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Injury and Intervention Coding: An overview OCA March 2011.

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Presentation on theme: "Injury and Intervention Coding: An overview OCA March 2011."— Presentation transcript:

1 Injury and Intervention Coding: An overview OCA March 2011

2 Whose idea was it to start to use standard codes? Auto Insurance Standard Invoice Prior to implementation of AISI, each health business and each type of health professional described injuries and treatments any way they chose to This led to confusion, because patients with similar injuries/treatments could be described as having very divergent injuries/treatments Adjudication was difficult There was no chance of any data collection/analysis

3 Whose codes are we using? World Health Organization Licensed to Canadian Institute of Health Information Licensed to HCAI/IBC ICD10-Ca: International Statistical Classification of Disease and Related Health Problems, Tenth Revision, Canada CCI: Canadian Classification of Health Interventions

4 Goal of Standard Coding Practices To introduce classification systems that can: Provide data to facilitate and advocate for effective management & treatment for injured claimants Facilitate collection of standardized data to support analysis to: Allow predictability in identifying resource and service needs of claimants To facilitate more effective reserving practices by insurers Inform stakeholders about how the system is working Influence and inform policy makers

5 www.cihi.ca

6 Can we change the descriptions of injuries/treatments? No This would defeat the purpose of standard coding practices Example: If the code for WAD II (S13.41) meant something different to each user, data analysis is compromised

7 What can the codes tell insurers? What is the problem that drives the patient’s need (reasonable and necessary) for the services outlined in YOUR treatment plan The link between the services proposed in a plan (or invoice) and the problem should be self-evident.

8 What can’t the codes tell insurers? ICD10-Ca and CCI were not designed for adjudication purposes Primary purpose: To categorize injuries/problems and interventions for data analysis Secondary purpose: To offer a high level description of the problem being treated and the interventions used Details about an individual claimants’ injuries or interventions must be done in narrative form in the body of OCFs

9 What can the codes tell insurers? Health care facilities and insurers must continue to communicate effectively about a claimant’s injury/problem and its treatment Coding is an addition to effective communication Coding does not replace effective communication between health providers and insurers

10 What can the codes tell insurers? Code Descriptions Are Standard (not editable) The codes are intended only to permit classification of injuries and interventions to permit analysis of data. Standard description does not offer depth of information adjuster needs to permit effective adjudication.

11 What can the codes tell insurers? Many codes reflect a number of different activities, but the code won’t tell insurers which activity you are referencing unless you tell them.

12 7SF15 – Brokerage, Service

13 Example: 7SF15 Used for any one or all of: Team conference; Care planning; Discharge planning; Activity programming; Clinical service rounds; Ward rounds The adjuster won’t know unless you tell him/her Use Narrative Sections of Forms to Convey Detailed Injury /Treatment Information

14 Where do you add more detail? OCF 18 Tab 5 - Use the narrative text box located below in Part 12 (up to 500 characters) or Use the last tab (Tab 6) and provide “Additional Comments” OCF 23: Use the last tab (Tab 5) and provide “Additional Comments” OCF 21B Use the last tab (Tab 5) and provide “Additional Comments” OCF 21C: Use the last tab (Tab 5) and provide “Additional Comments”

15 Coding  ICD10-Ca = Why is the claimant seeking care, or being referred to a health provider  The “problem” that drives health expenditures  NB: In HCAI, the problem must be “directly related to the automobile collision”  CCI (and GAP) = What interventions were provided  The health “product/service” that was purchased to address the problem

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17 ICD10-Ca – The Why The injury or sequelae code is not necessarily a diagnosis Any health professional can list any problem; however they should indicate who identified a problem/diagnosis if the problem/diagnosis is not within the scope of practice The problem may be a: Diagnosis: or Condition; or Problem; or Circumstance

18 ICD10-Ca (Main Problem) Main Problem – top lines The problem MOST responsible for the goods and services being proposed/billed for Other Problems – lower lines Problems that may co-exist but that may not drive YOUR costs E.g. depression (dx’d by psychologist or GP) secondary to fractured clavicle

19 ICD10-Ca Example Claimant sustained complete C5-6 SCI Home not accessible Home accessibility assessment Depression Psychological treatment Chronic pain Physiotherapy/Chiro treatment Main Problems OT - Z59.1 – inadequate housing Psych: F32 – Depressive episode PT/DC - R52.1 – Chronic intractable pain

20 Main & Other Problem Example (Main Problem and Other Problem)

21 Physical problems: S vs M S = single INJURY….and certain other consequences of external causes (S00 – S99) T = multiple INJURY involving multiple body regions (T00 – T98) M = DISEASES of the musculoskeletal system and connective tissue (M00 – M99)

22 Coding Classification F Mental & Behavioral Disorders (F00- F99) Z Factors influencing health status and contact with health services (Z00-Z99) Non-physical injuries, consequences or circumstances

23 Coding Classification R Symptoms, signs and abnormal clinical and lab findings not elsewhere classified (R00- R99) R25-R29 – nervous and musculoskeletal systems R40-R46 – cognition, perception, emotional state and behaviour R47-49 – speech and voice R50-R69 – general signs and symptoms

24 Bilateral Physical Injuries Left and right are not specified If bilateral injuries, do not use duplicate codes Instead, use T series “Injury,….and other consequence of external causes (multiple)” Example: bilateral femoral fractures T025 - fractures involving multiple regions of both lower limbs

25 What’s the right injury code? Claimant 1 – in MVA 45 yr old male, otherwise healthy Symptoms are painful neck, slight stiffness of neck, no neurological symptoms Claimant 2 – in MVA 45 yr old male with paraplegia caused 5 yrs ago from fall off a ladder at home Symptoms are painful neck, slight stiffness of neck, no neurological symptoms

26 What’s the right injury code? Claimant 1 WAD II Claimant 2 WAD II

27 What’s the right injury code? Claimant 1 WAD II Claimant 2 WAD II

28 Prior Conditions Prior conditions (Claimant 2) should be addressed in Part 8 of OCF 18 and Part 7 of OCF 23.

29 Treatment/Intervention Coding CCI GAP

30 CCI vs GAP CCI Licensed by CIHI to IBC/HCAI Applicable to all provinces Does not include goods or certain administrative activities GAP Not part of CCI Developed to address interventions that are specific to Ontario’s auto insurance sector Administrative services and goods included

31 CCI and GAP  Service Provider & service setting neutral  No separate MD, physiotherapy, chiropractic, massage or other profession-specific codes  Describes WHAT treatment is being used to manage the main problem and other problems  The problem and treatment should be logically linked

32 CCI Rubric  Rubric – 5-digit codes that provide the intervention, within the group and section  Example  1.SC.04  Section 1 Physical/Physiological Therapeutic Interventions  Group SC Therapeutic interventions to the spinal vertebrae  Intervention 04 – mobilization

33 CCI Rubric – High level codes  Qualifiers – generally not used in HCAI  Example  1.SC.04.JH  Section 1 Physical/Physiological Therapeutic Interventions  Group SC Therapeutic interventions to the spinal vertebrae  Intervention 04 – mobilization  Qualifier JH – using external approach with manual thrust

34 CCI Rubric  Qualifiers (digits 6 & 7) – generally not used in HCAI  3 Exceptions  7.SJ.30.LB  Documentation, support activity (for claim form)  7.SE.02.AB  Assessment of environment (private living space, includes home assessment)  7.SE.02.AW  Assessment of environment (workplace, includes ergonomic and workplace assessment)

35 CCI Rubric – High level codes  Qualifiers (digits 6 & 7) – generally not used in HCAI  Example: 1.TF.09 – stimulation of muscles of arm. Includes all forms of stimulation  i.e. no separate code for laser, versus US or TENS

36 Coding Assessments 2 Options GAP codes Insurer initiated assessments Health provider initiated assessments CCI codes

37 GAP Assessment Codes Insurer Initiated Examinations and reports (Sec 44) IXXAC Attendant Care IXXCA Catastrophic IXXCO Combined Assessments (addressing more than one type of benefit application) IXXDI Disability Pre 104 weeks IXXMR Med/Rehab IXXPW Disability Post 104 Weeks IXXDR Involvement in subsequent dispute resolution

38 GAP Assessment Codes Health Provider Initiated Examinations and reports (Sec 25) HXXAC Attendant Care HXXCA Catastrophic HXXCO Combined Assessments (addressing more than one type of benefit application) HXXDI Disability Pre 104 weeks HXXMR Med/Rehab HXXPW Disability Post 104 Weeks

39 CCI Assessment Codes CCI: Assessment (of/for) 2ZZ02 activities of daily living ^^ diagnostic (with history and physical examination) assistive or adaptive equipment, device or technology (need for) functional capacity/ability (physical) Rehabilitation situational/environmental

40 CCI Assessment Codes CCI: Assessment (of/for) 2.DZ.02 hearing function 2.GE.02 aphasia 2.AZ.08 developmental emotionality intellectual abilities

41 CCI Assessment Codes CCI: Assessment (of/for) 2.GE.02 language function laryngeal function speech (sound production, pattern, and sequencing, rate, rhythm) voice (pitch, intensity, quality, resonance, onset, prosody) 2.CZ.08 vision

42 Coding Assessments Recommend use of GAP codes for assessments Use of CCI assessment codes are also acceptable – but they will offer less insight for analysis GAP permits analysis by section (health provider or insurer initiated)

43 Assessment Details Assessment codes are intended to include all activities required to produce the assessment report booking, file review, administration, photocopying, report preparation, report review, etc

44 Why not detailed coding? 1. 1.Codes don’t exist for many of the admin activities 2. 2.Lack of consistency in codes selected for various administrative activities, leading to: I. I.Lack of standardization II. II.Inability to do analysis

45 Detailed Coding (not recommended)

46 Single line coding + explanation: Recommended

47 Where to explain? Use space available in OCF for narrative OCF 18 – Part 12 (Tab 5) 500 characters; or Additional Comments (Tab 6) 20,000 characters OCF 23 – Additional Comments (Tab 4) 20,000 characters OCF 21B – Additional Information (Tab 4) 500 characters Additional Comments (Tab 5) 20,000 characters

48 Questions?


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