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ICD-10 The Provider Perspective

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1 ICD-10 The Provider Perspective
Presented by: Joe Nichols MD Date: May 3, 2014

2 Agenda ICD-10, the basic facts How is ICD-10 different? What are the business impacts? Clinical documentation.  What’s needed to support proper coding in ICD-10? What do I need to do to prepare?

3 Source: Health Data Consulting
ICD-10 What is it?

4 Health Data Consulting © 2012
ICD10 Quick Facts ICD-10 international version Adopted by WHO in 1990 Most countries other than the US currently use ICD-10 ICD-10 (International version) ~ 12,500 diagnostic codes ICD-10 used for mortality reporting in the US ICD-10-CM (US version) ~ 69,000 diagnostic codes Final rule published – 2009 Compliance date – Oct 1, 2014 ICD-10-PCS ~72,000 codes Not part of an international standard Inpatient procedures only Source: Health Data Consulting Health Data Consulting © 2012

5 ICD-9 Diagnosis Codes vs. ICD-10-CM (Diagnosis Codes)
3 to 5 digits Alpha “E” and “V” on 1st character No place holder characters Terminology Index and Tabular Structure Coding Guidelines Approximately 14,000 codes Severity parameters limited Does not include laterality Combination codes limited 7 digits Alpha or numeric for any character Include place holder characters (‘x’) Similar Some what similar Approximately 69,000 codes Extensive severity parameters Common definition of laterality Combination codes common Purpose of the slide: This slide illustrate some key differences between ICD-9 and ICD-10 Talking Points: 7 digits are allow allowable in ICD-10 but as little as 3 characters may be valid. A code is only valid if there are no more detailed subcategories or codes underneath it. Currently the first character is always ‘alpha’ and the second character is ‘numeric’ but that could change over time. A place holder ( ‘x’ character) is used to assure that when a code is needed in the 5th ,6th or 7th position that the position of that code is maintained. An example will be given later assuming that the more details presentation is done Emphasize that the unlike the PCS codes the overall terminology and documentation structure is quite similar to ICD-9 Coding guidelines have similarities but there are a number of specific changes that will be discussed in the coding module Severity parameters will be illustrated in the leveraging ICD-10 module Combination codes are codes that contain multiple clinical concepts within a single code. This is the subsequent slides comparing a clinical example of a clinical example in Icd-9 and ICD-10-CM Health Data Consulting © 2012

6 Same Condition – Different Codes
What’s the Difference? September 2014 October 2014 Source: Health Data Consulting ICD-9 ICD-10 82111: Open fracture of Shaft of Femur S72351C: Displaced comminuted fracture of shaft of right femur, initial encounter for open fracture type IIIA, IIIB, or IIIC All codes for femur fractures = 16 All codes for femur fractures = 1530 Health Data Consulting © 2012

7 ICD9 Comparison to ICD10-CM
Diagnosis Codes – Clinical Example A patient is seen in the emergency room with. [severe] [persistent] [asthma] with [acute exacerbation]. ICD9 Code Description 49312 Intrinsic asthma with (acute) exacerbation ICD10 Code Description J4551 Severe persistent asthma with (acute) exacerbation Purpose of the slide: This illustrate the best ICD-9 code and the best ICD-10 code to represent this clinical scenarios. This slide focuses on ICD-9 Talking Points: The bracketed items in red are clinical concepts represented in the ICD-9 code Source: Health Data Consulting Health Data Consulting © 2012

8 ICD9 Comparison to ICD10-CM
Diagnosis Codes – Clinical Example A patient is seen in the emergency room with. [severe] [persistent] [asthma] with [acute exacerbation]. ICD9 Code Description 49312 Intrinsic asthma with (acute) exacerbation ICD10 Code Description J4551 Severe persistent asthma with (acute) exacerbation Purpose of the slide: This illustrate the best ICD-9 code and the best ICD-10 code to represent this clinical scenarios. This slide focuses on ICD-9 Talking Points: The bracketed items in red are clinical concepts represented in the ICD-9 code Health Data Consulting © 2012

9 ICD9 Comparison to ICD10-CM
Diagnosis Codes – Clinical Example A patient is admitted as the result of [rupture of the cardiac wall without bleeding into the pericardium]. The patient is [within 4 weeks] of a [myocardial infarction]. ICD9 Code Description 42979 Certain sequelae of myocardial infarction, not elsewhere classified, other ICD10 Code Description I233 Rupture of cardiac wall without hemopericardium as current complication following acute myocardial infarction Purpose of the slide: This illustrate the best ICD-9 code and the best ICD-10 code to represent this clinical scenarios. This slide focuses on ICD-9 Talking Points: The bracketed items in red are clinical concepts represented in the ICD-9 code Health Data Consulting © 2012

10 ICD9 Comparison to ICD10-CM
Diagnosis Codes – Clinical Example A patient is admitted as the result of [rupture of the cardiac wall without bleeding into the pericardium]. The patient is [within 4 weeks] of a [myocardial infarction]. ICD9 Code Description 42979 Certain sequelae of myocardial infarction, not elsewhere classified, other ICD10 Code Description I233 Rupture of cardiac wall without hemopericardium as current complication following acute myocardial infarction Purpose of the slide: This illustrate the best ICD-9 code and the best ICD-10 code to represent this clinical scenarios. This slide focuses on ICD-9 Talking Points: The bracketed items in red are clinical concepts represented in the ICD-9 code Health Data Consulting © 2012

11 Nature of the Changes Volume
Diagnosis Procedure Source: Health Data Consulting Health Data Consulting © 2012

12 “There are too many Codes”
There are lots of words in the dictionary, but that doesn’t seem to trouble authors… 34,250 (50%) of all ICD-10CM codes are related to the musculoskeletal system 17,045 (25%) of all ICD-10CM codes are related to fractures 10,582 (62%) of fracture codes to distinguish ‘right’ vs. ‘left’ There are over 1800 codes for fractures of the radius (forearm) but only ~ 50 concepts used repeatedly in different patterns Only a very small percentage of the codes will be used most providers Health Data Consulting © 2012

13 Current Distribution of ICD-9 diagnosis codes
3 Years of Data - All claims - All lines of business - 1million Lives Health Data Consulting © 2012 Source: Health Data Consulting

14 Lots of Codes, Lots of Repetition
2466 codes for fractures of the femur

15 Documentation Requirements
Recurring Concepts Concept Number of Codes Initial Encounter 13,932 Subsequent Encounter 21,389 Sequela 11,974 Right 12,704 Left 12,393 Routine Healing 2,913 Delayed Healing Nonunion 2,895 Malunion 2,595 Assault 1096 Self-harm 1057 Accidental 1262 Health Data Consulting © 2013

16 Health Data Consulting © 2012
Varying Code Volume By Clinical Area Clinical Area ICD-9 Codes ICD-10 Codes Fractures 747 17099 Poisoning and toxic effects 244 4662 Pregnancy related conditions 1104 2155 Brain Injury 292 574 Diabetes 69 239 Migraine 40 44 Bleeding disorders 26 29 Mood related disorders 78 71 Hypertensive Disease 33 14 End stage renal disease 11 5 Chronic respiratory failure 7 4 Health Data Consulting © 2012 Source: Health Data Consulting

17 Other Key Changes Code Example – Down’s Syndrome ICD-9 Code
ICD-9 Description 7580 Down’s Syndrome ICD-10 Code ICD-10 Description Q909 Down syndrome, unspecified Q900 Trisomy 21, nonmosaicism (meiotic nondisjunction) Q901 Trisomy 21, mosaicism (mitotic nondisjunction) Q902 Trisomy 21, translocation Health Data Consulting © 2012

18 Other Key Changes Code Examples – Benign neoplasms of the colon:
ICD-9 Code ICD-9 Description 2113 Benign neoplasm of colon ICD-10 Code ICD-10 Description D120 Benign neoplasm of cecum D121 Benign neoplasm of appendix D122 Benign neoplasm of ascending colon D123 Benign neoplasm of transverse colon D124 Benign neoplasm of descending colon D125 Benign neoplasm of sigmoid colon D126 Benign neoplasm of colon, unspecified K635 Polyp of colon Health Data Consulting © 2012

19 Other Key Changes Code Examples – Leukemia: ICD-9 Code
ICD-9 Description 20501 Acute myeloid leukemia, in remission ICD-10 Code ICD-10 Description C9201 Acute myeloblastic leukemia, in remission C9241 Acute promyelocytic leukemia, in remission C9251 Acute myelomonocytic leukemia, in remission C9261 Acute myeloid leukemia with 11q23-abnormality in remission C92A1 Acute myeloid leukemia with multilineage dysplasia, in remission Health Data Consulting © 2012

20 Current Physician thinking on ICD-10
The Challenge Current Physician thinking on ICD-10

21 “There are a bunch of dumb codes that make no sense.”
Clinician organizations have used codes like; “Hit by a spacecraft” or “Suicide by paintball gun” as examples of the “stupidity” of the ICD-10 codes. Interesting to note however is that the codes noted above are ICD-9 codes and have been around for a long time. The bottom line; don’t use the codes that don’t make sense or don’t accurately represent your patient’s condition. They may mean something to someone, but shouldn’t bother you. Health Data Consulting © 2012

22 “ICD-10 won’t help me take care of my patients.”
Difficult to make the case about how ICD-10 will help Dr. Smith with his encounter with Mary Jones Healthcare goes crosses the boundary of time and providers Improving healthcare requires a broad understanding of what works and what doesn't work Clinicians should be leaders in the healthcare industry by providing accurate data, accurate analysis of the data and change in healthcare to continuously improve the value their patients receive

23 “Documentation for ICD-10 is an unnecessary burden.”
The number and type of new concepts required for ICD-10 are not foreign to clinicians The focus of documentation is good patient care Patients deserve to have accurate and complete documentation of their conditions If other industries understand the value of accurate and complete documentation of data about encounters; shouldn’t we? Health Data Consulting © 2013

24 “ICD diagnosis codes are irrelevant to my business.”
ICD-10 codes are likely to factor into: Changes in reimbursement based on both “what” was done and “why” Managing financial risks for contracted populations (ACO’s) Changes in reimbursement based on more robust models of payment adjusted for risk and severity More sophisticated weighting of payments based on DRGs, episodes or other groupers of care. Health Data Consulting © 2013

25 It’s bigger than you think
Business Impacts It’s bigger than you think

26 Business Impacts Coding Contracting Billing
EHR updates Super Bill??? Training Coding software Contracting Scope of services Case rates Carve outs Billing Billing code updates Charge masters Billing Edits Benefits and coverage determinations View of the structure of PCS codes

27 Business Impacts (Cont.)
Compliance HIPAA Reporting National State Regional Initiatives Contract requirement Accreditation Reimbursement Pay for performance POA, “never events”, re-admissions, HACs, tiered payment models Network inclusion Denials Audits RAC Fraud and abuse Coding Health Data Consulting © 2013

28 Coding ICD-10-CM - Challenges
Getting there Example look up for “Coronary Artery Disease” + “Angina” Purpose of the slide: Illustrate the challenges in looking up a common condition “Coronary Artery Disease + Angina” in the standard ICD-10 alphabetical index Talking Points: Coding guidelines suggest going first to the index to search for a code and then to the tabular index. Health Data Consulting © 2012

29 Coding ICD-10 CM - Challenges
Same concept in many places Condition Tabular Category Number of codes Hypertension Hypertensive Disease 14 Other Categories (14) 115 Pneumonia Influenza and Pneumonia 38 Other Categories (18) 42 Genitourinary Disorders Diseases of the Genitourinary System 587 535 Health Data Consulting © 2012

30 Coding ICD-10 CM - Challenges
Relevant Quote "If you don't find it in the index, look very carefully through the entire catalogue."        -- Unknown

31 Health Data Consulting © 2010
Business Impacts Coding EHR updates Super Bill??? Training Coding software Contracting Scope of services Case rates Carve outs Billing Billing code updates Charge masters Billing Edits Benefits and coverage determinations View of the structure of PCS codes Health Data Consulting © 2010

32 Business Impacts Compliance Reimbursement Audits HIPAA Reporting
National State Regional Initiatives Contract Accreditation Reimbursement Pay for performance POA, “Never Events”, Tier Models Network inclusion Denials Audits RAC Fraud and abuse Coding View of the structure of PCS codes

33 Quality Measures Impacts
AMI example Definition of acute myocardial infarction (MI) has changed ICD-9 – Eight weeks from initial onset ICD-10 – Four weeks from initial onset Subsequent vs. Initial episode of care ICD-9 – Fifth character defines initial vs. subsequent episode of care ICD-10 – No ability to distinguish initial vs. subsequent episode of care Subsequent (MI) ICD-9 – No ability to relate a subsequent MI to an initial MI ICD-10 – Separate category to define a subsequent MI occurring within 4 weeks of an initial MI Health Data Consulting © 2013

34 Fraud Waste and Abuse If you can’t stop expenditures upfront …
4/13/2017 Fraud Waste and Abuse If you can’t stop expenditures upfront … Fraud, Waste and Abuse Enough money to take care of a lot of need. The Office of Management and Budget estimates that every $1 invested to fight fraud results in approximately $17 in savings. Purpose of the slide To answer some of the basic questions about ICD-10: what, why, who, and when. Talking Points The National Health Care Anti-Fraud Association estimates that fraud amounts to at last three percent of total health care spending, or more than $60 billion per year. Increases funding for the Health Care Fraud and Abuse Control fund to fight fraud in public programs. The Office of Management and Budget estimates that every $1 invested to fight fraud results in approximately $17 in savings. $60,000,000,000/Year Source: National Health Care Anti-Fraud Association / OMB

35 Coding: The Prime Directive
The goal of coding is to reflect as accurately as possible key parameters of the patient health condition and/or the procedures done to maintain or improve that condition. Coding focused on maximizing payment over accurate definition of the condition begins to cross the boundary of fraud and abuse. Health Data Consulting © 2012

36 Fraud, Waste and Abuse Medicare Definition Source: CMS

37 Fraud, Waste and Abuse Don’t get caught in the trap… With increasing challenges to control cost, the intensity of audits related to fraud, waste and abuse is increasing. In the “Justification of Estimates for Appropriations Committees” CMS states: “Although the ICD-10 code set will not eliminate all fraud, waste, and abuse, CMS believes that its increased specificity will make it much more difficult for fraud, waste and abuse to occur.” Source: CMS

38 Fraud, Waste and Abuse Don’t get caught in the trap…
4 Billion Recovered in 2013 Source: CMS

39 Healthcare on the “RAC”
Getting tighter… Source: CMS Health Data Consulting © 2012

40 Health Data Consulting © 2010
The Super Bill Not That Super Really… [Note] For all codes related to fractures of the radius: ICD-9 codes = 33 ICD-10 codes = 1818 Health Data Consulting © 2010

41 Health Data Consulting © 2012
Cash Flow Impacts inbound and outbound Coding Challenges Payment Delays Increased Cost Health Data Consulting © 2012

42 Health Data Consulting © 2012
Cash Flow Impacts inbound and outbound Source: CMS Health Data Consulting © 2012

43 Documentation and Coding – The Patient Interface
Where it all begins Physical Exam Internal Record Review History External Record Review Studies Assessment/Diagnosis

44 Bad Mojo Documentation is not a diagnosis
It could be better… Bad Mojo is not a diagnosis Poor quality documentation is bad for Payers, Providers and Patients. Billing accuracy Quality measures Population management Risk management Healthcare analytics Patient Care

45 Documentation 1889

46 Documentation 1889

47 Documentation 1889

48 Documentation 1889

49 Documentation 2013 Progress?

50

51 Health Data Consulting © 2012
Documentation Why is it important? Supports proper payment reduced denials Assures accurate measures of quality and efficiency Assures accountability and transparency Captures the level of risk and severity Provides better business intelligence Supports clinical research Enhances communication with hospital and other providers It’s just good care! Source: Health Data Consulting Health Data Consulting © 2012

52 Health Data Consulting © 2012
Good patient data It’s all about good patient care… Complete observation of all objective and subjective facts relevant to the patient condition Documentation of all of the key medical concepts relevant to patient care currently and in the future Coding that includes all of the key medical concepts supported by the coding standard and guidelines Health Data Consulting © 2012

53 Health Data Consulting © 2012
Medical Concepts Expressing the patient condition in codes. Medical Scenario: A [27 year old] [male] patient is seen in [follow-up] for a [Smith’s fracture] on the [right] that was exposed through an [open wound] with [minimal opening and minimal tissue damage]. The fracture has [not healed after 6 months]. Though not explicitly stated in this scenario certain expressions imply other concepts: “Smith’s fracture” >> [fracture], [radius], [distal], [dorsal angulation], [extra- articular], [displaced] “minimal opening and minimal tissue damage” >> [Gustilo classification I] “not healed after 6 months” >> [nonunion] Purpose of the slide: To illustrate how medical concepts may be documented in a clinical record as well as the fact the concepts may be implied and not explicitly stated Talking Points: Point out how the following slide demonstrates how the ontology would map the medical concepts indicated in this scenario to ICD-9, ICD-10 and Snomed codes that are chosen to represent as accurately as possible the patients conditions as defined in this scenario. Health Data Consulting © 2012

54 Health Data Consulting © 2012

55 Neurologic complications
Coding ICD-10 CM Diabetes Concepts Diabetes = 276 ICD-10 Codes / 83 ICD-9 Codes Unique concepts within in ICD-10 codes = 62 Diabetes Type Pregnancy Neurologic complications Type 1 diabetes First trimester Neurological complication Type 2 diabetes Second trimester Neuropathy Underlying condition Third trimester Mononeuropathy Drug or chemical induced Childbirth Polyneuropathy Pre-existing Puerperium Autonomic (poly)neuropathy Gestational Antepartum Amyotrophy Poisoning by insulin and oral hypoglycemic Postpartum Coma Adverse effect of insulin and oral hypoglycemic Underdosing of insulin and oral hypoglycemic Neonatal Secondary Health Data Consulting © 2012

56 Ophthalmologic Complications
Coding ICD-10 CM Diabetes Concepts Lab Findings Renal complications Ophthalmologic Complications Ketoacidosis Nephropathy Retinopathy Hyperosmolarity Chronic kidney disease Macular edema Hypoglycemia Kidney complication Cataract Hyperglycemia Ophthalmic complication Mild nonproliferative retinopathy Moderate nonproliferative retinopathy Severe nonproliferative retinopathy Proliferative retinopathy Background neuropathy Health Data Consulting © 2012

57 Vascular Complications
Coding ICD-10 CM Diabetes Concepts Vascular Complications Skin Complications Joint Complications Circulatory complications Dermatitis Neuropathic arthropathy Peripheral angiopathy Foot Ulcer Arthropathy Gangrene Skin complications Skin ulcer Health Data Consulting © 2012

58 Coding ICD-10 CM Diabetes Concepts Oral Complications Diabetic Control
Encounter Other Concepts Oral complications Diet-controlled Initial encounter Complications Periodontal disease Insulin controlled Subsequent encounter Right Uncontrolled Sequela Left Controlled Accidental Intentional self-harm Assault Family history Personal history Screening Health Data Consulting © 2012

59 Health Data Consulting © 2012
Source: Health Data Consulting Otitis Media Health Data Consulting © 2012

60 ICD-10 Relevant Documentation
Otitis Media Concepts: Type: Serous Supparative or non-supparative Tubotympanic Atticoantral Allergic Mucoid Health Data Consulting © 2012

61 ICD-10 Relevant Documentation
Otitis Media Concepts: Type (alternate terms): Sanguinous Seromucinous Exudative Transudative Secretory with effusion (non-purulent) Catarrhal Purulent Myringitis Health Data Consulting © 2012

62 ICD-10 Relevant Documentation
Otitis Media Concepts: Associated with: With spontaneous rupture of the TM Without spontaneous rupture of the TM Infectious or other external agent… Smoking Exposure to environmental tobacco smoke History of tobacco use Occupational exposure to environmental tobacco smoke Tobacco dependence Tobacco use Allergic or non-allergic Health Data Consulting © 2012

63 ICD-10 Relevant Documentation
Otitis Media Concepts: Temporal Factors: Acute or subacute or chronic Recurrent Laterality: Left or right Bilateral or unilateral Health Data Consulting © 2012

64 ICD-10 Relevant Documentation
Code Examples – Otitis Media: ICD-10 Code Description B053 Measles complicated by otitis media H6501 Acute serous otitis media, right ear H65113 Acute and subacute allergic otitis media (mucoid) (sanguinous) (serous), bilateral H65194 Other acute nonsuppurative otitis media, recurrent, right ear H6532 Chronic mucoid otitis media, left ear H66012 Acute suppurative otitis media with spontaneous rupture of ear drum, left ear H6613 Chronic tubotympanic suppurative otitis media, bilateral H6622 Chronic atticoantral suppurative otitis media, left ear J1183 Influenza due to unidentified influenza virus with otitis media Health Data Consulting © 2012

65 Health Data Consulting © 2013
Source: Health Data Consulting Fractures Radius Femur Health Data Consulting © 2013

66 ICD-10 Relevant Documentation
Fracture Concepts: Type of Fracture: Pathologic fracture Stress fracture Torus fracture Greenstick fracture Osteoporosis related Health Data Consulting © 2013

67 ICD-10 Relevant Documentation
Fracture Concepts: Type of Fracture: Open or Closed Gustillo type I or II Gustillo type IIIA, IIIB, or IIIC Physeal Fracture Salter Harris I Salter Harris II Salter Harris III Salter Harris IV Health Data Consulting © 2013

68 Health Data Consulting © 2013
Open Fractures Gustilo Classification Grade I:         - wound less than 1 cm w/ minimal soft tissue injury;         - wound bed is clean         - bone injury is simple w/ minimal comminution;         - w/ IM nailing, average time to union is weeks;  Grade II:         - wound is greater than 1 cm w/ moderate soft tissue injury;         - wound bed is moderately contaminated;         - fracture contains moderate comminution;         - w/ IM nailing, average time to union is weeks; *Source: Duke Orthopedics Health Data Consulting © 2013

69 Health Data Consulting © 2012
Open Fractures Gustilo Classification Grade III:     - following frx automatically results in classification as type III:          - segmental frx w/ displacement          - frx w/ diaphyseal segmental loss;          - frx w/ associated vascular injury requiring repair;          - farmyard injuries or highly contaminated wounds;          - high velocity BSW;          - frx caused by crushing force from fast moving vehicle *Source: Duke Orthopedics Health Data Consulting © 2012

70 Health Data Consulting © 2013
Open Fractures Gustilo Classification Grade III A:          - wound less than 10 cm w/ crushed tissue and contamination;          - soft tissue coverage of bone is usually possible;          - w/ IM nailing, average time to union is weeks;  Grade III B:          - wound greater than 10 cm w/ crushed tissue and contamination;          - soft tissue is inadequate and requires regional or free flap;          - w/ IM nailing, average time to union is weeks; Grade III C:          - is frx in which there is a major vascular injury requiring repair for limb salvage;          - fractures can be classified using the MESS:          - in some cases it will be necessary to consider BKA following tibial frx *Source: Duke Orthopedics Health Data Consulting © 2013

71 Growth Plate Fractures
Salter-Harris Classification Health Data Consulting © 2013

72 ICD-10 Relevant Documentation
Fracture Concepts: Laterality: Left Right Unilateral Bilateral Spatial Localization: Proximal Distal Medial Lateral Health Data Consulting © 2013

73 ICD-10 Relevant Documentation
Fracture Concepts: Encounter: Initial Subsequent Sequela Healing pattern: Routine Healing Delayed healing Nonunion Malunion Health Data Consulting © 2013

74 ICD-10 Relevant Documentation
Fracture Concepts: Fracture Patterns: Displace/Non-displaced Transverse, Oblique, Spiral Simple , Comminuted, Segmental 3 part.., Intra-articular/Extra-articular Avulsion Health Data Consulting © 2013

75 ICD-10 Relevant Documentation
Fracture Concepts: Fracture Patterns: Osteochondral or Articular Blowout Fracture Longitudinal Pilon Fracture Compression Fracture Wedge Fracture Health Data Consulting © 2012

76 ICD-10 Relevant Documentation
Fracture Concepts - Radius: Parts of the Bone: Radius Radial Head Radial Styloid Shaft Neck Radius and ulna Radial tuberosity

77 ICD-10 Relevant Documentation
Fracture Concepts-Radius: Named Fractures of the Radius: Colles’ Smith’s Galeazzi’s Barton’s Chauffeur’s

78 ICD-10 Relevant Documentation
Code Example – Radial Fractures: ICD-10 Code Description M84534G Pathological fracture in neoplastic disease, left radius, subsequent encounter for fracture with delayed healing S52121B Displaced fracture of head of right radius, initial encounter for open fracture type I or II S52112P Torus fracture of upper end of left radius, subsequent encounter for fracture with malunion S52321A Displaced transverse fracture of shaft of right radius, initial encounter for closed fracture S52331J Displaced oblique fracture of shaft of right radius, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing S52549M Smith's fracture of unspecified radius, subsequent encounter for open fracture type I or II with nonunion S59111S Salter-Harris Type I physeal fracture of upper end of radius, right arm, sequela S52516K Nondisplaced fracture of unspecified radial styloid process, subsequent encounter for closed fracture with nonunion Health Data Consulting © 2013

79 Health Data Consulting © 2013
The Femur Anatomy Health Data Consulting © 2013

80 The Femur Fracture Patterns Sub Capital Inter-Trochanteric
Sub-Trochanteric Oblique Transverse Supra-Condylar Spiral Medial Condylar Lateral Condylar Intra-Condylar

81 ICD-10 Relevant Documentation
Code Example – Femur: ICD-10 Code Description M80052A Age-related osteoporosis with current pathological fracture, left femur, initial encounter for fracture M84351D Stress fracture, right femur, subsequent encounter for fracture with routine healing S72032H Displaced midcervical fracture of left femur, subsequent encounter for open fracture type I or II with delayed healing S72051P Unspecified fracture of head of right femur, subsequent encounter for closed fracture with malunion S72142K Displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with nonunion S72322A Displaced transverse fracture of shaft of left femur, initial encounter for closed fracture S72335B Nondisplaced oblique fracture of shaft of left femur, initial encounter for open fracture type I or II S72422G Displaced fracture of lateral condyle of left femur, subsequent encounter for closed fracture with delayed healing Health Data Consulting © 2013

82 Getting Specific When is unspecified OK?
Slides High level discussion of the business impacts of ICD-10 Getting Specific When is unspecified OK?

83 Health Data Consulting © 2012
Coding specificity What’s an unspecified code? Does specificity require more than one code? When is unspecified the right choice? When should unspecified change to specified? Health Data Consulting © 2012

84 Poorly Specified Coding
A proposed definition “Coding that does not fully define important parameters of the patient condition that could otherwise be defined given information available to the observer (clinician) and the coder.” Health Data Consulting © 2012

85 Health Data Consulting © 2012
Coding specificity More than one code. Beyond the primary code, accurate representation of the patient’s health condition may require other codes to represent: Causation Infectious, chemical, physical or other agents Location of Injury External causes of injury Manifestations Comorbid condition or contributing factors Sequela Findings Multiple other factors associated with the primary condition being treated or evaluated Health Data Consulting © 2012

86 Coding specificity Sometimes unspecified makes sense…
A place for “unspecified” codes Sometimes unspecified makes sense… The patient may be early in the course of evaluation The claim may be coming from a provider who is not directly related to diagnosis of the patients condition The clinician seeing the patient may be more of a generalist and not able to define the condition at a level of detail expected by a specialist Source: Health Data Consulting

87 Health Data Consulting © 2012
Coding specificity No place for “unspecified” codes If there is sufficient information available to more accurately define the condition For basic concepts such as: Laterality (Right, Left, Bilateral, Unilateral) Anatomical locations Trimester Type of diabetes Known complications or comorbidities Description of severity, acute or chronic or other known parameters… Where care is implemented that demands a more specific level of detail At specialty level that should be able to define the detail required Health Data Consulting © 2012

88 Clinical / Business/Coding Relationships
Creating a new working relationship The role of the clinician is to document as accurately as possible the nature of the patient conditions and services done to maintain or improve those conditions The role of the coding professional is to assure that coding is consistent with the documentation The role of the business manager is to assure that all billing is accurately coded and supported by the documented facts. Source: Health Data Consulting Health Data Consulting © 2012

89 Getting your ducks in a row
Slides High level discussion of the business impacts of ICD-10 Implementation Getting your ducks in a row

90 Implementation Strategy
Short term goals with a long term visions What solution do I need today? Will that solution extend to tomorrows needs? Awareness of touch points with other initiatives Overlap and conflicts Down Stream Impacts What works well for one business area, may bring another business area to it’s knees Positioning for competitive advantage Can you predict risk better than you competitor? Are you perceived as a supporter and facilitator for the transition challenge to providers and other stakeholders? Can you manage the “burden of illness” of your population better than your competitors? Health Data Consulting © 2012

91 Health Data Consulting © 2012
Phases of Transition Assessment Inventory of impacted systems and processes Identifying risk Analysis/Planning Prioritizing focus Establishing business area specific approaches Creating specifications for mapping to support implementation Implementation and Operations Translating codes from 9 to 10 and from 10 to 9 using crosswalks Changing analytic models to support both codes Operationalization of coding to ICD10 from source information Changing processing logic to operate directly from ICD10 codes Leveraging ICD10 capabilities Using the enhanced information within ICD10 codes to improve processing and analysis based on improved concepts buried within the ICD10 codes Health Data Consulting © 2012

92 Scenario-Based Testing
What is it? The scenario: The identification of some event or condition that we are familiar with today Recreating that event virtually through some verbal or data representation Defining a variety of assumptions and variables around this virtual representation Applying one or more of these scenarios in a Reference Implementation Model (RIM). Walk through current systems or processes using these scenarios with varying assumptions and variables to determine if expected results can be achieved and the required changes to achieve those expected results. Health Data Consulting © 2012

93 Health Data Consulting © 2012
Leveraging ICD10 A changing world of cost containment Accurate and complete documentation and coding provides opportunities to support the transition into a “value-based”, “accountable care” reimbursement environment. Better representation of severity and risk Recognition of varying levels of complexity Better claim information to support automated processing and more rapid reimbursement Opportunities to reduce audit risk exposure Improved business intelligence to support population risk management More accurate measures of quality and efficiency Health Data Consulting © 2012

94 Health Data Consulting © 2012
Summary Key Points ICD-10 will be a substantial change in the standard for defining the patient’s health state and the institutional procedures performed to maintain or improve that health state. There are significant impacts and changes to both the clinical and business side of the practice. Coding accuracy and productivity will be substantially impacted during the transition and will impact both cost and revenue. There are significant new opportunities to leverage ICD-10 in a new payment environment (ACO). Source: Health Data Consulting Purpose of the slide: Summation of key point discussed in the presentation Health Data Consulting © 2012

95 Health Data Consulting © 2012
Summary Action Items Establish awareness across members of your organization Clearly define strategic goals Identify internal and external dependencies Identify and prioritized key risks Clearly define all business requirements and implementation tasks Create a realistic project plan and support it as a priority Test early and often. Get started now!! Source: Health Data Consulting Purpose of the slide: Summary of important action items to consider moving forward Health Data Consulting © 2012

96 Questions ? Slides High level discussion of the business impacts of ICD-10

97 Online Resources CMS - https://www.cms.gov/ICD10/
Coding Documentation (Indexes, Coding Guidelines, Code Files) General Equivalency Mapping [GEM] (Mapping files, Guidelines, Procedure and Diagnosis) FAQ, Coordination and maintenance Committee minutes WEDI - List serves Workgroups White papers Implementation forums Industry advocacy and issue Access to standards leaders AHIMA - Training and certification Extensive documentation libraries Bookstore Communities of practices ICD-10 focused conferences Source: Health Data Consulting

98 Online Resources Blogs HIMSS- http://www.himss.org/ Vendors
White papers Bookstore Webinars Vendors Consulting Organization Online news ICD-10 watch -http://www.icd10watch.com/ Blogs Source: Health Data Consulting

99 Online Resources Health Data Consulting white papers:
ICD-10 Vendor Evaluation ICD-10 A Primer ICD-10 Physician Impacts ICD-10 Hospital Impacts Scenario Based Testing ICD-10 The Case for Moving Forward Transition to ICD-10: Getting Started Reconciling Analytics Across the ICD-10 Transition Contingency Planning Source: Health Data Consulting


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