The Impact of Physician and ICD-10

Terminology On ObamaCare Initiatives

July, 2015

James S. Kennedy, MD, CCS

1

Disclaimer The materials utilized in this presentation are intended solely for use in

conjunction with today’s seminar. Although great efforts have been taken in the preparation of today’s

material, the speaker and his employer does not assume responsibility for errors or omissions or for damages resulting from the use of the information contained therein.

Advice is general, thus participants should consult professional counsel for specific legal, ethical, technical and clinical questions prior to claim submission.

This lecture was prepared with information that was publicly available on April 1, 2015

ICD-9-CM, ICD-10 and MS-DRGs are constantly evolving. Please consult official guidance prior to code preparation or submission.

2

Speaker Information

• James S. Kennedy MD CCS President, CDIMD Engaged in Clinical Documentation and Coding Integrity (CDCI)

physician/CDS/coder education, training, and process development • Education and Certifications Medical School – UT Memphis, 1979 Board Certified – Internal Medicine, 1983 AHIMA CCS Certification – 2001 • Publications

– 2007 – AHIMA – Severity Adjusted DRGs, an MS-DRG Primer – 2009 – ACDIS – Physician Query Handbook – Ongoing – “Minute for the Medical Staff” in HcPRO’s Medical Records Briefings – Ongoing – “Coding Clinic Update” – HcPRO’s CDI Journal (ACDIS)

• Contact (615) 479-7021 – Cellular jkennedy@cdimd.com

3

Objectives • Have a firm understanding of how CMS and the state of

California evaluate physician/hospital quality

• Know the differences between the CDC’s ICD-9-CM and ICD-10-CM/PCS terminology

• Master challenging definitions impacting severity and risk adjustment

• Devise a plan to assure the integrity of their ICD-10-CM/PCS data measuring patient outcomes

4

Like the Phone Book Interesting Characters – Terrible Plot

Dictionary without

Definitions

Dictionary w/o Definitions

Note that clinical terms are assigned numbers which, if submitted, labels the patient with that condition

ICD-10 Implementation Date October 1, 2015 - Tentative

7

Diagnoses Procedures

ICD-10-CM (Clinical Modification)

All entities - providers and facilities for diagnoses 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!!

Morbidity Uses Varying Implementation Throughout the World

The US is one of the last industrialized country to

adopt ICD-10 for clinical use

US Modifications – ICD-10-CM and 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

9

ICD-10-CM/PCS 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 that are abstracted by a data analyst (e.g. like STS, NCDR, or ATS databases) – The provider must use the magic words that drive ICD-10-

CM/PCS code assignment based upon patient circumstances

10

ICD-10 Physician Revenue Cycle Impact

• Ancillary claim payment

– “Medical necessity” is currently based on an ICD-9-CM

• ICD-10 codes after October 1, 2014

– Payers typically release diagnosis codes supporting “medical necessity” through provider bulletins

• ICD-10 Payer Transition

– Starts with the CMS General Equivalence Mappings

– Additional modifications added according to their policies

– Results often published on the web or in their bulletins

• Hard to find

CMS National Coverage Determinations Home PT Monitoring

• Note that codes for secondary hypercoagulable states are not included.

http://tinyurl.com/CMSICD10LCDs

http://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD-10-guidance.pdf

“Family of Codes”

• “Family of codes” is the same as the ICD-10 three-character category. – Codes within a category are clinically related and provide

differences in capturing specific information on the type of condition.

– For instance, category H25 (Age-related cataract) contains a number of specific codes that capture information on the type of cataract as well as information on the eye involved.

• Examples include: H25.031 (Anterior subcapsular polar age-related cataract, right eye), which has six characters; H25.22 (Age-related cataract, morgagnian type, left eye), which has five characters; and H25.9 (Unspecified age-related cataract), which has four characters.

• One must report a valid code and not a category number. In many instances, the code will require more than 3 characters in order to be valid.

Medi-Cal ICD-10 Medical Necessity - Crosswalk

• Medi-Cal implementation of ICD-10 – Medi-Cal will be using a crosswalk solution in the legacy

California Medicaid Management Information System (CA-MMIS).

• Medi-Cal has mapped all ICD-10 codes to corresponding ICD-9 codes by starting with the General Equivalence Mappings (GEMs) provided by the Centers for Medicare & Medicaid Services (CMS) and modifying the mappings to align with existing Medi-Cal policy.

• Claims will be run against the crosswalk to determine the ICD-9 value to process through the system.

• Will an ICD-10 to ICD-9 crosswalk be published? – Medi-Cal will not publish the crosswalk. – However, the provider manuals will be updated with the

ICD-10 codes as appropriate.

Mapping Tool http://tinyurl.com/I9toI10crosswalk

Note how ICD-10-CM combined benign, malignant, and unspecified HTN into one code, I10 - HTN

Potential Problems with GEMS:

• A single ICD-9-CM code may now be represented by multiple ICD-10-CM codes • One to many

• Multiple ICD-9-CM codes may map to only one ICD-10 code • Many to one

• An ICD-10 code cannot be arbitrarily chosen from the GEM • A code may not represent the complexity of the illness (e.g. unspecified

code) – this could result in underpayments • A code may overstate the complexity of the illness – this could result in

audits and retrospective recovery of payments

ALWAYS VERIFY CODES IN THE ICD-10-CM BOOK PRIOR TO CLAIM SUBMISSION. DO NOT RELY ON ANY GEM TOOL ALONE

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StJHS’s ICD-10 Strategy - CDI

Physician

CDI Team

ICD-10 Coder

What’s Old? ICD-9-CM

19

What’s New ICD-10-CM

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ICD-9-CM and ICD-10-CM/PCS

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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Overall Changes

• 34,250 (50%) are related to the musculoskeletal system

• 17,045 (25%) 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’

Differences from ICD-9-CM to ICD-10-CM

ICD-9-CM

Diagnosis Codes ICD-10-CM

Diagnosis Codes

Laterality No Laterality

Laterality –

Right or Left account for 35-40% of codes

Code Construction

3-5 digits 7 digits

First digit is alpha (E or V) or numeric

Digit 1 is alpha; Digit 2 is numeric

Digits 2-5 are numeric Digits 3–7 are alpha or numeric

Decimal is placed after the third character

Decimal is placed after the third character

Placeholders No placeholder characters “X” placeholders

# of Codes 14,000 codes 69,000 codes

Severity Limited Severity Parameters Extensive Severity Parameters

Combination Limited Combination Codes Extensive Combination Codes

Excludes Notes

1 type of Excludes Notes 2 types of Excludes Notes

Clinical Changes Expansions and Deletions

• Marked expansion of codes – Trauma, overdoses, or complications

treatment phases – Office encounters – Asthma – Diabetes mellitus – Obstetrics (trimesters) – Non-pressure ulcer staging – Myocardial infarction timing and vessel

involvement – Open fractures staging – Cerebral hemorrhage location – Ischemic stroke vessel involvement – Coma (Glasgow Coma Scale) – Atrial flutter and fibrillation – Drug underdosing

• Deletion of MD language, such as: – Urosepsis

• Must say “sepsis due to UTI”

– SIRS due to infection • Must say “sepsis” or

“severe sepsis”

– Accelerated or malignant hypertension

• Must describe the organ dysfunction caused by hypertension to measure severity

MD progress notes and DC summaries must use ICD-10-CM’s language (Index or Table) as to defend the assigned code

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 Combination Codes with Hematuria

General Equivalence Mapping Priapism and Impotence

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

General Equivalence Mapping Other Specified Disorders

Clinical Changes Expansions and Deletions

• Marked expansion of codes – Trauma, overdoses, or complications

treatment phases – Office encounters – Asthma – Diabetes mellitus – Obstetrics (trimesters) – Non-pressure ulcer staging – Myocardial infarction timing and vessel

involvement – Open fractures staging – Cerebral hemorrhage location – Ischemic stroke vessel involvement – Coma (Glasgow Coma Scale) – Atrial flutter and fibrillation – Drug underdosing

• Deletion of MD language, such as: – Urosepsis

• Must say “sepsis due to UTI”

– SIRS due to infection • Must say “sepsis” or

“severe sepsis”

– Accelerated or malignant hypertension

• Must describe the organ dysfunction caused by hypertension to measure severity

MD progress notes and DC summaries must use ICD-10-CM’s language (Index or Table) as to defend the assigned code

New Specificity in ICD-10-CM ICD9 ICD9 Title ICD10 ICD-10 Title Mapping Theory

0723 Mumps pancreatitis B263 Mumps pancreatitis Exact match

5770 Acute pancreatitis B252 Cytomegaloviral pancreatitis I10 combines 2 or more I9 codes

5770 Acute pancreatitis K850 Idiopathic acute pancreatitis Approximate match

5770 Acute pancreatitis K851 Biliary acute pancreatitis Approximate match

5770 Acute pancreatitis K852 Alcohol induced acute pancreatitis

Approximate match

5770 Acute pancreatitis K853 Drug induced acute pancreatitis

Approximate match

5770 Acute pancreatitis K858 Other acute pancreatitis Approximate match

5770 Acute pancreatitis K859 Acute pancreatitis, unspecified

Approximate match

5771 Chronic pancreatitis K860 Alcohol-induced chronic pancreatitis

Approximate match

5771 Chronic pancreatitis K861 Other chronic pancreatitis Approximate match

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ICD-10-CM, the term “hyperbilirubinemia” does not code to jaundice

The physician must say “jaundice”

Meditech 5.67

Code for Acute Pancreatitis Does Not Account for Necrosis

• SIRS with or without organ dysfunction due to pancreatitis does

« Note the SIRS criteria

1992 Definition of SIRS 2 out of 4

1. Body temperature >38°C or <36°C

2. Heart rate >90/minute

3. Respiratory rate >20/minute or PaCO2 lower than 32 mmHg

4. White blood cell count >12,000 /μL or <4,000/μL

Sepsis vs. SIRS ICD-9-CM vs. ICD-10-CM Table of Diseases

ICD-9-CM SIRS (systemic inflammatory response syndrome) 995.90

due to infectious process 995.91

with acute organ dysfunction 995.92

non-infectious process 995.93

with acute organ dysfunction 995.94

ICD-10-CM Syndrome, systemic inflammatory response

NO CODE FOR SIRS DUE TO INFECTION (aka sepsis) or SEPSIS SYNDROME

of non-infectious origin (without organ dysfunction) R65.10

-- with acute organ dysfunction R65.11

PHYSICIAN MUST SAY “SEPSIS”, NOT “SIRS due to INFECTION”,

TO GET “SEPSIS” IN ICD-10

X

Sepsis in Meditech 5.67

ICD-9-CM vs. ICD-10-CM Appendicitis with peritonitis

ICD-9-CM • 540.0 With generalized peritonitis

– Appendicitis (acute) with: perforation, peritonitis (generalized), rupture:

• fulminating • gangrenous • obstructive • Cecitis (acute) with: perforation, peritonitis

(generalized), rupture • Rupture of appendix

– Excludes: acute appendicitis with peritoneal abscess (540.1)

• 540.1 With peritoneal abscess – Abscess of appendix

• With generalized peritonitis

• 540.9 Without mention of peritonitis – Acute:

• appendicitis without mention of perforation, peritonitis, or rupture:

• Fulminating • gangrenous • inflamed • obstructive

– cecitis without mention of perforation, peritonitis, or rupture

ICD-10-CM • K35.2 Acute appendicitis with generalized

peritonitis – Appendicitis (acute) with generalized (diffuse)

peritonitis following rupture or perforation of appenix

– Perforated appendix NOS – Ruptured appendix NOS

• K35.3 Acute appendicitis with localized peritonitis

– Acute appendicitis with or without perforation or rupture NOS

– Acute appendicitis with or without perforation or rupture with localized peritonitis

– Acute appendicitis with peritoneal abscess

• K35.8 Other and unspecified acute appendicitis

– K35.80 Unspecified acute appendicitis • Acute appendicitis NOS • Acute appendicitis without (localized)

(generalized) peritonitis

– K35.89 Other acute appendicitis

Appendicitis in Meditech 5.67

APR-DRG Relative Weights Appendicitis with Appendectomy

Appendicitis with Appendectomy

2.58

1.75

1.02

0.75

0

Appendicitis with focal peritonitis

Sepsis with focal or generalized peritonitis

Severe Sepsis with generalized peritonitis

Higher depending on the organ dysfunction

2012 Diagnostic Criteria for Sepsis Infection, documented or suspected & “some” of the following:

• General variables – Fever (> 38.3°C or 101°F) – Hypothermia (core temperature < 36°C) – Heart rate > 90/min or more than two SD

above the normal value for age – Tachypnea – Altered mental status – Significant edema or positive fluid balance

(> 20 mL/kg over 24 hr) – Hyperglycemia (plasma glucose > 140

mg/dL or 7.7 mmol/L) in the absence of diabetes

• Inflammatory variables – Leukocytosis (WBC count > 12,000/μL) – Leukopenia (WBC count < 4000/μL) – Normal WBC count with greater than 10%

immature forms – Plasma C-reactive protein > two or SD

above the normal value – Plasma procalcitonin > two or SD above

the normal value

• Hemodynamic variables – Arterial hypotension (SBP < 90 mm Hg,

MAP < 70 mm Hg, or an SBP decrease >40 mm Hg in adults or less than two SD below normal for age)

• Organ dysfunction variables – Arterial hypoxemia (Pao2/Fio2 < 300) – Acute oliguria (urine output < 0.5

mL/kg/hr for at least 2 hrs despite adequate fluid resuscitation)

– Creatinine increase > 0.5 mg/dL or 44.2 μmol/L

– Coagulation abnormalities (INR > 1.5 or aPTT > 60 s)

– Ileus (absent bowel sounds) – Thrombocytopenia (platelet count <

100,000/μL) – Hyperbilirubinemia (plasma total bilirubin

> 4 mg/dL or 70 μmol/L) – Tissue perfusion variables – Hyperlactatemia (> 1 mmol/L) – Decreased capillary refill or mottling

Source: http://www.sccm.org/Documents/SSC-Guidelines.pdf

2005 Clinical Indicators of Sepsis in Pediatrics

Sepsis vs. SIRS ICD-9-CM vs. ICD-10-CM Table of Diseases

ICD-9-CM SIRS (systemic inflammatory response syndrome) 995.90

due to infectious process 995.91

with acute organ dysfunction 995.92

non-infectious process 995.93

with acute organ dysfunction 995.94

ICD-10-CM Syndrome, systemic inflammatory response

NO CODE FOR SIRS DUE TO INFECTION (aka sepsis) or SEPSIS SYNDROME

of non-infectious origin (without organ dysfunction) R65.10

-- with acute organ dysfunction R65.11

PHYSICIAN MUST SAY “SEPSIS”, NOT “SIRS due to INFECTION”,

TO GET “SEPSIS” IN ICD-10

X

New in ICD-10-CM Chronic Non-Pressure Ulcer Codes

• Requires dynamic staging much like pressure ulcers – Different methodology – Note if present on admission

L97111 Non-pressure chronic ulcer of right thigh limited to breakdown of skin

L97112 Non-pressure chronic ulcer of right thigh with fat layer exposed

L97113 Non-pressure chronic ulcer of right thigh with necrosis of muscle

L97114 Non-pressure chronic ulcer of right thigh with necrosis of bone

L97119 Non-pressure chronic ulcer of right thigh with unspecified severity

ICD-10-PCS Debridement

DRG Impact Wound Debridement

Documentation DRG DRG Name RW Reimbursement

Pressure ulcer with excision or debridement

592 (w/MCC) Skin Ulcers

1.4249 $11,399

593 (w/CC) 1.0196 $8,156

Pressure ulcer with excisional skin debridement

570 (w/MCC) Skin Debridement

2.3952 $19,162

571 (w/CC) 1.4664 $11,731

Excisional debridement of subcutaneous tissue or fascia, or muscle

579 (w/MCC) Other Subcutaneous Procedures

2.7263 $21,810

580 (w/CC) 1.5727 $12,582

Excisional debridement of (not to) bone

981 (w/MCC) Procedure unrelated to PDx

4.9968 $39,974

982 (w/CC) 2.8150 $22,520

Surgeons must document BOTH the words “excisional”

and “debridement” to get the higher weighted DRGs

Wound Debridement ICD-10 Requirements

• If the word “debridement” is used, indicate – If it is excisional, non-excisional, or

the removal of a foreign body

– The instrument used • Scissors, scalpel, VersaJet, cautery, wire,

curette, irrigation, whirlpool, etc.

– The type of tissue excised • Skin, subcutaneous area, fascia, tendon,

muscle, bone, joint

– The anatomic location

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Breast Surgery

• A 40 yo lady with a proportionally large left breast “mass” with calcifications on mammography presents for surgery. – An open biopsy indicates high-grade carcinoma

without clear margins, thus a complete mastectomy with a “sentinel node” biopsy was performed.

– Frozen section of the lymph node shows cancer, thus further axillary lymph node “dissection” was carried out.

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Need for Nature and Anatomic Location of the Breast Tumor

• “Mass” is NOT a neoplasm or tumor – Physician must say

“tumor” or “neoplasm” – For inpatients, cannot

take information from the pathology reports

• Need the anatomic location of the tumor – Often, the location is on

an outpatient document that is not available to the hospital

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Must code the

laterality or

else the claim

can be denied

Lymph Node Biopsy & “Dissection”

• No code in ICD-10 for “dissection”

• Was the lymph node biopsy diagnostic or therapeutic?

• Excision or resection? – All of the axillary lymph

nodes - resection? • Radical = resection

– Some of the axillary lymph nodes - excision?

• Sampling = excision

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Axillary Lymph Nodes

50

Source: Public Domain

http://tinyurl.com/86ndkex

• Vary from 20-30 – Brachial (or "lateral") – Pectoral (or "anterior") – Subscapular (or

"posterior") – Central – Apical (or "medial" or

"subclavicular")

• Was it the provider’s intent to remove some or all of the lymph nodes? – ICD-10-CM coding rules

allow for the word “radical” to mean “all of the tissue” within a certain area

Amputations Need for Exact Operative Anatomy • Lower Body (include laterality)

– Hindquarter – Femoral Region – Knee Region – Upper/Lower Leg

• High (proximal) • Mid (mid portion) • Low (distal)

– Foot • Complete or partial

ray(s)/metatarsal(s)

– Toe • High (proximal phalanx) • Mid (PIP joint or middle phalanx) • Low (DIP joint or distal phalanx)

• Upper Body (include laterality) – Forequarter – Shoulder Region – Elbow Region – Upper/Lower Arm

• High (proximal) • Mid (mid portion) • Low (distal)

– Hand • Complete or partial

ray(s)/metacarpal(s)

– Thumb/Finger • High (proximal phalanx) • Mid (PIP joint or middle phalanx) • Low (DIP joint or distal phalanx)

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Cleft Palate Repair

• Palate description

– Hard/Soft/Both

• Bilateral/Unilateral

• Complete/Incomplete

• With/without Cleft Lip Involvement

– If Cleft Lip involvement—Bilateral/Unilateral

52

Omentum

• Any operation on the omentum requires that the physician document “greater omentum” or “lesser omentum” – ICD-10 does not

allow for “omentum” alone

53

Need for Exact Operative Anatomy

Coders need to know what biliary, GI,

circulatory, or other anatomy is partially

or completely removed, divided,

transferred, or inspected

ICD-10-PCS Lysis of Postoperative Adhesions

• 15-20% of open heart procedures commonly have adhesions – Almost 100% of

reoperations

• Requires a tedious lysis of adhesions, typically lasting around an hour, to reach the operative site

• Incidental injuries are common

• How do we handle this in ICD-10-PCS?

Coding Clinic (ICD-10), 1st Q, 2014, p.4 Lysis of Adhesions

• Carefully review the entire operative report (and not just the title) to determine the clinical significance of the adhesions and the complexity of the lysis of adhesions. – Coders should not code adhesions and lysis thereof, based solely on mention

of adhesions or lysis in an operative report. – Determination as to whether the adhesions and the lysis are significant

enough to code and report must be made by the surgeon.

• If obstruction is not present but a strong band prevents the surgeon from access to the organ (being removed), requiring lysis before the operation can proceed, then – Both the diagnosis of adhesions and the lysis procedure should be coded,

unless instructional notes in the Alphabetical Index, Tabular List, or guidelines preclude the separate coding.

• If adhesions exist without causing any symptoms in the patient or increasing the difficulty of performing the operative procedure. then – Coding a diagnosis of adhesions and the procedure of lysis of adhesions is

inappropriate.

Exact Body Part Being Released

57

While there are options for

unspecified parts of the

esophagus, stomach, small

intestine and large intestine…

ICD-10-PCS does have

specificity for which part of

these organs is being released

Other structures

can be freed as

well, including:

• Gallbladder

• Peritoneum

• Kidney

• Ureter

• Uterus

• Fallopian Tube

• Others

Lysis of Cardiac Adhesions Anatomy Requirements in the Table

Unlike the gut, there

is no option for lysis

of adhesions

surrounding the

heart

DRG Consequences Lysis of Cardiac Adhesions w/CABG

CABG with no documentation of extensive lysis of adhesions • PDX - I25.110 - ASHD of

native coronary artery with unstable angina pectoris

• PProc – 021009W – for the CABG

MS-DRG 236 – Coronary Bypass w/o Cardiac Cath w/o MCC – 3.7777 NOTE: Also the resultant MS-DRG if only the pericardium is being released

CABG with documentation of extensive lysis of adhesions adherent to the heart

• PDX - I25.110 - Atherosclerotic heart disease of native coronary artery with unstable angina pectoris

• SDx – I31.0 – Chronic adhesive pericarditis

• PProc – 021009W for the CABG

• SProc – Adhesiolysis

– 4 code options - 02N(6,7,K,L)0ZZ

– Codeable only if the surgeon describes the exact HEART anatomy being released

MS-DRG 229 – Other Cardiothoracic Procedures with CC – 4.4606

Expected costs CV Surgery

60

MS-DRG MDC MS-DRG Title Weights Payment

216 05 CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W CARD CATH W MCC 9.5238 $76,190

217 05 CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W CARD CATH W CC 6.3291 $50,633

218 05 CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W CARD CATH W/O CC/MCC 5.5693 $44,554

219 05 CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W MCC 7.7067 $61,654

220 05 CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W CC 5.2056 $41,645

221 05 CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD CATH W/O CC/MCC 4.6347 $37,078

231 05 CORONARY BYPASS W PTCA W MCC 7.7247 $61,798

232 05 CORONARY BYPASS W PTCA W/O MCC 5.5976 $44,781 233 05 CORONARY BYPASS W CARDIAC CATH W MCC 7.3493 $58,794

234 05 CORONARY BYPASS W CARDIAC CATH W/O MCC 4.8816 $39,053 235 05 CORONARY BYPASS W/O CARDIAC CATH W MCC 5.7089 $45,671

236 05 CORONARY BYPASS W/O CARDIAC CATH W/O MCC 3.7952 $30,362 237 05 MAJOR CARDIOVASC PROCEDURES W MCC 5.0843 $40,674 238 05 MAJOR CARDIOVASC PROCEDURES W/O MCC 3.4241 $27,393

Medicare-Severity DRGs PDx, CCs and MCCs

• CC = Complications and comorbidities – Moderate resource

consumption increase, averaging • Medicine – $2,400 • Surgery – $6,000

• MCC = Major CCs – Major resource consumption

increase, averaging • Medicine – $4,800 • Surgery – $13,000

CC and MCC definers

√ Significant acute disease (e.g., AMI, stroke, acute respiratory

failure, acute renal failure, pneumonia, septicemia)

√ Acute exacerbations of significant chronic diseases

(e.g., acute systolic heart failure) √ Advanced or end-stage chronic

diseases (e.g., AIDS (not positive HIV), stage IV,

V chronic kidney disease or end-stage renal disease)

√ Chronic diseases associated with extensive debility

(e.g., functional quadriplegia)

http://www.cms.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html

MS-DRG CC/MCC Table

Not a CC CC MCC

AMS or acute delirium

Unresponsive

Delirium due to a

“medical condition” or

postprocedural state

Toxic or metabolic

encephalopathy

Unconscious or coma

Oxygen dependency

Chronic

respiratory failure

Acute on chronic

respiratory failure

Cystitis

Urosepsis (no code)

UTI or acute cystitis

Bacteremia Sepsis due to UTI

CAD

Stable angina

Demand ischemia

AS of CABG graft

NSTEMI

STEMI

HFpEF

HFrEF

Systolic CHF

Diastolic CHF

Acute systolic CHF

Acute diastolic CHF

Systolic and Diastolic Heart Failure

• As above, not codeable in ICD-9-CM as diastolic or systolic HF • Physician must state “diastolic” or “systolic” or both to get CC or

MCC

63

Heart Failure in Meditech 5.67

Hypoxemia and Hypercapnia Respiratory Insufficiency/Failure

Always list the underlying cause, such as

status asthmaticus, drug overdose, CHF

Entity MS-DRG

Hypoxemia No CC

Hypercapnia No CC

Respiratory insufficiency or distress

No CC

Acute respiratory insufficiency or distress

Not a CC

Acute resp. failure MCC

Chronic resp. failure CC

Respiratory Failure in Meditech 5.67

MS-DRG CC/MCC Table

Not a CC CC MCC

Diabetes Mellitus

Uncontrolled -

Hyperosmolar state

DKA

Blood loss anemia

Acute blood loss

anemia

Toxic anemia

(x chemotherapy)

+ HIV AIDS or +HIV with

previous Hx of AIDS

Ranson’s criteria

(w/pancreatitis)

SIRS

(due to pancreatitis)

SIRS w/organ

dysfunction

Stool with

+ occult blood GI bleeding

GI bleeding from

defined site

(e.g., PUD)

68

Acute Blood Loss Anemia (not ↓ Hct)

• “Acute blood loss anemia” - CC • Major Bleeding Definition

– Clinically overt – Associated with a fall of the hemoglobin level of 2.0 g/dL (e.g. Hct

drop of 6) or required transfusion of at least 2 units of red cells, or involved a critical organ or was fatal

MS-DRG MS-DRG Title Weights Payment 377 G.I. HEMORRHAGE W MCC 1.7775 $14,220 378 G.I. HEMORRHAGE W CC (e.g. acute blood loss anemia) 1.0021 $8,017

379 G.I. HEMORRHAGE W/O CC/MCC 0.6776 $5,421

+HIV (not reportable in CA) vs. HIV Disease (MCC)

• +HIV (no code)

– Includes HIV-infected individual who never had exhibited symptoms

– Based on documentation of +HIV only

• HIV-disease (MCC)

– Currently having acute HIV symptoms

– + HIV with previous HIV-related symptoms

– + HIV with current or previous HIV-related disease

– Current AIDS or previous history of AIDS

69

Must Be Documented on Each Admission

MS-DRG CC/MCC Table

Not a CC CC MCC

Acute renal

insufficiency

Toxic nephropathy

Acute renal failure

Acute kidney injury

Acute tubular necrosis

Acute cortical necrosis

CRI or CKD CKD Stage 4 or 5 ESRD

Chronic/persistent

atrial fibrillation

Persistent

atrial fibrillation

Acute systolic/diastolic

HF due to rapid afib

Past Hx of multiple

DVT on warfarin

Hypercoagulable

state -

Peripheral neuropathy Autonomic peripheral

neuropathy -

Underweight with

anorexia

Cachexia

Malnutrition Severe malnutrition

MDC 5 – DVTs With Hypercoagulable State

MS-DRG MS-DRG title Weights

294 DEEP VEIN THROMBOPHLEBITIS W CC/MCC 1.0373

295 DEEP VEIN THROMBOPHLEBITIS W/O CC/MCC 0.6403

• Primary hypercoagulable states (CC) Initial Recurrent

– Factor V Leiden – 12%–20% / 40%–50%

– Protein C def – 2%–5% / 5%–10%

– Protein S def – 1%–3% / 5%–10%

– AT3 deficiency – 1%–2% / 2%– 5%

• Secondary hypercoagulable states (CC) – Active cancer, chemotherapy (L-asparaginase, thalidomide,

anti-angiogenesis therapy), myeloproliferative disorders, HIT, nephrotic syndrome, intravascular coagulation and fibrinolysis/DIC, TTP, sickle cell disease, oral contraceptives or estrogen, pregnancy/postpartum state, selective estrogen receptor modulator therapy (tamoxifen and raloxifene), antiphospholipid antibodies, PNH, Wegener granulomatosis

Thrombophilia now

has a code

“Still to be ruled out”

Adult Malnutrition New Definition

http://www.tinyurl.com/2012Malnutrition

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Adult Malnutrition Meets 2 out of 6 Criteria

• Insufficient energy intake

• Weight loss

• Loss of muscle mass

• Loss of subcutaneous fat

• Localized or generalized fluid accumulation that may sometimes mask weight loss

• Diminished functional status as measured by handgrip strength

2 out of 6

criteria used

based on

inflammatory

status

Prealbumin

and albumin

are no

longer

criteria for

malnutrition

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Adult Malnutrition Criteria

• Acute vs. chronic illness

• Severe vs. non-severe disease

• Albumin/prealbumin don’t matter

http://tinyurl.com/2012malnutrition

Dieticians Impact on Malnutrition Capture

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CMS’s Emphasis Upon Complications

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What are AHRQ PSIs?

• The Patient Safety Indicators (PSIs) are a set of indicators providing information on potential in hospital complications and adverse events following surgeries, procedures, and childbirth. – The PSIs were developed after a comprehensive

literature review, analysis of ICD-9-CM codes, review by a clinician panel, implementation of risk adjustment, and empirical analyses.

– Pediatric measures are also in place

http://www.qualityindicators.ahrq.gov/modules/psi_overview.aspx

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NQF-approved PSI 90 – Composite

http://tinyurl.com/NQF-PSIs 78

NQF Individual Measures

http://tinyurl.com/NQF-PSIs

79

ICD-9-CM - http://www.cdc.gov/nchs/data/icd9/icd9cm_guidelines_2011.pdf

ICD-10-CM - http://www.cdc.gov/nchs/data/icd9/icd10cm_guidelines_2014.pdf

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Definition of a Complication in Coding Clinic

• It is important to note that not all conditions that occur during or following surgery are classified as complications. – First, there must be more than a routinely expected condition or

occurrence, and – There must be a cause-and-effect relationship between the care

provided and the condition, and • Differentiation between surgical/pharmaceutical care and diseases

– There is indication in the documentation that it is a complication.

• The coder cannot make the determination whether something that occurred during surgery is a complication or an expected outcome. – Only a physician can diagnose a condition, and the physician must

explicitly document whether the condition is a complication. – If it is not clearly documented, the coder should query the physician

for clarification.

Source: Coding Clinic, First Quarter 2011 Pages: 13-14

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Accidental Lacerations During Surgery Coding Clinic, 2nd Quarter 2007, pp. 11–12

• Question: During an procedure, the surgeon noted, “a small capsular injury of the spleen, which was hemostatic.” – This injury did not require repair.

• An esophagogastroduodenscopy (EGD) was then performed for evaluation of the distal esophagus since the mass had adhered at the gastroesophageal junction. – The EGD revealed a serosal injury to the stomach, which

was repaired with interrupted Lembert sutures. The surgeon did not include the intraoperative tears in the diagnostic statement. What are the appropriate code assignments?

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Coding Clinic Answer

• Answer: Query the provider, and if the provider states the tear is not clinically significant, omit codes for both the diagnosis and procedure. – When a tear is documented in the operative report, such as a

small serosal tear of the stomach, the surgeon should be queried as to whether the small tear was an incidental occurrence inherent in the surgical procedure or whether the tear should be considered by the physician to be a complication of the procedure.

– If the provider documents that the seromuscular tear is a complication of the surgery, assign code 998.2, Accidental puncture or laceration during a procedure, as an additional diagnosis. This advice is consistent with that previously published in Coding Clinic, 3rd Quarter 1990, p. 18.

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A Compliant Complications Query 2013 ACDIS-AHIMA Practice Brief

• Clinical scenario: During the removal of an abdominal mass, the surgeon documents, in the description of the operative procedure, a “serosal injury to the stomach was repaired with interrupted sutures.”

• Query: In the description of the operative procedure a serosal injury to the stomach was noted and repaired with interrupted sutures. Was this serosal injury and repair: – A complication of the procedure _____________ – Integral to the above procedure _____________ – Not clinically significant ____________________ – Other ___________ – Clinically Undetermined____________

Please document your response in the health record or below accompanied by clinical substantiation.

• Rationale: This is an example of a query necessary to determine the clinical significance of a condition resulting from a procedure. http://www.tinyurl.com/2013QueryPB

84

PSI 11 – Postoperative Respiratory Failure

85

Immediate Postoperative Progress Note

Discharge Summary

86

Bottom Line

• ICD-9-CM (and ICD-10) codes are crucial – Definitions are critical – Documentation infrastructure must support the

higher specificity

• Physicians are be incentivized to document and code completely in their offices – Especially important if they form Accountable Care

Organizations or participate in other entities emphasizing cost efficiency and outcomes.

• This lecture will orient the healthcare provider of what is needed now and what we can expect in the future

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