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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.
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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
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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
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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
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What’s Old? ICD-9-CM
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What’s New ICD-10-CM
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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
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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
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Risk-Adjustment
Dementia
Underlying Cause of Dementia
Underlying Cause of Dementia
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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
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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
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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)
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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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Note: This calculator is for estimation purposes only.
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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