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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 5 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 9 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! 12 Something must be wrong…. The way it was… 1983 – 2007 DRG 468 Major OR Procedure unrelated to the $$$$$ Principal Diagnosis 2007 – Date MS-DRG 981-983 Extensive OR Procedure Unrelated to PDX (6.8917-3.8591-2.5275) 13 Did Your FY16 ST-PEPPER Look Like This? 14 398 Codes Removed From MS-DRG 981-983, 987-989 OR Procedures “Unrelated” to PDX FY17 IPPS Final Rule ICD-10 replication errors Revert to ICD-9 MS-DRG counterparts Almost all result in lower $$ Will impact CMI 15 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) 16 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) 17 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 18 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) 21 22 23 24 25 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. 59 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. 61 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! www.acsteam.net facebook.com/acsconsults linkedin.com/administrative consultant service 80