PHYSICIAN DOCUMENTATION IMPROVEMENT...3/28/2016 1 1 PHYSICIAN DOCUMENTATION IMPROVEMENT For...
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3/28/2016 1 1 PHYSICIAN DOCUMENTATION IMPROVEMENT For ICD-10-CM Presented by: Marian J. Wymore, MD, CPC All information contained herein is the confidential and proprietary property of Marian J. Wymore, MD, CPC and may not be reproduced, published or distributed to, or for, any third parties without the express prior written consent of Marian J. Wymore, MD,CPC. Objectives: Physician Documentation Improvement for ICD-10-CM 2 Learn the importance of physician documentation improvement on accurate and precise ICD-10-CM coding. Develop a greater understanding of the change in verbiage necessary for physicians to use. Suggestions on how to educate your physicians on how to include this terminology. Understand why improved clinical documentation improves quality, more appropriate reimbursement, and more timely payment. Relationship between accurate and precise documentation, ICM-10 codes, risk adjustment, and STARS measures.
Transcript of PHYSICIAN DOCUMENTATION IMPROVEMENT...3/28/2016 1 1 PHYSICIAN DOCUMENTATION IMPROVEMENT For...
3/28/2016
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PHYSICIAN
DOCUMENTATION
IMPROVEMENT
For ICD-10-CM
Presented by:
Marian J. Wymore, MD, CPC
All information contained herein is the confidential and proprietary property of Marian J. Wymore, MD,
CPC and may not be reproduced, published or distributed to, or for, any third parties without the express
prior written consent of Marian J. Wymore, MD,CPC.
Objectives: Physician Documentation
Improvement for ICD-10-CM
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Learn the importance of physician documentation
improvement on accurate and precise ICD-10-CM
coding.
Develop a greater understanding of the change in
verbiage necessary for physicians to use.
Suggestions on how to educate your physicians on how
to include this terminology.
Understand why improved clinical documentation
improves quality, more appropriate reimbursement,
and more timely payment.
Relationship between accurate and precise
documentation, ICM-10 codes, risk adjustment,
and STARS measures.
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Where To Begin
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1. Understanding resistance to change:
busy schedules, probably inadequate sleep,
possible overwhelm or burnout
2. Ask for providers’ input and identify leadership
3. Establish relationship of mutual respect
4. What’s in it for me? Quantify potential financial incentives
5. Educational programs that work with providers’ schedules
6. Offer support
Physician Documentation
Improvement
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1. Don’t assume provider’s understand coding, HCCs,
or STARS. Clarify “family of codes”, 3-7 characters of
ICD-10 codes, current HCCs, amount of
documentation necessary for active problems, define
“quality” “STARS” & goal of 5
2. Educate providers to expand clinical thinking to
include improved documentation specificity for ICD-
10-CM, risk adjustment, and STARS. Providers
appreciate consolidation of trainings.
3. Provide tools to improve documentation and
capture HCCs.
4. Facilitate provider efforts to fulfill on quality
measures.
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ICD-10 Documentation Specificity
and HCCs
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• Providers may find the additional verbiage for detailed
diagnostic coding choices in ICD-10-CM time consuming
initially.
• Educate physicians in specific documentation verbiage
for most common diagnoses, and how to efficiently find
codes under ICD-10 for conditions not often encountered.
• Look for trends in decreases in capture rate for HCCs
that may occur from insufficient documentation and use
of “without complications” or unspecified codes.
• Documentation to specificity level of family of codes only
may be insufficient to capture HCC (even if Medicare
lenient until Oct. 1, 2016.)
Clinical Documentation
Improvement for Providers
5 Questions to ask yourself to improve documentation of
patient encounter:
SADSS
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All information contained herein is the confidential and proprietary property of Marian J. Wymore, MD, CPC and/or ICodify and may not be
reproduced, published or distributed to, or for, any third parties without the express prior written consent of Marian J. Wymore, MD,CPC.
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SADSS
S: Can I be more Specific?
All information contained herein is the confidential and proprietary property of Marian J. Wymore, MD, CPC and/or ICodify and may not be
reproduced, published or distributed to, or for, any third parties without the express prior written consent of Marian J. Wymore, MD,CPC.
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SADSS
A: Acuity/Chronicity
Document if problem is:
Acute? Chronic? Acute on chronic?
PMH (past medical history) vs. active/under treatment?
Affecting care of current condition?
Why on meds?
All information contained herein is the confidential and proprietary property of Marian J. Wymore, MD, CPC and/or ICodify and may not be reproduced,
published or distributed to, or for, any third parties without the express prior written consent of Marian J. Wymore, MD,CPC.
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SADSS
D: Is the diagnosis Due to coexisting/comorbid condition?
Document cause and effect
Lots of combination codes in ICD-10
All information contained herein is the confidential and proprietary property of Marian J. Wymore, MD, CPC and/or ICodify and may not be reproduced, published or distributed to, or for, any third parties without the express prior written consent of Marian J. Wymore, MD,CPC.
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SADSSS: Does medical record Support dx?
history
physical findings
assessment
treatment plan
medication
current year? HCC-Risk Adjustment
Example: hemiparesis
Update EMR
Not sufficient to code a more specific diagnosis without chart documentation to back it up
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All information contained herein is the confidential and proprietary property of Marian J. Wymore, MD, CPC and/or ICodify and may not be
reproduced, published or distributed to, or for, any third parties without the express prior written consent of Marian J. Wymore, MD,CPC.
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SADSSEMR: Support Diagnosis
Patient Problem list and PMH often extensive and
automatically regenerated in new progress note.
Many listed diagnoses are not addressed on DOS, and may appear to be PMH.
Providers should document any active conditions assessed at
time of service /at least once per year for HCCs.
Document:
Any Associated Diagnoses or Conditions
that are under treatment
And/or
That are affecting care of current condition,
decision making, treatment or management
Update medical record with any additional or more specific diagnoses
from ER, inpatient, specialist, or other provider visits since last DOS. 11
SADSSProvider should Document:
Any Associated Diagnoses or Conditions that are under
treatment
And/or
That are affecting care of current condition, decision
making, treatment or management
Includes:
all acute and chronic medical conditions
complications
manifestations
mental, behavioral, neurologic, or congenital disorders
obstetric, dermatologic, musculoskeletal dx
injuries or poisonings
substance abuse
infections
signs & sx (if primary dx not known)
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SADSSS: Any quality measures to address?
STARSWeighted x1:
Breast/colorectal screening
Annual flu shot
Assess:
physical activity
BMI
functional status
pain
medication review (document condition being treated)
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All information contained herein is the confidential and proprietary property of Marian J. Wymore, MD, CPC and/or ICodify and may not be
reproduced, published or distributed to, or for, any third parties without the express prior written consent of Marian J. Wymore, MD,CPC.
SADSSSTARS Measures
Weighted x3:
Review high risk meds:
Consider adjustment? Elimination? Substitution?
Document diagnosis, treatment plan, and justification
Document drug dependency eg. opiates/sedative-hypnotics
Reference:
American Geriatrics Society
BEERS Criteria for potentially inappropriate medication use
Med compliance- diabetes/HTN/statins
Control- blood sugar/blood pressure
Improving/maintaining- mental and physical health
Plan for all cause readmission
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All information contained herein is the confidential and proprietary property of Marian J. Wymore, MD, CPC and/or ICodify and may not be
reproduced, published or distributed to, or for, any third parties without the express prior written consent of Marian J. Wymore, MD,CPC.
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SADSS
STARS MeasuresWeighted x1.5
patient reported outcomes
patient satisfaction
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All information contained herein is the confidential and proprietary property of Marian J. Wymore, MD, CPC and/or ICodify and may not be
reproduced, published or distributed to, or for, any third parties without the express prior written consent of Marian J. Wymore, MD,CPC.
ICD-10 Documentation, HCCs
and STARS Measures
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When providers document diagnoses to the highest level of
specificity, and capture all appropriate HCCs, there will be
more STARS measures to fulfill on.
Examples:
Type 2 Diabetes Mellitus
Rheumatoid Arthritis
Educate providers on actionable STARS measures and support
their efforts to help patients realize these goals.
Important to maintain STARS ratings of 3.5 or greater, optimally
4.5 to 5.
Medicare is emphasizing quality care and will continue raise
the bar.
Inadequate STARS ratings will jeopardize contracts.
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Positive Reinforcement
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1. Respect and acknowledgment for actions taken by
providers/results
2. Share data often
3. Competition: comparison with self, peers, ratings
4. Financial incentives
5. Emphasize quality/providers want to do a good job
6. Satisfaction with work/well being
7. Support
Peer Pressure
If Severity of Illness (SOI) is inadequately
documented by provider:
Morbidity & mortality will appear excessive
Quality will appear low
Risk Adjustment payments will not reflect
the costs associated with the treatment and
management of the sicker patients
Show physicians data on how they
stack up against others
(and what data is publically available…)
All information contained herein is the confidential and proprietary property of Marian J. Wymore, MD, CPC and/or ICodify and may not be
reproduced, published or distributed to, or for, any third parties without the express prior written consent of Marian J. Wymore, MD,CPC.
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Clinical Documentation
Improvement for ICD-10-CM
All diagnoses must be precisely documented by
providers
Provide available detail for coding highest number of
characters (3 to 7)
Avoid using unspecified codes or symptoms
Update medical record when more specific
diagnosis made. Refer to specialists’ consultation
reports when available.
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All information contained herein is the confidential and proprietary property of Marian J. Wymore, MD, CPC and/or ICodify and may not be
reproduced, published or distributed to, or for, any third parties without the express prior written consent of Marian J. Wymore, MD,CPC.
GEMs/Crosswalks
Were not designed to simply translate codes ICD-9 to ICD-10
“The GEMs are not a substitute for learning how to use ICD-10-CM
and ICD-10-PCS.”
“In coding individual claims, it will be more efficient and
accurate to work from the medical record documentation and
then select the appropriate code(s) from the coding book or
encoder system.”
“The GEMs are a tool to assist with converting larger ICD-9-CM
databases to ICD-10 CM and ICD-10-PCS.”
https://www.cms.gov/Medicare/Coding/ICD10/Downloads/GEMs-
CrosswalksBasicFAQ.pdf
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Improved accuracy and specificity
of clinical documentation by
providers necessary
Coders can’t diagnose
The more specific diagnostic and treatment information
documented by provider, the higher the chances that the
coders will be able to pick up clinically relevant data for
assigning appropriately detailed codes
Accurate code assignment results in less queries, more timely
and appropriate reimbursement, assessment of quality, risk,
severity of illness, and outcomes, better data, and enhanced
communication
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22http://www.cdc.gov/nchs/icd/icd10cm.htm#icd2016
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Expand Clinical Thinking
Vital Signs: Great place to start!
BP?
BMI? high/low?
BMI 40 or greater is Morbid Obesity HCC
BMI 35-40 risk adjusts (HCC) only if
provider documents severe (or morbid) obesity
What else does BMI > 35 make you think of clinically?
Diabetes, osteoarthritis, sleep apnea, HTN, etc…
BMI may be coded from medical record, but
provider must document any associated conditions that
support diagnosis of morbid obesity 23
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ICD-10-CM
Chapter 4: Endocrine, Nutritional, and Metabolic DiseasesE66 Overweight and Obesity
Code first obesity complicating pregnancy, childbirth and the
puerperium, if applicable (099.21-)
Use additional code to identify BMI if known (Z68.-)
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More ICD-10 Verbiage
Additional characters required- red #
Code first underlying disease (eg. E53.8 vitamin B12 deficiency +
G32.0 Subacute combined degeneration of spinal
cord in diseases classified elsewhere (HCC)
Use additional code
Includes/excludes
With/Without (eg. gangrene)
Mild, Moderate, Severe (eg. Malnutrition)
Single episode, recurrent (eg. Major Depression)
Temporality (eg. Old MI now > 4 weeks)
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Specify Malnutrition E 40-46
BMI alone inadequate!
document “malnutrition” or “cachexia”
document degree/severity
Protein-calorie malnutrition
mild E44.1
moderate E44.0
Unspecified severe (protein-calorie) E43
Specify if:
Malabsorption (no longer risk adjusts) K91.2
Following GI surgery K91.2
Intrauterine, etc…
Neglect (child, infant) T76.0226
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Rheumatoid Arthritis Verbiage in ICD-10
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4M05 Rheumatoid arthritis with rheumatoid factor
5 pages of codes ICD-10-CM manual
Familiarization with specific verbiage simplifies and
streamlines provider documentation
M05._ complications- 4th character
M05.0 Felty’s syndrome
M05.1 Rheumatoid lung disease with RA
M05.2 Rheumatoid vasculitis with RA
M05.3 Rheumatoid heart disease with RA
M05.4 Rheumatoid myopathy with RA
M05.5 Rheumatoid polyneuropathy with RA
M05.6 RA with or M05.7 with RF without
other organ or systems involvement
M05.8 Other RA with RF
M05.9 RA with RF unspecified
M05._ _ Joint(s)? vs multiple sites-5th character
M05._ _ _ right/left?-6th character
Rheumatoid Arthritis, DMARDs
and STARS(Disease Modifying Anti-Rheumatic Drugs)
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Treatment is time sensitive:
When PCP makes diagnosis of RA and refers to specialist for treatment,
important for providers to communicate regarding time frame for
initiating treatment with DMARDs for optimal results.
When diagnosis of RA is made, treatment with DMARDS is a STARS
measure.
May require calls from PCP to specialist to arrange timely
consultation, diagnostic testing, and initiation of treatment.
Update documentation in medical record to
include diagnosis and treatment from
specialist reports.
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Provider Documentation
Improvement Incorporating STARS and HCCs
Document Type of Diabetes (HCC)
Type 1 - E10._ _ _
Type 2 – E11._ _ _
specify if long term (current) use of insulin
Due to underlying condition – E08._ _ _
eg. Cushing’s; pancreatitis (chronic is HCC)
Drug or chemical induced – E09._ _ _
eg. Steroids
Other specified diabetes mellitus – E13._ _ _
eg. Due to genetic defects; s/p pancreatectomy 29
Additional STARS measures indicated
because of diagnosis of DM:
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• ABI/Flochec (screen for Diabetic peripheral angiopathies)
• NCV/DPN (screen for DM neuropathies)
• HgbA1C (screen for control of blood sugar)
• Opthalmalogic exam q 2 year (q 1 yr if abnormal)
• Urine microalbumin/Cr ratio (screen for nephropathy/CKD)
• eGFR and serum Cr (screen for CKD)
• PTH if eGFR <60 (screen for hyperparathyroidism)
• Check Vit D if PTH abnormal (screen for Vit D deficiency)
Screening tests may reveal complications, then
accurate physician documentation will result
in appropriate ICD-10 combination code
assignment and additional risk adjustment
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Document Specifics of Complications
4Type of DM: E08 to E13
Complications of each type of DM: E08._ to E13._ (4th digit)
Specifics of each complication of each type of DM:
E08._ _ to E13._ _ (to 5th digit)
More detail about specifics of each complication
E08._ _ _ to E13._ _ _ (to 6th digit)
i.e. E11.3_ _ _
Type 2 DM with ophthalmic complications requires 5 to 6 characters
Refer to opthalmology consultation for accurate dx documentation
If no further subdivisions available, category is code.
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Combination Codes
Type 2 Diabetes Mellitus with Kidney Complications E11.2_
E11.21 Type 2 DM with diabetic nephropathy
ICD-9: 2 codes were used (DM w renal manifestations + diabetic nephropathy)
E11.22 Type 2 DM with diabetic Chronic Kidney Disease
+ 2nd code representing stage CKD (N18.1-N18.6)
Stage 4, Stage 5 and ESRD Risk Adjust- HCC
ICD-9: 2 codes (DM w renal manifestations + CKD stage)
E11.29 Type 2 DM with other diabetic kidney complication
eg. Type 2 DM with renal tubular degeneration
Document dialysis status Z99.2-HCC32
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Documentation for Combination Codes
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Document complications as cause and effect
“due to___” “with___” “diabetic___”
Can’t code “possible”, “probable”, “consistent with”, or “and”
Can code “evidence of”
Provider documented diagnoses separately
Assessment:
DM Type 2 without complications- E11.9
CKD Stage 4 – N18.4
Provider specified CKD due to DM
Assessment:
Type 2 DM with CKD Stage 4 - E11.22 + N18.4
*Sicker patient, higher risk adjustment HCC
for complicated DM
and additional HCC for CKD Stage 4
ICD-10: 1 five character code
ICD-9: previously 2 codes for DM with
peripheral angiopathy
(3 codes if with gangrene)
E11.59- with other circulatory complications
(+ code other)
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E11.52 Type II DM with diabetic peripheral angiopathywith gangrene
E11.51 Type II DM with diabetic peripheral angiopathywithout gangrene
With Without
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Document blood sugar control:
DM with Hyperglycemia E11.65
Document “Poorly controlled”, “adequately/inadequately controlled”,
or “out of control” (but no longer “controlled/uncontrolled”)
Lab results in chart alone are not sufficient
DM with Hypoglycemia
With Coma E11.641
Without Coma E11.649
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New Categories in ICD-10
Document:
DM with skin complications E11.62_
Diabetic dermatitis/ diabetic necrobiosis lipoidica
DM with foot ulcer E11.621
use additional code to identify site L97.4_ _, L.97.5_ _
DM with other skin ulcer E11.622
use additional code to identify site L97.1_ _ - L97.9_ _
L98.41_ - L98.49_
DM with other skin complications E11.628
DM with oral complications E11.63_
Periodontal disease/other
DM with diabetic arthropathy E11.61_
Neuropathic/Charcot’s joints/other36
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More ICD-10 Lingo
Anatomic Location
Laterality
Accurate and detailed description including location,
size, depth, right/left
eg. Non-pressure chronic ulcer of right heel with
fat layer exposed L97.412
(If due to Type 2 DM, code first E11.621)
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Many Documentation Changes in
ICD-10 may affect Risk Adjustment
Major DepressionDocument Episode:
Major Depressive Disorder, single episode F32._
Major Depressive Disorder, recurrent F33._
Document Severity:
mild
moderate
severe (single episode is HCC if severity documented)
With/Without Psychosis
Document Partial/Full Remission (if applicable)
Major Depression risk adjusts (HCC) if document
recurrent or single episode plus mild/moderate/severe
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Document symptoms only if not
sure of diagnosis:
irritability and anger R45.4
unhappinessR45.2
apathyR45.3etc….
Documentation of Cancer
Document Activity versus PMH:
Active malignancy risk adjusts (excludes most skin CA and in-situ tumors)
Acute/Chronic malignancy? (eg. leukemia, lymphoma)
Remission status? partial/full (eg. leukemia, lymphoma)
Active or ongoing treatment: HCC if ongoing treatment
including meds eg. Tamoxifen/Lupron
Document Malignant/Benign/In-Situ:
Type/Location/Laterality/Morphology
Primary/Secondary
Document each tumor if multiple
Grade/Stage
Metastatic to? Lymph node involvement?
Residual?
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Document Coexisting Conditions
and Complications
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Malignancy complicated by:
Cachexia
Pancytopenia/Thrombocytopenia/
Neutropenia
Specify etiology if known:
Cyclic neutropenia?
Neutropenic fever?
Drug/chemo induced?
Due to? neoplasm, infection, etc…
Risk Adjusts: sicker cancer patient
greater SOI
7th Character
Code to 7th character for:
Episode/encounter- for injuries, fractures
Fetus # for OB
___ ___ ___. ___ ___ ___ ___
A-initial encounter/active treatment
D-subsequent
S- sequela (previously “late effects” in ICD-9)
Orthopedics uses more characters for encounters:
i.e. G-complication (delayed healing of fracture)
If Gustilo, may use A-H, J,K,M,N, P-S42
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Let’s code my ballroom dance mishap…
Placeholder X Alert-requires 7th character
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Going pretty well…
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Oops…. S70.01XA Contusion of right hip
W04.XXXA fall while being carried or supported by another
person (A for initial encounter after extension X alert)
Place of occurrence of the external cause-Y92.51 private commercial establishments
Activity code-Y93.41 activity, dancing
Blood alcohol level-Y90.0 less than 20mg/100ml
Bone density? Osteoporosis management is a STARS measure45
Alcohol and Drug
Use/Abuse/Dependency
Specify substance and use/abuse/dependence
Alcohol F10._ _ _ Document intoxication/uncomplicated/delirium/ psychotic delusions, etc..
Opoid F11._ _ _
Cannabis F12._ _ _
Sedative Hypnotic F13._ _ _
Cocaine F14._ _ _
Hallucinogen F16._ _ _
Inhalants F18._ _ _
Other stimulant (amphetamine-related/caffeine) F15._ _ _
Nicotine F17._ _ _
Document cigarettes, chewing tobacco, or other and any nicotine-
induced disorders
eg. F17.213 Nicotine dependence, cigarettes, with withdrawal
Other or polysubstance related disorder F19._ _ _
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More Specifics related to
Alcohol/Drug use/abuse/dependencyDocument:
Disorders due to substance use:
Substance-induced mood or anxiety disorder,
psychotic disorder, delusions, hallucinations,
or perceptual distortions
Substance induced sexual dysfunction or sleep disorders
Persistent amnestic disorder or dementia; other
Specify intoxication/uncomplicated/with withdrawal/
in remission
Physiologic or psychological dependency coded with same
codes
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Acute/Chronic/Acute on Chronic
COPD/Chronic Lung disorders (RA/HCC)
On O2?
J96.10 Chronic respiratory failure, unspecified
With hypoxia (J96.11) With hypercapnia (J96.12)
J44.1 COPD with Acute Exacerbation
Bronchitis? Pneumonia? Organism?
J44.0 COPD w acute lower resp inf
use additional code to identify the infection
Influenza due to unidentified influenza virus
J11.00 with unspecified pneumonia
J11.08 with specified pneumonia
J13 Pneumonia due to Streptococcus pneumoniae 48
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PROVIDER GOALS?
ASK THEM
Any benefits of improving
CLINICAL DOCUMENTATION?
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Provider responses include: Enhance diagnostic accuracy & quality of care
Improve communication with other providers and
hospital
Better Data:
Severity of Illness
Morbidity and Mortality
Outcomes
International compatibility
Disease tracking
Clinical Research
Medical necessity for testing and treatments
Timely and accurate reimbursement
Value based payment: support risk adjustment and
quality measures50
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OPPORTUNITY:
Establish stronger Doctor/patient relationship
“Face time”
Inquire about goals & patient’s perceived outcomes in
addition to chief complaint
Ask about activity of chronic conditions
Inquire about meds/compliance/side effects
Share STARS measures and commitment to patient getting highest quality care
Document discussion and pertinent physical findings
Patient trust and confidence in provider improves:
patient compliance and outcomes
patient satisfaction and STARS ratings
Not optional: integral part of treatment
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