Inpatient Rehabilitation Facility Reimbursement and ICD · PDF file · 2015-08-11Inpatient Rehabilitation Facility Reimbursement and ICD-10-CM James S. Kennedy, MD, ... •ICD-9 and

Inpatient Rehabilitation Facility Reimbursement

and ICD-10-CM

James S. Kennedy, MD, CCS

1

Goals

• Describe ICD-10’s Impact on Inpatient Rehabilitation Facility’s (IRF’s) revenue cycle

• Develop strategies that maintain the integrity of ICD-10-based documentation and coding in the ICD-10 environment

2

Goals • Identify what is new or different in ICD-10-CM/PCS as

compared with ICD-9-CM, emphasizing its impact on • Physician and facility quality and cost-efficiency

measurement • Physician knowledge and work-flow • Physician office and hospital revenue cycles

• Review clinical aspects of the ICD-10-CM/PCS classification and terminology

• Outline St. Joseph’s ICD-10 strategy and plans for engaging the medical staff in ICD-10 documentation and coding integrity

ICD-10 Implementation Date Tentatively on October 1, 2015

Diagnoses Procedures ICD-10-CM

(Clinical Modification) Used by all entities: (providers & facilities) for diagnoses To be used in all settings: – Hospital inpatients – Hospital outpatients – Physicians offices – Emergency department – Home health – Long-term care – Rehabilitation facilities

ICD-10-PCS (Procedure Coding System)

Used by inpatient facilities ONLY • Includes outpatient facility services

rendered within the prior 72 hours of writing the inpatient order

• Very different than ICD-9-CM or CPT

CPT • Physician and outpatient/observation

facility services still utilize CPT • CPT does not change!!

International Classification of Disease Versions

• First edition, known as the International List of Causes of Death, was adopted by the International Statistical Institute in 1893

• WHO took in 1948 when the Sixth Revision, which included causes of morbidity for the first time, was published. • 1977 - ICD-9

• 1993 - ICD-10

• 2017 (tentative) - ICD-11

US Modifications – ICD-10-CM & PCS The Cooperating Parties

• CDC • Responsible for diagnoses

• CMS • Responsible for inpatient

procedures

• American Hospital Assn. • Responsible for interpreting

ICD-9 or ICD-10 (Coding Clinic)

• American HIM Assn. • Provides input from coding

community

ICD-10 Basics

• ICD-10-CM/PCS (and ICD-9-CM) are NOT clinical languages (like SNOMED) • ICD-9 and ICD-10 are useful for classifying healthcare

data for administrative purposes, including reimbursement claims, health statistics, and other uses where data aggregation is advantageous

• ICD-10-CM/PCS is based ONLY on provider documentation of clinical language, not on a patient’s clinical characteristics • The provider must use the magic words that drive ICD-

10-CM/PCS code assignment

7

Overall Changes

• 34,250 (50%) of all ICD-10-CM codes are related to the musculoskeletal system

• 17,045 (25%) of all ICD-10-CM codes are related to fractures

• 10,582 (62%) of fracture codes to distinguish ‘right’ vs. ‘left’

• ~25,000 (36%) of all ICD-10 codes to distinguish ‘right’ vs. ‘left’

Cerebrovascular Diseases

• Cerebrovascular diseases (I60-I69) • Use additional code to identify presence of:

• alcohol abuse and dependence (F10.-)

• exposure to environmental tobacco smoke (Z77.22)

• history of tobacco use (Z87.891)

• hypertension (I10-I15)

• occupational exposure to environmental tobacco smoke (Z57.31)

• tobacco dependence (F17.-) = SMOKER

• tobacco use (Z72.0)

9

Stroke Differentiation from TIA

Stroke Specificity in ICD-10

• Mechanism • Embolus • Thrombus

• Vessel involvement • Carotid – right or left • Cerebral – right of left

• Anterior • Middle • Posterior

• Vertebral – right of left • Basilar

• Consequences • Monoparesis or

hemiparesis • Right of left • Dominant or non-

dominant side • “Weakness” only codes

to these if documented as due to the stroke

• Aphasias • Dysarthrias • Dysphagias • Dementia

Acute Cerebral Infarctions

12

ICD-10 Enhances Specificity Intracerebral Hemorrhage ICD-9-CM

• 431 Intracerebral hemorrhage

• Hemorrhage (of): • basilar • bulbar • cerebellar • cerebral • cerebromening

eal • cortical • internal

capsule • intrapontine • pontine • subcortical • ventricular

• Rupture of blood vessel in brain

ICD-10-CM

• I61 Nontraumatic intracerebral hemorrhage • I61.0 - Nontraumatic intracerebral hemorrhage in

hemisphere, subcortical • Deep intracerebral hemorrhage (nontraumatic)

• I61.1 Nontraumatic intracerebral hemorrhage in hemisphere, cortical • Cerebral lobe hemorrhage (nontraumatic) • Superficial intracerebral hemorrhage (nontraumatic)

• I61.2 Nontraumatic intracerebral hemorrhage in hemisphere, unspecified

• I61.3 Nontraumatic intracerebral hemorrhage in brain stem • I61.4 Nontraumatic intracerebral hemorrhage in cerebellum • I61.5 Nontraumatic intracerebral hemorrhage,

intraventricular • I61.6 Nontraumatic intracerebral hemorrhage, multiple

localized • I61.8 Other nontraumatic intracerebral hemorrhage • I61.9 Nontraumatic intracerebral hemorrhage, unspecified

Expansion from one code to 9 codes

Stroke in Meditech 5.67

Use of Imaging Reports Coding Clinic, 3rd Quarter, 2014, page 5

• Question: If a patient is diagnosed with a cerebral infarction or hemorrhagic stroke, can the imaging results be used to identify the specific vessel associated with these conditions?

• Answer: It is appropriate to utilize imaging reports to provide greater specificity of the anatomic site as documented by the physician. • Therefore, if a patient is diagnosed with a cerebral infarction

or hemorrhagic stroke, it would be appropriate to utilize the imaging report to determine the location of the stroke or infarction.

Comment: One cannot code a new diagnosis from the imaging study, just increased specificity of the anatomic location an already documented diagnosis

Intracranial Nontraumatic Hemorrhage of Newborns

APR SOI ROM

2 2

2 2

4 3

4 4

2 2

3 2

Admissions to Rehabilitation Late Effects of Stroke Sequelae of cerebrovascular disease

Category I69 is to be used to indicate conditions in I60-I67 as the cause of sequelae. The 'sequelae' include conditions specified as such or as residuals which may occur at any time after the onset of the causal condition

• Excludes1: • personal history of cerebral infarction without residual deficit

(Z86.73) • personal history of prolonged reversible ischemic neurologic deficit

(PRIND) (Z86.73) • personal history of reversible ischemic neurological deficit (RIND)

(Z86.73) • sequelae of traumatic intracranial injury (S06.-) • transient ischemic attack (TIA) (G45.9)

17

While Hemiparesis = Hemiplegia, Monoparesis ≠ Monplegia

Monoparesis after a stroke = I69.x98 (depending on the underlying event) Plus M62.81 – Muscle weakness

Stroke Consequences “Sided” Weakness

43821

Late effects of cerebrovascular disease, hemiplegia affecting dominant side

Note: In ICD-9-CM and

ICD-10, hemiparesis

and hemiplegia share

the same code

Note: The right side is

presumed to be

dominant unless

documented otherwise

Note: Weakness of a

side can be interpreted

to be hemiparesis if

attributed to a stroke

I69051 Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right dominant side

I69052 Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left dominant side

I69151 Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side

I69152 Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left dominant side

I69251 Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side

I69252 Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting left dominant side

I69351 Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side

I69352 Hemiplegia and hemiparesis following cerebral infarction affecting left dominant side

I69851 Hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side

I69852 Hemiplegia and hemiparesis following other cerebrovascular disease affecting left dominant side

I69951 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side

I69952 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side

Stroke Consequences “Bilateral” “Sided” Weakness

• In ICD-10-CM, “quadriparesis” = “quadriplegia”

• Explicit documentation of neurologic quadriparesis due to (multiple) stroke(s) adds weight to hospital and physician risk adjustment

Other Neurological Muscle Weaknesses

If the coding system asks you to specify if a muscle weakness is due to

• A stroke or not

• Cerebral palsy

• Spinal cord injury

• Other specified neurological diseases

Pay attention!

Functional Quadriplegia (Quadraparesis) (versus Neurological Quadraplegia)

• The ICD-10-CM Official Guidelines is the only definition of this term on the planet - Not listed on PubMed.Gov

• Functional quadriplegia (code R53.2) is the lack of ability to use one’s limbs or to ambulate due to extreme debility. • It is not associated with neurologic deficit or injury, and

code R53.2 should not be used for cases of neurologic quadriplegia.

• It should only be assigned if functional quadriplegia is specifically documented in the medical record

Meditech 5.67

23

Sequelae of Strokes

24

ICD-10-CM Injury Codes Location Oriented

Episodes of Care Trauma and Complications Encounters

• Initial encounter: The first diagnosis of a condition or receiving active treatment for an injury or illness (even if in an established patient) • Fracture care: Initial care by ED physician, orthopaedist • Complications: Applies until all planned active treatment is completed

• Subsequent encounter: care during a period of healing or recovery (even if you’re the first MD to see the patient) • Fracture care: cast change, suture removal, etc. • Complications: Applies AFTER all planned active treatment is

completed

• Sequela: After the healing process is complete. • Permanent consequences to the fracture (e.g. malunions, nonunions)

Initial vs. Subsequent Rehabilitation Facilities • Question: The patient, who is status post treatment of multiple

fractures currently in the healing phase, is transferred to a rehabilitation facility. • At the rehab facility the patient is covered by a new physician that has

never seen the patient before. • Should the 7th character for the fractures be reported as “A” initial

encounter because it’s a new physician, even though the patient is considered to be in the healing phase?

• Answer: The key to selecting the 7th character for “initial encounter” is whether there is still active treatment (e.g., surgical treatment, emergency department encounter, or evaluation and continuing (ongoing) treatment). • The fact that the patient is new to the physician does not have any

relevance in determining the 7th character. • Rehabilitation services are not considered active treatment and the

encounter should be reported with the appropriate 7th character for “subsequent encounter.”

27

Coding Clinic, First Quarter ICD-10 2015 Page: 21

Traumatic Fractures LEO C. FAR

• Location and Laterality • Proximal, mid, or distal shaft • Laterality (right vs. left)

• Episode of care (NEW) • “initial encounter” • “subsequent encounter” • “sequela”

• Open vs. closed

• Classifications • Salter classifications • Guistilo-Anderson

classification for open fractures (NEW)

• Others

• Fracture patterns, such as greenstick, oblique, spiral, comminuted

• Alignment • Displaced or nondisplaced • Angled, distracted, over-riding

• Results (NEW in ICD-10) • Routine or delayed healing • Union or nonunion

Multiple Trauma

CMG CMG Description (M=motor, C=cognitive, A=age) Relative Weight

Tier 1 Tier 2 Tier 3 None

201 Traumatic brain injury M>53.35 and C>23.5 0.8145 0.6636 0.5954 0.568

202 Traumatic brain injury M>44.25 and M<53.35 and C>23.5 1.0591 0.8629 0.7741 0.7385

203 Traumatic brain injury M>44.25 and C<23.5 1.2162 0.9909 0.889 0.8481

204 Traumatic brain injury M>40.65 and M<44.25 1.3397 1.0915 0.9793 0.9342



207 Traumatic brain injury M<22.05 2.564 2.089 1.8741 1.788

401 Traumatic spinal cord injury M>48.45 1.0264 0.879 0.8131 0.7251

402 Traumatic spinal cord injury M>30.35 and M<48.45 1.4108 1.2081 1.1176 0.9966

403 Traumatic spinal cord injury M>16.05 and M<30.35 2.3059 1.9747 1.8268 1.6289

404 Traumatic spinal cord injury M<16.05 and A>63.5 4.0832 3.4967 3.2348 2.8845

405 Traumatic spinal cord injury M<16.05 and A<63.5 3.3355 2.8564 2.6425 2.3563

701 Fracture of lower extremity M>42.15 0.97 0.806 0.7727 0.7036

702 Fracture of lower extremity M>34.15 and M<42.15 1.2429 1.0327 0.9901 0.9016

703 Fracture of lower extremity M>28.15 and M<34.15 1.5056 1.2511 1.1994 1.0922

704 Fracture of lower extremity M<28.15 1.9359 1.6086 1.5421 1.4044

1701 Major multiple trauma without brain or spinal cord injury M>39.25 1.0432 0.929 0.8566 0.7881

1702 Major multiple trauma without brain or spinal cord injury M>31.05 and M<39.25 1.3109 1.1674 1.0764 0.9903

1703 Major multiple trauma without brain or spinal cord injury M>25.55 and M<31.05 1.5378 1.3694 1.2627 1.1617

1704 Major multiple trauma without brain or spinal cord injury M<25.55 1.9856 1.7682 1.6303 1.5

1801 Major multiple trauma with brain or spinal cord injury M>40.85 1.0662 0.9437 0.8082 0.7231

1802 Major multiple trauma with brain or spinal cord injury M>23.05 and M<40.85 1.6884 1.4945 1.2798 1.1451

1803 Major multiple trauma with brain or spinal cord injury M<23.05 2.8097 2.4869 2.1297 1.9055

29

Multiple Significant Trauma With Craniotomy

Trauma diagnoses plus 2 organ system diagnoses

• Any closed or open fracture, dislocation, strain or sprain

• Concussion

• Nerve or blood vessel injuries

• Traumatic brain injury • Does not include “closed

head injury”

• Injury to any internal organs • Often omitted, such as

lung, cardiac, or renal contusions

• Subcutaneous emphysema

• Insect bites

3 organ system diagnoses

1. Head • Skull fracture; TBI; concussion

2. Chest • Fracture of 4 or more ribs or sternum; fx of larynx or trachea; injury to

heart, lung, or vessels (often not documented)

3. Abdomen • Injury to abdominal organs (often not documented), BV, or bowel;

compartment syndrome

4. Renal • Renal/adrenal Injury

5. Urinary • Injury to pelvic organs

6. Pelvis & spine • Fracture or crush injury; injury to nerve plexus

7. Upper limb • Fracture, dislocation, or nerve injury

8. Lower limb • Fracture, dislocation, or nerve injury

Potentially Missed Significant Traumas

• Nasal fractures

• Nerve injury

• Subcutaneous emphysema

• Puncture wounds

• Traumatic shock (elevated

lactate levels with evidence

of hypoperfusion)

• Traumatic anuria (not

oliguria)

• Traumatic muscle ischemia

• Most body contusions

• Blisters

• Insect bites

• In ICD-10 • Open fractures cannot be

coded without their Gustilo-

Anderson classification

• Concussions must have over 1

hour of unconsciousness

• Only Salter-Harris I–IV are

identified (not 5–9)

IRF Revenue Cycle

32

Case Mix Groups (CMGs) drive IRF reimbursement

Rheumatoid Arthritis Without Organ Involvement

33

Rheumatoid Arthritis Without Organ Involvement

34

Rheumatoid Arthritis

35

To code rheumatoid arthritis correctly in ICD-10-CM, the physician must state if it is sero-positive (with rheumatoid factor) or sero-negative

Rheumatoid Arthritis Also not any organ dysfunction

36

Meditech 5.67

37

2015 Stroke CMGs

CMG CMG Description

(M=motor, C=cognitive, A=age) Relative Weight Average Length of Stay

Tier 1 Tier 2 Tier 3 None Tier 1 Tier 2 Tier 3 None

0101 Stroke M>51.05

0.7853 0.7150 0.6512 0.6248 9 10 8 8

0102 Stroke M>44.45 and M<51.05 and C>18.5

0.9836 0.8955 0.8155 0.7826 11 11 10 10

0103 Stroke M>44.45 and M<51.05 and C<18.5

1.1636 1.0594 0.9648 0.9258 12 14 12 12

0104 Stroke M>38.85 and M<44.45

1.2121 1.1036 1.0050 0.9644 13 13 12 12

0105 Stroke M>34.25 and M<38.85

1.4155 1.2888 1.1737 1.1262 14 14 14 14

0106 Stroke M>30.05 and M<34.25

1.6135 1.4691 1.3379 1.2838 16 16 15 15

0107 Stroke M>26.15 and M<30.05

1.8026 1.6412 1.4946 1.4342 17 19 17 17

0108 Stroke M<26.15 and A>84.5

2.2467 2.0456 1.8629 1.7876 22 24 21 21

0109 Stroke M>22.35 and M<26.15 and A<84.5

2.0570 1.8728 1.7055 1.6366 19 20 19 19

0110 Stroke M<22.35 and A<84.5

2.6928 2.4518 2.2328 2.1425 28 27 24 24

38

2015 Brain Injury CMGs

CMG CMG Description



0201 Traumatic brain injury

M>53.35 and C>23.5 0.8145 0.6636 0.5954 0.5680 10 9 8 8

0202

Traumatic brain injury

M>44.25 and M<53.35 and

C>23.5 1.0591 0.8629 0.7741 0.7385 12 10 9 10


M>44.25 and C<23.5 1.2162 0.9909 0.8890 0.8481 13 12 12 11


M>40.65 and M<44.25 1.3397 1.0915 0.9793 0.9342 12 13 12 12


M>28.75 and M<40.65 1.5924 1.2974 1.1640 1.1104 14 15 14 14


M>22.05 and M<28.75 1.9327 1.5747 1.4127 1.3477 19 18 16 16


M<22.05 2.5640 2.0890 1.8741 1.7880 32 25 21 20

0301 Non-traumatic brain injury

M>41.05 1.1022 0.9324 0.8453 0.7798 10 11 10 10


M>35.05 and M<41.05 1.3799 1.1673 1.0582 0.9762 13 13 12 12


M>26.15 and M<35.05 1.6371 1.3849 1.2555 1.1583 16 15 14 14


M<26.15 2.1541 1.8222 1.6520 1.5240 23 21 18 17

39

2015 Spinal Cord Injury CMGs

CMG CMG Description



0401 Traumatic spinal cord injury

M>48.45 1.0264 0.8790 0.8131 0.7251 12 12 10 9


M>30.35 and M<48.45 1.4108 1.2081 1.1176 0.9966 15 14 14 13


M>16.05 and M<30.35 2.3059 1.9747 1.8268 1.6289 26 21 20 20


M<16.05 and A>63.5 4.0832 3.4967 3.2348 2.8845 54 40 33 33


M<16.05 and A<63.5 3.3355 2.8564 2.6425 2.3563 26 34 29 27

0501 Non-traumatic spinal cord injury

M>51.35 0.8418 0.6804 0.6237 0.5643 9 10 9 8


M>40.15 and M<51.35 1.1580 0.9359 0.8579 0.7763 11 12 10 10


M>31.25 and M<40.15 1.4373 1.1616 1.0648 0.9635 15 13 13 12


M>29.25 and M<31.25 1.6935 1.3687 1.2546 1.1352 17 15 15 14


M>23.75 and M<29.25 1.9365 1.5651 1.4346 1.2981 20 17 17 16


M<23.75 2.7066 2.1875 2.0052 1.8144 26 25 23 21

40

Tier 1 Diagnoses

Code Choice Code Title Tier J38.01 Paralysis of vocal cords and larynx, unilateral 1 J38.02 Paralysis of vocal cords and larynx, bilateral 1 J38.4 Edema of larynx 1 Z43.0 Encounter for attention to tracheostomy 1 Z93.0 Tracheostomy status 1 Z99.2 Dependence on renal dialysis 1

41

Tier 2 Diagnoses Code Choice Code Title Tier A04.7 Enterocolitis due to Clostridium difficile 2 A04.8 Other specified bacterial intestinal infections 2

B96.5 Pseudomonas (aeruginosa) (mallei) (pseudomallei) as the cause of diseases classified elsewhere 2

I69.091 Dysphagia following nontraumatic subarachnoid hemorrhage 2 I69.191 Dysphagia following nontraumatic intracerebral hemorrhage 2 I69.291 Dysphagia following other nontraumatic intracranial hemorrhage 2 I69.391 Dysphagia following cerebral infarction 2 I69.891 Dysphagia following other cerebrovascular disease 2 I69.991 Dysphagia following unspecified cerebrovascular disease 2 K91.2 Postsurgical malabsorption, not elsewhere classified 2 R13.0 Aphagia 2 R13.10 Dysphagia, unspecified 2 R13.11 Dysphagia, oral phase 2 R13.12 Dysphagia, oropharyngeal phase 2 R13.13 Dysphagia, pharyngeal phase 2 R13.14 Dysphagia, pharyngoesophageal phase 2 R13.19 Other dysphagia 2

42

Tier 3 Diagnoses

• Asymptomatic Hepatitis C

• B20 HIV-Disease • Code for asymptomatic HIV doesn’t add weight

• Diabetes with complications • Includes hyperglycemia (Hgb A1C > 7 or multiple BS over

250) • Includes all other specified complications

• Document all consequences of old and current strokes • Vocal cord paralysis • Hemiparesis

43

Tier 3 Diagnoses

• Heart failure if documented as systolic or diastolic • Heart failure NOS does not qualify

• Pneumonia if still treated

• Acute and chronic pulmonary insufficiency following surgery

• Cellulitis

• Peripheral Atherosclerosis • With ulcer

• With gangrene

44

Documents

Inpatient Rehabilitation Facility Reimbursement and ICD · PDF file · 2015-08-11Inpatient Rehabilitation Facility Reimbursement and ICD-10-CM James S. Kennedy, MD, ... •ICD-9 and