1

ICD-10’s Impact on Physician Practice Psychiatry

Medical Necessity,

Quality Management, and

Cost Efficiency Determinants

Disclaimer

• This presentation is designed to provide accurate and authoritative

information in regard to the subject matter. The information includes both

reporting and interpretation of materials in various publications, as well as

interpretation of policies of various organizations. This information is

subject to individual interpretation and to changes over time. – The speaker does not warrant that the written or oral opinions expressed in this

lecture apply to every situation. Prior to implementing any of the suggestions

discussed at this meeting, the attendee is advised to seek counsel from his or her

compliance officer or their legal counsel.

– CDIMD, the individual speakers, and all affiliated entities support accurate coding

of every clinical circumstance based upon physician documentation, recognize the

role and responsibility of treating physicians to utilize language they deem

appropriate to their circumstances, and support compliance to all local, state, and

federal laws.

2

Objectives

Subject Task

1 ICD-10 Understand what is new and different from ICD-9

2 Risk Adjustments What they are; How they are used

3 Quality and Cost-Efficiency Analysis

How it is accomplished

4 Changing Reimbursements

Based on quality and cost-efficiency analysis and risk adjustments

5 Literature Review

Clinical terms and the thresholds between severities illness • Physicians define the terms (conditions) • The bureaucracy assigns relative weights to the

terms

6 Role of Clinical Documentation Integrity

Translating medical language into the language of claims processing. Helping physicians to get #1 above correct, so 2, 3, and 4 are correct

Like Explaining the Phone Book Interesting Characters – Terrible Plot

Dictionary without Definitions

ICD-10 Implementation Date October 1, 2015

5

Diagnoses Procedures

ICD-10-CM (Clinical Modification)

Used by Everyone 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) Inpatient Facility ONLY!!!

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 Evolving 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

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Countries in Blue Have Adopted ICD-10 for Morbidity

• The US is the last industrialized country to adopt ICD-10 • The US is the only country to tie ICD-10 to billing & reimbursement

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

8

ICD-10 Basics

• ICD-10-CM/PCS (and ICD-9-CM) are NOT clinical languages (like SNOMED) – ICD-9-CM and ICD-10-CM/PCS 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

9

What’s Old? ICD-9-CM

10

What’s New ICD-10-CM

11

ICD-9 and ICD-10

Diagnoses and Procedures

Code Type ICD-9-CM ICD-10-CM ICD-10 PCS

Diagnosis 14,567 codes 69,832 codes

Inpatient Procedures

3,878 codes 71,920 codes

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Major DSM-5 Changes

• Subtypes of schizophrenia (e.g. residual, paranoid, disorganized) are eliminated due to their limited reliability and validity.

• Separate diagnoses for autism, Asperger’s Syndrome, and pervasive developmental Disorder, NOS have been eliminated and are now classified under the new term Autism spectrum disorder. However, in ICD-10-CM:

• Non-physiologic feeding and eating disorder of early childhood is now classified as avoidance/restrictive food intake disorder

ICD-10 Code

Description MS DRG CC/MCC

APR DRG SOI

APR DRG ROM

F840 Autistic disorder CC 1 1

F845 Asperger’s syndrome CC 1 1

Major DSM-5 Changes

• Somatiform disorders are now classified as Somatic Symptom and Related Disorders and the terms somatization disorder, hypochondriasis, pain disorder, and undifferentiated somatoform disorder have been removed.

• Some new disorders described in DSM-5 include: – Premenstrual Dysphoric Disorder – Disruptive Mood Dysregulation Disorder of childhood (onset

before age 10 years) – Hoarding Disorder – Social (pragmatic) Communication Disorder – Disinhibited Social Engagement Disorder – Rapid Eye Movement Sleep Behavior Disorder – Caffeine Withdrawal

ICD-10-CM Accommodations of DSM-5

• CMS and CDC Coordination and Maintenance Committee – Partial freeze on ICD-10 updates

– Only limited updates to ICD-10 code sets October 1, 2015

– Regular updates will not begin until October 1, 2016

– Thus, it is uncertain when the coder and CDS specialist will see modifications to ICD-10-CM codes that reflect the most up to date terminology and classifications. In the interim, the new DMS-5 disorders, classifications, and nomenclature changes can create challenges for the coder in ascribing proper credit for the physician’s care.

DSM-5 Preparation for ICD-10-CM

• General Equivalence Mapping

– With each disorder in the DSM-5 manual, an ICD-9-CM code is followed by an ICD-10-CM code in parenthesis. A blank line indicated an ICD code is not applicable.

– DSM-5 includes many new disorders, nomenclature changes, and new combination codes; hence, not always a match.

ICD-9-CM and ICD-10-CM Coding Rules

• Code assignment is based ONLY on provider documentation – Even if it quacks, waddles, has web feet, no code for

“duck” can be entered unless the physician says “duck”

– Coders may not clinically interpret the record

• For inpatients, coders may not pathology or diagnoses from IP X-ray reports – They are allowed to obtain the anatomic location, but

not the pathology

• Coders may not code from IP pathology reports

Sign and Symptoms Unspecified Codes

• Use of sign/symptom and “unspecified” codes have acceptable, even necessary, uses. – While specific diagnosis codes should be reported when they are

supported by the available medical record documentation and clinical knowledge of the patient’s health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter.

– Each healthcare encounter should be coded to the level of certainty known for that encounter.

• If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis. – It would be inappropriate to select a specific code that is not

supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code.

Major DSM-5 Changes

• Substance abuse and substance dependency is no longer separately classified. The classification is now substance use disorder, mild, moderate, or severe. – The term addiction is eliminated.

– When withdrawal, intoxication, substance-induced or other substance-related mental disorder is present, the manual provides criteria and directs further specific code selection based on these co-occurrences.

DSM-5 vs. ICD-10-CM Crosswalk Study

• The ICD-10 and DSM-5 reached a similar conclusion for – Patients that did not meet alcohol use disorder diagnosis – Patients that meet the most severe forms of alcohol use

disorder

• ICD-10 and DSM-5 discrepancy for – Mild and moderate cases of alcohol use disorder

• Roughly one-third of DSM-5 mild cases would not receive a diagnosis per the ICD-10 clinical version

• May lead to reduced access to treatment services for a fairly large number of individuals

Source: Psychology & Psychiatry, March 17, 2015, http://medicalxpress.com/print345833934.html

Principle #1 ICD-10-CM: A Dictionary w/o

Definitions

Principle #1 ICD-10-CM: A Dictionary w/o

Definitions

Principle #1 ICD-10-CM: A Dictionary w/o

Definitions

Definitions – DSM-5 – or others? Use vs. Abuse vs. Dependency

• Use – legal use of a drug or chemical • Abuse – Illegal or excessive use of a drug or chemical causing adverse

consequences • Dependency (at least 2 of the following)

– Item taken in larger amounts or over a longer period than intended – Persistent desire or unsuccessful efforts to cut down or control use – Great deal of time spent to obtain the chemical – Craving or a strong desire to use – Continued use despite adverse consequences due to drug/chemical – Failure to meet major role obligations at home, work, or school – Recurrent use in situations that are hazardous (2 DWIs) – Continued use despite knowledge of having a physical or mental condition

that is worsened by the chemical use – Tolerance (need for more drug to have the same effect) – Withdrawal symptoms when drug is discontinued

Source: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5)

Definitions – DSM-5 – or others? Remission

• Remission - After full criteria for dependency were previously met, none of the criteria (except for craving or a strong desire to use) have been met for a least 3 months – Early remission – between 3 to 12 months – Sustained remission – over 12 months

• Intoxication - Reversible substance-specific syndrome due to recent ingestion of a substance

• Delirium - A disturbance in attention (e.g. reduced ability to direct, focus, or sustain) and awareness (reduced orientation to environment that develops over a short period of time, that is different over baseline, and tends to fluctuate in severity over the course of a day than cannot be better explained by a preexisting neurocognitive disorder

Source: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5)

Alcohol/Drug Use and Alcohol/Drug-Induced Organic Mental Disorders

MS-DRG MS-DRG title Weights

894 ALCOHOL/DRUG ABUSE OR DEPENDENCE, LEFT AMA 0.4509

895 ALCOHOL/DRUG ABUSE OR DEPENDENCE W REHABILITATION THERAPY

1.1939

896 ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W MCC

1.5146

897 ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC

0.6824

• Rehabilitation therapy:

– Detoxification services for substance abuse treatment with group or individual

counseling for substance abuse treatment

• Cognitive, behavioral, cognitive-behavioral, 12-step, interpersonal, vocational,

psychoeducation, motivational enhancement, confrontational, continuing care, spiritual

• ICD-10-PCS root operation definition for individual or group (2 or more)

counseling (potentially qualifying for MS-DRG 895)

– The application of psychological methods to treat an individual with addictive

behavior

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Assigned Relative Weights to Alcohol-Associated Diagnoses ICD-10

Code Description

HCC

#

HCC

CM RW

HCC

IN RW

MS DRG

CC/MCC

APR DRG

SOI

APR DRG

ROM

F1010 Alcohol abuse, uncomplicated 1 1

F10120 Alcohol abuse with intoxication, uncomplicated 55 0.420 0.053 1 1

F10121 Alcohol abuse with intoxication delirium

55 0.420 0.053 CC 3 2

F10129 Alcohol abuse with intoxication, unspecified 55 0.420 0.053 1 1

F1014 Alcohol abuse with alcohol-induced mood disorder

55 0.420 0.053 CC 1 1

F10150 Alcohol abuse with alcohol-induced psychotic disorder with delusions

54 0.420 0.053 1 1

F10151 Alcohol abuse with alcohol-induced

psychotic disorder with hallucinations 54 0.420 0.053 CC 1 1

F10159 Alcohol abuse with alcohol-induced

psychotic disorder, unspecified 54 0.420 0.053 CC 1 1

F10180 Alcohol abuse with alcohol-induced anxiety disorder

55 0.420 0.053 CC 1 1

F10181 Alcohol abuse with alcohol-induced sexual dysfunction

55 0.420 0.053 CC 1 1

F10182 Alcohol abuse with alcohol-induced sleep disorder

55 0.420 0.053 1 1

F10188 Alcohol abuse with

other alcohol-induced disorder 55 0.420 0.053 CC 1 1

F1019 Alcohol abuse with

unspecified alcohol-induced disorder 55 0.420 0.053 CC 2 1

HCC = Hierarchical Condition Category; HCC CM RW = HCC Community Relative Weight; HCC IM RW = Institutional RW (i.e., nursing home); SOI = Severity of Illness; ROM = Risk of Mortality

ICD-10Code

Description

HCC

HCCCMRW

HCCINRW

MSDRGCC/MCC

APRDRG

SOI

APRDRGROM

F1020 Alcohol dependence, uncomplicated 55 0.420 0.053

1 1

F1021 Alcohol dependence, in remission 55 0.420 0.053

1 1

F10220 Alcohol dependence with intoxication,

uncomplicated 55 0.420 0.053

1 1

F10221 Alcohol dependence with intoxication

delirium 55 0.420 0.053 CC 3 2

F10229 Alcohol dependence with intoxication, unspecified

55 0.420 0.053

1 1

F10230 Alcohol dependence with withdrawal, uncomplicated

55 0.420 0.053 CC 1 1

F10231 Alcohol dependence with withdrawal delirium

54 0.420 0.053 CC 3 2

F10232 Alcohol dependence with withdrawal with perceptual disturbance

54 0.420 0.053 CC 1 1

F10239 Alcohol dependence with withdrawal,

unspecified 55 0.420 0.053 CC 1 1

F1024 Alcohol dependence with alcohol-induced

mood disorder 55 0.420 0.053 CC 1 1

F10250 Alcohol dependence with alcohol-induced

psychotic disorder with delusions 54 0.420 0.053

1 1

F10251 Alcohol dependence with alcohol-induced psychotic disorder with hallucinations

54 0.420 0.053 CC 1 1

F10259 Alcohol dependence with alcohol-induced

psychotic disorder, unspecified 54 0.420 0.053 CC 1 1

F1026 Alcohol dependence with alcohol-induced persisting amnestic disorder

54 0.420 0.053

2 1

F1027 Alcohol dependence with alcohol-induced persisting dementia

54 0.420 0.053 CC 2 2

F10280 Alcohol dependence with alcohol-induced anxiety disorder

55 0.420 0.053 CC 1 1

F10281 Alcohol dependence with alcohol-induced sexual dysfunction

55 0.420 0.053 CC 1 1

F10282 Alcohol dependence with alcohol-induced sleep disorder

55 0.420 0.053

1 1

F10288 Alcohol dependence with other alcohol-induced disorder

55 0.420 0.053 CC 1 1

F1029 Alcohol dependence with unspecified

alcohol-induced disorder 55 0.420 0.053 CC 2 1

Same for any

alcohol or

drug (e.g.,

cocaine,

marijuana,

nicotine, or

psychoactive)

use, abuse, or

dependency

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How Does This Impact Physicians?

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CMS’s Game Plan

What Physicians

Understand Now

What’s Relatively

New to Docs

What’s About To Hit Them

Medicare’s Ultimate Goal

Medicare Physician Value Based Modifier

2017 Implementation (2015 Data) Medicare Physician Value Based Modifier

Quality Composite Score

Low Average High

Co

st Low +0.0% +2.0%* +4.0%*

Average -2.0% +0.0% +2.0%*

High -4.0% -2.0% +0.0%

*Groups of physicians eligible for an additional +1.0x if reporting Physician Quality Reporting System quality measures and average beneficiary risk score is in the top 25% of all beneficiary risk scores.

• Cost calculation

• Total per capita costs for all attributed beneficiaries and those with

Diabetes

Coronary artery disease

Chronic obstructive pulmonary disease

Heart failure

Medicare Spending Per Beneficiary

Physician Quality and Cost Efficiency Distributions

• Low cost – 4.5%

• Average cost – 89.4%

• High cost – 6.2%

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Source: 2015 CMS Proposed Physician Rule

Physician Value-Based Payment Modifier

Quality and Cost Composite

35

https://portal.cms.gov

Physician Risk-Adjustment Observed vs. Expected Costs

Determine by Patient’s Characteristics

and Provider Care Quality Observed Costs Risk Adjusted Costs = ---------------------------------- Expected Costs

Determined by Documentation and Coding using ICD-9-CM

or ICD-10-CM/PCS

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Alcohol/Drug Use and Alcohol/Drug-Induced Organic Mental Disorders

• If the admission can be viewed as an poisoning, then poisoning codes prevail

37 Definitions and thresholds not well established: Influence, intoxication, toxicity?

ICD-10-CM: Episode of Care Trauma and Medication-related Events (only)

• Initial encounter: making the first diagnosis or receiving active treatment for an injury or illness. – Fx care: Emergency physician, orthopedist, radiologist, etc.

– Poisonings – initial treatment during the hospital stay

• Subsequent encounter: care during a period of healing or recovery. – Cast change, suture removal, etc.

– Poisonings – could be during a hospital stay or immediate visit

• Sequela: After the healing process is complete. – Fx care: Arthritis remotely after trauma, etc.

– Poisonings – If related to a long-standing consequence (e.g. anoxic encephalopathy from carbon monoxide poisoning

ICD-10-CM: Based on pt’s phase of healing, not physician’s encounter

ICD-10 Changes Poisonings

When coding a poisoning or reaction to the improper use of a medication (e.g., overdose, wrong substance given or taken in error, wrong route of administration)

• Add additional diagnoses for all manifestations of poisonings, such as: – Toxic encephalopathy

– Acute respiratory failure

– Unconsciousness • Codes to coma

– Many others

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ICD-10 Changes Medication Underdosing

• If a patient’s condition is due to underdosing of prescribed medications – Seizures due to

subtherapeutic medication level

– Hypothyroidism due to inadequate Synthroid compliance

– Hyperglycemia in diabetic due to inadequate insulin administration

• Further divided into: – Intentional, such as due to

financial hardship or willful noncompliance

– Unintentional, such as due to age-related debility or other defined reasons

Note:

• Currently does not influence DRGs

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Patient Noncompliance

While “Z-codes” or “external cause” codes are not required by CMS, they do add information useful in patient and provider profiling

Meditech 5.67

General Equivalence Mapping

This exercise will NOT capture new ICD-10 specificities Validate all mappings using ICD-10 Index, Table, and Guidelines

General Equivalence Mapping: Psychiatry

• This exercise will NOT capture new ICD-10 specificities • Validate all mappings using ICD-10 Index, Table, and Guidelines

GEM Phobias

Note the expansion of the phobia codes

GEM Anxiety, Conversion, and Factitious DO

GEM Schizophrenia

• Note that in ICD-10, the chronicity of schizophrenia is removed

GEM Schizophrenia

• Note that in ICD-10, the chronicity of schizophrenia is removed

Meditech 5.67

Psychiatry

Major depressive affective DO, recurrent

Major depressive DO, single

Obesity

Anxiety

Dementia w/ behavioral DO

Depressive D/O Single

29620 Major depressive affective disorder, single

episode, unspecified F329

Major depressive disorder, single episode,

unspecified

Approximate

match

29621 Major depressive affective disorder, single

episode, mild F320

Major depressive disorder, single episode,

mild Exact match

29622 Major depressive affective disorder, single

episode, moderate F321

Major depressive disorder, single episode,

moderate Exact match

29623

Major depressive affective disorder, single

episode, severe, without mention of

psychotic behavior

F322 Major depressive disorder, single episode,

severe without psychotic feature Exact match

29624

Major depressive affective disorder, single

episode, severe, specified as with

psychotic behavior

F323 Major depressive disorder, single episode,

severe with psychotic features

Approximate

match

29625

Major depressive affective disorder, single

episode, in partial or unspecified

remission

F324 Major depressive disorder, single episode, in

partial remission Exact match

29626 Major depressive affective disorder, single

episode, in full remission F325

Major depressive disorder, single episode, in

full remission Exact match

29620 Major depressive affective disorder, single

episode, unspecified F329

Major depressive disorder, single episode,

unspecified

Approximate

match

Depressive Disorder Recurrent

29630 Major depressive affective disorder, recurrent episode, unspecified

F3340 Major depressive disorder, recurrent, in remission, unspecified

Approximate match

29630 Major depressive affective disorder, recurrent episode, unspecified

F339 Major depressive disorder, recurrent, unspecified

Approximate match

29631 Major depressive affective disorder, recurrent episode, mild

F330 Major depressive disorder, recurrent, mild

Exact match

29632 Major depressive affective disorder, recurrent episode, moderate

F331 Major depressive disorder, recurrent, moderate

Exact match

29633

Major depressive affective disorder, recurrent episode, severe, without mention of psychotic behavior

F332 Major depressive disorder, recurrent severe without psychotic features

Exact match

29634

Major depressive affective disorder, recurrent episode, severe, specified as with psychotic behavior

F333 Major depressive disorder, recurrent, severe with psychotic symptoms

Approximate match

29635

Major depressive affective disorder, recurrent episode, in partial or unspecified remission

F3341 Major depressive disorder, recurrent, in partial remission

Exact match

29636 Major depressive affective disorder, recurrent episode, in full remission

F3342 Major depressive disorder, recurrent, in full remission

Exact match

Meditech 5.67

HCC Capture

Recurrent Depression

Mania

Mania in Remission

• Mania in full remission adds weight • Moderate and severe mania add inpatient med/surg weight

Meditech 5.67

Bipolar Disorders

Bipolar Disorders Less Specific Codes

Meditech 5.67

Risk-Adjustment

Dementia

Underlying Cause of Dementia

Underlying Cause of Dementia

Meditech 5.67

Dementia

• Added value for stating if there is behaviorial disturbance

Psychosis

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Delirium in DSM-5

Disturbance in attention (ie, reduced ability to direct, focus, sustain, and shift attention) and orientation to the environment; 1. Develops over a short period of time (usually hours to a few days) 2. Represents an acute change from baseline not solely attributable

to another neurocognitive disorder 3. Tends to fluctuate in severity during the course of a day 4. A change in an additional cognitive domain, such as memory

deficit, disorientation, or language disturbance, or perceptual disturbance that is not better accounted for by a preexisting, established, or evolving other neurocognitive disorder

5. Disturbances in No. 1 and 3 must not occur in the context of a severely reduced level of arousal, such as coma.

Delirium and Encephalopathy

• Delirium is a manifestation

• Encephalopathy is an underlying cause

– Delirium does not equal encephalopathy

– Encephalopathy does not equal delirium

“Delirium due encephalopathy of . . .”

MUSIC: “caused by,” “due to,” “resulting in”

Meditech 5.67

Toxic/Metabolic Encephalopathies Definitions

• Toxic and metabolic encephalopathies are a group of neurological disorders characterized by an altered mental status – A delirium, defined as a disturbance of consciousness characterized

by a reduced ability to focus, sustain, or shift attention that

– Cannot be accounted for by preexisting or evolving dementia and that is caused by the direct physiological consequences of a general medical condition.

• Confusion or delirium in Alzheimers would not be an encephalopathy

– Fluctuation of the signs and symptoms of the delirium over relatively short time periods is typical.

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Description HCC MS-DRG CC/MCC

APR-DRG SOI

APR-DRG ROM

Toxic/Metabolic Encephalopathy No relative weight MCC 3 3

Encephalopathy

• “Encephalopathy,” if no cause is documented, should always be queried.

• Looking for “encephalopathy due to . . .”

– i.e., “metabolic encephalopathy due to a sodium of 123 mEq/L”

– Admittedly, this trying to make simple, something that is not. It is very hard. There is no good literature on these definitions and thresholds.

Encephalopathy Multiple Options in ICD-10-CM

Encephalopathy (acute) G93.40 - acute necrotizing hemorrhagic G04.30 - - postimmunization G04.32 - - postinfectious G04.31 - - specified NEC G04.39 - alcoholic G31.2 - anoxic —see Damage, brain, anoxic - arteriosclerotic I67.2 - centrolobar progressive (Schilder) G37.0 - congenital Q07.9 - degenerative, in specified disease NEC G32.89 - demyelinating callosal G37.1 - due to - - drugs (see also Table of Drugs and Chemicals) G92 - hepatic —see Failure, hepatic - hyperbilirubinemic, newborn P57.9 - - due to isoimmunization (conditions in P55) P57.0 - hypertensive I67.4 - hypoglycemic E16.2 - hypoxic —see Damage, brain, anoxic - hypoxic ischemic P91.60 - - mild P91.61 - - moderate P91.62 - - severe P91.63

- in (due to) (with) - - birth injury P11.1 - - hyperinsulinism E16.1 [G94] - - influenza —see Influenza, with, encephalopathy - - lack of vitamin (see also Deficiency, vitamin) E56.9 [G32.89] - - neoplastic disease (see also Neoplasm) D49.9 [G13.1] - - serum (see also Reaction, serum) T80.69 - - syphilis A52.17 - - trauma (postconcussional) F07.81 - - - current injury —see Injury, intracranial - - vaccination G04.02 - lead —see Poisoning, lead - metabolic G93.41 - - drug induced G92 - - toxic G92 - myoclonic, early, symptomatic —see Epilepsy, generalized, specified NEC

- necrotizing, subacute (Leigh) G31.82

- pellagrous E52 [G32.89]

- portosystemic —see Failure, hepatic

- postcontusional F07.81

- - current injury —see Injury, intracranial, diffuse

- posthypoglycemic (coma) E16.1 [G94]

- postradiation G93.89

- saturnine —see Poisoning, lead

- septic G93.41

- specified NEC G93.49

- spongioform, subacute (viral) A81.09

- toxic G92

- - metabolic G92

- traumatic (postconcussional) F07.81

- - current injury —see Injury, intracranial

- vitamin B deficiency NEC E53.9 [G32.89]

- - vitamin B1 E51.2

- Wernicke's E51.2

76

Encephalopathy by itself must be queried for specificity Red = MCC

Delirium vs. Encephalopathy

• Delirium (manifestation) – Acute change or fluctuation

in mental status and inattention, accompanied by either disorganized thinking or an altered level of consciousness

• Encephalopathy (condition) – Global brain dysfunction

– CDIMD opinion: If the global brain dysfunction can be explained by an underlying condition or its exacerbation, then the term “encephalopathy” is integral to that condition

– Exacerbation of a neurodegenerative condition is NOT an encephalopathy

COMA DELIRIUM

Acute mental

status change Fluctuating

mental status

Inattention Disorganized

thinking

Altered level of

consciousness

Hallucinations

Delusions,

Illusions

Arousable to Voice

Unarousable

to Voice

77

Hypertensive Encephalopathy

• Hypertensive encephalopathy is the term applied to a relatively rapidly evolving syndrome of severe hypertension in association with headache, nausea and vomiting, visual disturbances, confusion, and—in advanced cases—stupor and coma – Multiple seizures are frequent and may be more marked on one side of the

body – Diffuse cerebral disturbance may be accompanied by focal or lateralizing

neurologic signs, either transitory or lasting, which should suggest cerebral hemorrhage or infarction, i.e., the more common cerebrovascular complications of severe chronic hypertension

– A clustering of multiple microinfarcts and petechial hemorrhages in one region may occasionally result in a mild hemiparesis, aphasic disorder, or rapid failure of vision

• Special characteristics of signal changes in the occipital white matter may occur – The terms reversible posterior leukoencephalopathy (RPLE) and posterior or

reversible leukoencephalopathy syndrome (PRES)

Source: Adams and Victor's Principles of Neurology, 9th Edition, 2009 78

Hepatic Encephalopathy

• A wide array of transient and reversible neurologic and psychiatric manifestations usually found in patients with chronic liver disease and portal hypertension, but also seen in patients with acute liver failure – Occurs in 50%–70% of patients

with cirrhosis

• Treatment options – Diet – low protein – Medications – lactulose, neomycin,

rifaximin, probiotics

• Serves as a reason for admission – Only an MCC if with coma

Grade Impairment

Intellectual function Neuromuscular function

0 Normal Normal

Minimal, subclinical

Normal examination findings. Subtle changes in work or driving.

Minor abnormalities of visual perception or on psychometric or number tests

1 Personality changes, attention deficits, irritability, depressed state

Tremor and incoordination

2 Changes in sleep-wake cycle, lethargy, mood and behavioral changes, cognitive dysfunction

Asterixis, ataxic gait, speech abnormalities (slow and slurred)

3 Altered level of consciousness (somnolence), confusion, disorientation, and amnesia

Muscular rigidity, nystagmus, clonus, Babinski sign, hyporeflexia

4 Stupor and coma Oculocephalic reflex, unresponsiveness to noxious stimuli

79

Mental Diseases and Disorders Inpatient Med-Surg

MS-DRG MS-DRG title Weights 876 O.R. PROCEDURE W PRINCIPAL DIAGNOSES OF MENTAL ILLNESS 2.8172

880 ACUTE ADJUSTMENT REACTION & PSYCHOSOCIAL DYSFUNCTION 0.6388 881 DEPRESSIVE NEUROSES 0.6541

882 NEUROSES EXCEPT DEPRESSIVE 0.6953 883 DISORDERS OF PERSONALITY & IMPULSE CONTROL 1.2682

884 ORGANIC DISTURBANCES & MENTAL RETARDATION 1.0060

885 PSYCHOSES 1.0048

886 BEHAVIORAL & DEVELOPMENTAL DISORDERS 0.9173

887 OTHER MENTAL DISORDER DIAGNOSES 0.9795

• Consists primarily of psychological symptoms as the PDx

• Alternatives are:

– Explicitly described brain diseases (e.g., Alzheimer’s disease)

– Psychoactive drug use, abuse, or dependency (see MDC 20)

– Drug poisoning (see MDC 21)

80

Medicare Psychiatric IPPS Determinants

• Principal Diagnosis

• Secondary Diagnosis

• Geographic Location

– Urban vs. Rural

• Emergency Department Availability

– Yes or No

• ECT given

– Yes or No

• Presence of an Emergency Room

• Teaching Status

• Wage Factors

• Cost of Living

Each of these have a multiplier that determines the per-diem reimbursement

Inpatient Prospective Payment Adjustment Federal Payment

Patient Age Patient is between 45 and 50 1.01 $11,207.93

Principal Diagnosis

DRG 895: Alcohol/drug abuse or

dependence with rehabilitation

therapy 1.02

(select as many comorbidities that apply below) Federal Payment with Outliers

Comorbidity Chronic Obstructed Pulmonary Disease 1.12 $11,207.93

Comorbidity Tracheostomy 1.06Comorbidity Uncontrolled Diabetes Mellitus with or without complications1.05 Federal Portion (Blended)

Comorbidity Renal Failure, Chronic 1.11 $11,207.93

Comorbidity (blank) 1.00 (Transition Complete)

Length of Stay (days) 10 1.00

If LOS greater than 21 days, enter # of

days:

Geographic Location Rural 1.17

Emergency Department No Emergency Department 1.19

Teaching Adj. 1.00

Wage Area Colorado 0.9704

Cost of Living Adjustment (COLA) Rest of U.S. 1.00

Electroconvulsive Therapy (ECT) 1 $268

Blend Year Complete 1.00

Federal Per Diem Base Rate $637.78

Inpatient Psychiatric Facility PPS Calculator RY 2009 with MS-DRGs

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056 Degenerative nervous system disorders w MCC 1.05

057 Degenerative nervous system disorders w/o MCC 1.05

080 Nontraumatic stupor & coma w MCC 1.07

081 Nontraumatic stupor & coma w/o MCC 1.07

876 O.R. procedure w principal diagnoses of mental illness 1.22

880 Acute adjustment reaction & psychosocial dysfunction 1.05

881 Depressive neuroses 0.99

882 Neuroses except depressive 1.02

883 Disorders of personality & impulse control 1.02

884 Organic disturbances & mental retardation 1.03

885 Psychoses 1.00

886 Behavioral & developmental disorders 0.99

887 Other mental disorder diagnoses 0.92

894 Alcohol/drug abuse or dependence, left AMA 0.97

895 Alcohol/drug abuse or dependence w rehabilitation 1.02

896

Alcohol/drug abuse or dependence w/o rehabilitation

therapy w MCC 0.88

897

Alcohol/drug abuse or dependence w/o rehabilitation

therapy w/o MCC 0.88

Secondary Diagnoses

Secondary Diagnosis

May 2012 Game Changer Source:

Source: http://www.tinyurl.com/2012ASPENmalnutrition

86

Source: White J V et al., JPEN J Parenter Enteral Nutr, 2012;36:275-283

Adult Malnutrition Circumstance Based

87

Adult Malnutrition Criteria

• Acute vs. chronic illness

• Severe vs. non-severe disease

• Albumin/prealbumin don’t matter http://tinyurl.com/2012malnutrition

88

Why Not Albumin/Visceral Proteins?

• Acute Phase Response – Inflammatory disease, illness, injury illicit cytokine-mediated response – Interleukin-1 (IL-1), interleukin-6 (IL-6), tumor necrosis factor (TNF) – Alter hormone secretion and target organ function – Favor a catabolic state

• Acute Phase Metabolic Response – Elevation of resting energy expenditure – Export of amino acids from muscle to liver – Increase in gluconeogenesis – Expansion of extracellular fluid – Shift towards production of positive acute phase reactants, i.e., CRP

89

Source: New Characteristics and Criteria to Define Adult Malnutrition, ASPEN Clinical Nutrition Webinar, Jane V. White, PhD, RD

Including Malnutrition Codes Impacts the DRG

90

% of DRGs with malnutrition adding a CC % of DRGS with severe malnutrition adding an MCC Source: ProviderPrecise (consortium of Falcon Consulting & CDIMD)

Inpatient Prospective Payment Adjustment Federal Payment

Patient Age Patient is between 45 and 50 1.01 $11,207.93

Principal Diagnosis

DRG 895: Alcohol/drug abuse or

dependence with rehabilitation

therapy 1.02

(select as many comorbidities that apply below) Federal Payment with Outliers

Comorbidity Chronic Obstructed Pulmonary Disease 1.12 $11,207.93

Comorbidity Tracheostomy 1.06Comorbidity Uncontrolled Diabetes Mellitus with or without complications1.05 Federal Portion (Blended)

Comorbidity Renal Failure, Chronic 1.11 $11,207.93

Comorbidity (blank) 1.00 (Transition Complete)

Length of Stay (days) 10 1.00

If LOS greater than 21 days, enter # of

days:

Geographic Location Rural 1.17

Emergency Department No Emergency Department 1.19

Teaching Adj. 1.00

Wage Area Colorado 0.9704

Cost of Living Adjustment (COLA) Rest of U.S. 1.00

Electroconvulsive Therapy (ECT) 1 $268

Blend Year Complete 1.00

Federal Per Diem Base Rate $637.78

Inpatient Psychiatric Facility PPS Calculator RY 2009 with MS-DRGs

After making selections (above), scroll down for payment calculation information.

Note: This calculator is for estimation purposes only.

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