
Thank You!
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consultant service
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