Post on 07-Sep-2018
Randy C. Roth, MD Chief Medical Officer Singing River Health System April 1, 2016
“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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Clinical Medicine
Medical Record
Utilization
Quality
Medical Legal
Reimbursement
Physician Profiles
& Hospital Report Cards Data
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
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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ICD-10 is the biggest change in Healthcare since ICD-9 in the 1970’s.
Professional coders will transition from working with approximately 30,000 different codes to working with over 70,000 different codes.
There is unknown potential cash impact to all providers.
Physicians will be asked to improve clinical documentation or asked for additional documentation.
ICD-9 Version
Having Coffee at Home: Cup of coffee
with sugar & cream
Outcome: Cup of Coffee
ICD-10 Version
Having Coffee at Starbucks: Size: Tall, Grande, Venti
Milk: Non-fat, Low-fat, Whole
Temp: Normal Hot, Extra-Hot
Flavors: Vanilla, Hazelnut, Toffee Nut
Outcome: Grande, Non-fat, Extra-hot, Vanilla Latte
ICD-9 Version
Broken Arm September 30, 2015:
Left, Upper Arm Fracture
Outcome: Open Fracture Left Humerus
ICD-10 Version
Broken Arm October 1, 2015: Type: Traumatic, Pathologic
Location: Bone, Left/Right, Joint Involved
Nature: Open/Closed, Displaced/Non-displaced
Encounter: Initial, Subsequent, Sequela
Healing: Routine, Delayed, Nonunion, Malunion
Outcome: Initial encounter for Traumatic
Open Fracture of Left Humerus
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
ICD-9-CM diagnosis
3–5 characters
Allows for 1 letter (1st position); otherwise 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-9-CM procedures
4 characters only
All characters are numeric
ICD-10-PCS
Same as ICD-10-CM except each code must have 7 characters
Letter “Z” used as a placeholder
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 use.
Future reimbursement methods will likely incorporate profiles in the formula (e.g., pay for performance).
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)
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.
Need good documentation habits
Need specialty specific documentation education
Buy-In to CDI is imperative in order to survive in the conversion of ICD-9 to ICD-10
These are additional conditions, apart from principal diagnosis
Comorbid Conditions: Present on admit; chronic, but active; even if not acutely symptomatic
Complications need to be Documented: Acute blood loss anemia, thrush, hyponatremia, acute respiratory failure RW – Relative Weights: All DRGs have a weight when multiplied by the Case Rate, that determines payment to the Hospital
If two or more conditions are present and are equally addressed, either can be used as the principal diagnosis
Try not to contradict previous hospitalists
Acute systolic heart failure as primary with staph pneumonia as additional RW=1.54
vs. Staph pneumonia as primary with CHF as additional RW=2.05 This is important because .1 equals about $1,000 in Collections to the Hospital
Sepsis SIRS
Sepsis
Severe Sepsis
Septic Shock AKI (Acute Kidney Injury)
Acute and Chronic Respiratory Failure
Alzheimer’s Dementia with Behavioral Disturbances
Encephalopathy
BMI Derangements of <19 or >40
Acute Delirium
Fecal Impaction (if treat)
Hemiplegia/paresis or Functional Quadriplegia
Hyponatremia
AKI
Pickwickian Syndrome
Pathologic Fracture
Thrush
Stage 3 or 4 Decubiti Ulcer (POA and Site)
Mallory –Weiss syndrome
Functional Quadriplegic
Diverticulitis, with sigmoid resection, no other diagnoses = RW of 1.63
Diverticulitis, same resection, with documented chronic CHF = RW of 2.57
GI bleed with no other diagnoses = RW of .70 but GI bleed with acute blood loss anemia = RW of 1.01
Decubitus ulcer, chronic CHF, non-excisional debridement = RW of .99
with excisional debridement = RW of 1.49
The Higher
the RW, the
Higher the
Payment
Acute Respiratory Failure: Acute Respiratory Distress or Apnea +
ABGs (room air)
pO2 < 60 = SpO2 < 88%
pCO2 > 50 (+ pH<7.35), if COPD
While being on a Ventilator (or BiPAP) indicates the presence of acute respiratory failure, it is not mandatory.
The following cannot be coded as Respiratory Failure:
respiratory insufficiency, respiratory distress, hypoxemia.
Sepsis
SIRS due to an underlying infection
Validation that the patient “looks sick” / “septic” / “toxic”
Two or more of the following:
Fever (38.3°C/101°F) Hypothermia (36°C/96°F) Heart rate >90 Respiratory rate >20 WBC >12,000 or < 4,000 or Bands >10%
A positive blood culture is not required “Urosepsis” = UTI only
Heart Failure
“CHF” is non-specific: Do Not use it!
Must state if: SYSTOLIC heart failure DIASTOLIC heart failure COMBINED systolic and diastolic heart failure
Specify if currently Acute* vs Chronic (* including “acute exacerbation” / “acute on chronic”)
Check Echocardiogram
Pneumonia
Must specify the “possible/probable/most likely/suspected” organism.
For example: Staph; Pseudomonas; “gram-negative”; “Aspiration Pneumonia.”
Consider the antibiotic you are using: What organism(s) does it “cover”?
VAP, CAP, “nosocomial” all default to “simple” pneumonia.
Encephalopathy
Definition: Significant generalized alteration in mental function due to an underlying process
For all patients with “mental status alteration,” is it really:
TOXIC encephalopathy ? METABOLIC encephalopathy ?
If so, please indicate in medical record
Acute Renal Failure
Increase in Serum Cr by 0.5 mg/dl within 2 weeks (or by 20%, if baseline > 2.5 mg/dl)
Correction of creatinine upon rehydration = baseline
Acute Renal Failure due to dehydration
Acute renal failure occurring with dehydration is a significant risk factor for morbidity and mortality.
Acute renal failure in the presence of dehydration, coding rules instruct us to code the acute renal failure first.
Chronic Kidney Disease (Specify Stage 1-5 or ESRD)
Term GFR Approx. Serum Cr
Chronic Renal Insufficiency or Failure
CKD Stage 1 >90 <0.9
CKD Stage 2 60-89 1.0-1.3 not CC’s
CKD Stage 3 30-59 1.4-2.5
CKD Stage 4 15-29 2.5-4.5 CC
CKD Stage 5 <15 >4.5 CC
ESRD (Need for dialysis)
Major CC
Pathologic Vertebral Fracture
Pathologic Fracture of Vertebral Body Minimal/Mild trauma Due to underlying abnormal bone
Severe osteoporosis Malignancy (“lytic lesion”); Myeloma Metabolic bone disease (e.g. CKD or hyperparathyroidism)
Usually elderly, debilitated, chronic illness, immobility “Pathologic Fracture due to [underlying condition] .”
Not vertebral compression fracture
Due to trauma: MVA, fall >6 feet, other high-velocity injury Mild or no osteoporosis; no malignancy Any age
Other Key Terms
Acidosis / Alkalosis
Unstable Angina Crescendo / Pre-Infarction Angina Angina at rest
Arrhythmia (any type) Even if transient
AV-block (2nd or 3rd degree)
Atelectasis (especially post-op)
Cellulitis
Chronic Respiratory Failure Instead of severe COPD; end-stage COPD; COPD with home O2
Cor Pulmonale, acute
Pericarditis, acute
Decubitus Ulcers Even Stage 1 (non-blanching erythema) Any location
Dehydration (Is it also acute renal failure?) Drug dependence/abuse (if current
continuous-use)
GI hemorrhage
Excisional Debridement Cutting away of tissue with scalpel (not scissors) Any wound or ulcer OR, bedside, or procedure room
Ileus
Pancreatitis (acute or chronic)
Peritonitis
Hyponatremia / Hypernatremia Requiring some type of management / treatment
Not just incidental lab finding
Malnutrition Significant unintentional weight-loss
Low body weight / BMI
Physical exam findings (e.g. muscle atrophy)
Low albumin, pre-albumin, transferrin, and/or cholesterol
Phlebitis (including DVT, IV site, etc.)
Melena
Hemiplegia / Hemiparesis Including post-stroke
Schizophrenia / Bi-polar Disorder Even if controlled with medication
Major Depressive Disorder
Delirium / Hallucinations
Pt admitted for GI Hemorrhage unspecified.
Pt had a dx of rectal mass with positive findings.
Physician queried without further documentation of the adenocarcinoma found in the pathology report.
DRG without documentation of the rectal malignancy 379 GI Hemorrhage without CC/MCC RW .6937 =$3214
DRG with documentation of the rectal malignancy
378 GI Hemorrhage with CC RW 1.0029 = $4646
Revenue Difference: $1,432.00
Patient admitted due to AV Blockage w/insertion of a pacemaker
Physician discussed the abnormal BUN and Creatinine but never followed up on the abnormal labs.
Query was submitted without a response.
DRG without the Acute Renal Failure documentation
244 Permanent Cardiac Pacemaker Implant without CC/MCC RW 2.1608 = $10,010
DRG with Acute Renal Failure documented
243 Permanent Cardiac Pacemaker Implant with CC RW 2.6716 = $12,376
Revenue Difference: $ 2,366
Pt here with cellulitis of the foot. They had ESRD as an MCC.
Query was submitted and documentation was given for the sharp instruments used allowing the excisional debridement to be coded.
DRG without documentation of the excisional debridement goes to a non-excisional debridement
602 Cellulitis with MCC RW 1.4607 = $6767
DRG with documentation of the excisional debridement 570 Skin Debridement with MCC RW 2.4154 = $11,189
Revenue Difference: $4,422
Patient here for joint replacement.
Query submitted to specify the obesity and the physician documented Morbid Obesity w/BMI of 47.4.
Please note: BMI cannot be coded without an obesity diagnosis but the BMI is the actual CC.
DRG without the Obesity documentation: 484 Major Joint & Limb Reattachment procedure of Upper Extremity without CC/MCC RW 2.2298 = $10,329
DRG with the Obesity documentation:
483 Major Joint & Limb Reattachment procedure of Upper Extremity with CC/MCC RW 2.6488=$12,270
Revenue Difference: $1,941
Patient admitted for mastectomy for breast cancer. During the mastectomy a sentinel node biopsy was performed. The pathology came back positive for metastatic adenocarcinoma of the lymph node.
Query sent to add the diagnosis for the pathology findings without an answer.
DRG without the metastatic lymph node documentation
581 Other Skin, Subcutaneous tissue and breast procedures without CC/MCC RW 1.0605 = $4912
DRG with the metastatic lymph node documentation
580 Other Skin, Subcutaneous tissue and breast procedures with CC RW 1.5398 = $7133
Revenue Difference: $2,221
Negative DRG Shifts $2.96M - $8m
Productivity Impact:
Potential DRG shift:
0
5
10
AR
Day
s AR Change
Coding Payor lag Denials At Peak*
2.3 4.0 0.5 6.8
Coding Payor lag Denials At Trough*
$1.73M $3.03M $0.38M $5.14M
Estimated Maximum Increase in AR Days
Estimated Maximum Cash Deficit
*The components will not be equal to the peak due to the varied timing of the effects
CODER TRAINING
CODER TRAINING
CODER TRAINING
I10 DELAYED TO 2015
IMPACT ANALYSIS COMPELTED
FTI PHYSICIAN TRAINING
FTI PHYSICIAN TRAINING
CODER/CDI REFRESHER
HOSPITAL DUAL CODING
ICD10 PREP CLASS FOR
COMMUNITY
PHYSICIAN CALCULATOR GO LIVE
Coder & Chart Documentation Specialist Training over 100 hours of classroom and WebEx training over the last 18 months. Certifications required for all Coders by January 1, 2016 Physician Education 1.5 hrs. on ICD-10 Basics & The Affects of Documentation.
System Upgrades for Epic and 3M software. Payer Testing with BCBS, Aetna, Cigna and UHC. Testing Claims with Medicare and vendor clearinghouse.
- Weekly Work Sessions Minimum of 1.5 hrs. with Singing River Health System Clinic Coders and Office Managers through the last week of September. Weekly Review of clinical documentation for educational opportunities with physicians and nurse practitioners, etc. Continuous Payer Testing with other non governmental third party payers. ICD-10 Prep Class will be held every Wednesday evening for 2 hours (8 week class). Review Process for Hospice of Light and the use of Standing Orders.
ICD-10 is here, don’t delay any education.
Physician profiling is here, document your severity and specificity.
Part B – Physician Payment is dependent on correct descriptions, represented by ICD-10.
Part A – Hospital Payment is continuing to decline, and in order to stay in operation they must be able to capture everything the providers are treating.