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Timothy N. Brundage, MD, CCDSCertified Clinical Documentation Specialist
Physician CDI Preparation for ICD-10
Clinical Documentation Integrity Program:
“We do not believe there is anything inappropriate, unethical, or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment that is supported by documentation in the medical record.”◦ CMS 2008 IPPS Final Rule, http://
www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1533-FC.pdf, page 208
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Why does CDI Matter?
Clinical Medicine
Medical Record
Utilization
Quality
Medical legal
Reimbursement
Physician Profiles
& Hospital Report CardsData
Coded
Physician documentation in the medical record is an important instrument in the economics of healthcare
Cost per patient Resource utilization Length of stay Complication Rates Morbidity Scores Mortality Scores Outcome Analysis Audits
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Why does CDI Matter?Medicine Under The Microscope
Documentation reflects severity of illness (SOI) and risk of mortality (ROM) scores.
Specificity is vital, a definitive diagnosis must be documented.
Physician profiles are developed from documented information
Golden Rule: “If it is not written in coding language, it didn’t happen”
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In this World of Documentation
ICD Versions ICD-9
◦ 1977 – Worldwide use
◦ 1979 – U.S. modification Clinical & mortality
ICD-10 ◦ 1994 – Release of full ICD-10 by WHO
Published in 42 languages
◦ 1999 – Adopted for death certificates in the United States Mortality
◦ 2014 – U.S. modification Clinical
ICD-11◦ 2015 – Tentative rollout worldwide
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Differences Between ICD-9-CM and ICD-10-CM/PCS
ICD-9-CM diagnosis◦ 3–5 characters◦ Allows for 1 letter (1st
position); otherwise numeric
ICD-9-CM procedures◦ 4 characters only◦ All characters are
numeric
ICD-10-CM◦ 3 to 7 characters◦ 1st character is alpha (except
U); others are either alpha or numeric Numbers 0–9; letters A–H,
J–N, P–Z Alpha characters are not
case-sensitive
ICD-10-PCS◦ Same as ICD-10-CM except
each code must have 7 characters Letter “Z” used as a placeholder 7
ICD-9-CM Structure – Format
X .X X X X5E 1 4 0 0.V
Category Etiology, anatomic site, manifestation
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Numeric or alpha (E or V) Numeric
3–5 characters8
ICD-10-CM Structure – Format
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X X X X
Category
.Etiology, anatomic
site, severity
Added code extensions (7th character) for obstetrics, injuries, and external causes of injury
X X XAMS 3 2 0. 1 0 A
Additional characters
Alpha (except U)
2–7 numeric or alpha
3–7 characters
The most challenging aspect of CDI
How do you motivate physicians to educate themselves?
Physician Buy In to CDI
• Without all diagnoses documented, profiles will inappropriately reflect higher than expected mortality
• Complete documentation, reflective of the true severity of illness of patients will justify outcomes
Profiles are used for both commercial and public useFuture reimbursement methods will likely incorporate profiles in the formula (e.g., pay for performance)
Teach Physicians about Quality Data
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Hospital Report cards Healthgrades, Delta Group, Leapfrog Medicare Physician Data (since 2007) Federal and state regulatory agencies (e.g. OIG) The Joint Commission (TJC) Centers for Medicare and Medicaid Services (CMS) Quality Improvement Organizations (QIO)
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Physician Profiling
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Healthgrades.com
Predicted Mortality Rates for some disease processes in this case:◦ Community Acquired Pneumonia = 10%◦ Sepsis = 30%◦ Septic shock = 50%
If the patient survives, quality ratings will be much higher in the public reporting data because the physician took care of a “sicker” patient.☻Expected mortality will be higher than actual mortality.
Physician Quality Ratings
Don’t need to turn doctors into coders Need good documentation habits Need specialty specific documentation
education Begin the process of education now for ICD-9
and incorporate ICD-10 issues into the education
ICD-10 Physician Education
