1. Coding Quality Task Force Chart Review Orthopedic Chart September 22, 2006

2. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 Diagnosis Typing

3. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 Comorbidities Comorbidities are all conditions that coexist at the time of admission or develop subsequently and demonstrate at least one of the following: significantly affects the treatment received requires treatment beyond maintenance of the preexisting condition increases the length of stay (LOS) by at least 24 hours. Consider the following in determining whether a condition qualifies as a comorbidity. To support a determination of significance, there must be documented evidence in the physician’s documentation or discharge summary that the condition required at least one of the following: clinical evaluation/consultation, excluding pre-operative anesthetic consults, where new or amended course of treatment is recommended and instituted therapeutic treatment/intervention with a code assignment of 50 or greater from Section 1 of CCI diagnostic intervention, inspection or biopsy with a code assignment from Section 2 of CCI extended the length of stay (LOS) by at least 24 hours Therapeutic intervention on the Flagged Interventions list in Appendix B (see also the coding standard entitled Selection of Interventions to Code From Section 1); or Diagnostic Imaging intervention as outlined in the coding standard Diagnostic Imaging Interventions. Reference – Canadian Coding Standards ICD-10-CA and CCI 2006 – page 9

4. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 Diagnosis Type (2).Post-admit Comorbidity A Diagnosis Type (2) is a condition that arises post-admission, has been assigned an ICD-10-CA code and satisfies the requirements for determining comorbidity. Reference – Canadian Coding Standards ICD-10-CA and CCI 2006 – page 10

5. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 CHART REVIEW 72 year old female with osteoarthritis of the right knee. Presents to hospital for elective total knee replacement Original surgery, January 4 th January 5 th, experienced pain in the right calf and DVT was investigated = doppler negative January 9 th, pain persists with knee swelling

6. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 CHART REVIEW, continued Continued pain, investigated and was clinically diagnosed with dislocation of the surgical knee January 9 th, patient had a closed reduction January 11 th, recurrent dislocation January 11 th, revision of the total knee replacement January 24 th, patient discharged to rehab

7. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 Hospital Dx Coding Selections Hospital AHospital BHospital CHospital D T84.04 M M17.9 MT84.04 M T84.04 2 I10.0 1T84.04 2 M17.9 1S76.18 2 T84.04 2Y83.1 9 D62 2 M17.9 1 Y83.1 9 D64.9 2 I10.0 1M17.9 1 K59.0 3I10.0 1 K21.9 3I10.0 1 E03.9 3K21.9 3 E66.9 3 E03.9 3K21.9 3 E88.0 3E03.9 3 K21.9 3Z72.0 3

8. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 Hospital Dx Coding Selections Hospital EHospital FHospital GHospital H M17.1 MM17.9 M M17.1 M T84.04 2 I10.0 1 T84.04 2T84.8 2Y83.1 9K59.0 1 D62 2Y83.1 9S82.0 2T84.04 2 S86.88 2D62 1M24.46 2S86.98 2 Y83.1 9D72.8 1D62 2Y83.1 9 D72.8 3E03.9 3I10.0 1D62 2 I10.0 3I10.0 1E03.9 3D72.8 1 E03.9 3 K21.9 3 E66.9 3

9. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 Hospital Dx Coding Selections Hospital I T84.04 M S86.88 2 T84.04 2 Y83.1 9 M17.9 1 I 10.0 3 D64.9 3

10. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 Calculating Dx Consensus 4T84.04 M1 S76.18 2 7E66.9 3 3M17.9 M2S86.88 27E03.9 3 2M17.1 M1S86.98 26K21.9 3 2D72.8 12 I 10.0 3 9T84.04 21M24.46 21K59.0 3 4 M17.9 1 1S82.0 21Z72.0 3 7 D62 2 1T84.8 21E88.0 3 2D64.9 21K59.0 12D72.8 3 9Y83.1 9 7I 10.0 1

11. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 Diagnosis Consensus 5/3M17.91Gonarthrosis, unspecified 9T84.042Mechanical complication of knee prosthesis 7D622Acute post hemorrhagic anemia 9Y83.19Surgical operation with implant of artificial internal device 7I10.01Benign hypertension 7E03.93Hypothyroidism, unspecified 6K21.93Gastro-esophageal reflux disease without esophagitis 6E66.93Obesity, unspecified

12. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 Other Dx Codes Used, not making the cut 2D64.9 2Anaemia, unspecified 1S76.18 2Other and unspecified injury of quadriceps muscle and tendon 2S86.88 2Other and unspecified injury of other muscles and tendons at lower leg level 1S86.98 2 Other and unspecified injury of unspecified muscle and tendon at lower leg level 2D72.8 1Other specified disorders of white blood cells (leukocytosis) 1M24.46 2Recurrent dislocation and subluxation of joint, lower leg 1S82.0 2Fracture of patella, closed 1T84.8 2Injury of other nerves at lower leg level 1K59.0 3Constipation 1E88.0 3Disorders of plasma-protein metabolism, not elsewhere classified 3D72.8 3Other specified disorders of white blood cells 1Z72.0 3Tobacco use

13. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 Let’s recap Admission = January 4 th Initial OR = January 4 th Pain began January 5 th, ?DVT = (-) findings Clinical dx of dislocation, January 9th Closed reduction, January 9th Second dislocation, January 11 th Revision, January 11 th

14. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 Recap continued…. Patient discharged January 24th to rehab LOS = 20 days ALOS for TKA = 5 - 8 days Did the mechanical complication of the knee replacement lend to more resources being used?

15. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 Post Admit or Complication taking over case, Canadian Coding Standard says…. If a post-admit comorbidity qualifies as the MRDx, it must be recorded as both the MRDx and as a diagnosis Type (2) Does the above Standard apply here?? Let’s wait and see what CIHI coded……

16. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 Osteoarthrits, primary or unspecified

17. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 Canadian Coding Standards, page 152

18. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 Query ID: 5334 Date: Jul 09, 2002 Patient Type: Inpatient When a Doctor states that the patient has degeneration hip disease with no injury or trauma mentioned would you code M16.1 (primary) or M16.9 (unspecified)? This very question is before the World Health Organization this year. The ICD-10 Update Reference Committee is expected to debate whether "primary" and "unspecified" coxarthrosis are not virtually synonymous. There has been a recommendation to collapse these subcategories. Having given you the current international situation vis a vis this question, we are recommending that -- until this question has been decided by the international community -- you continue to use "primary coxarthrosis" when the physician clearly states that there is no underlying cause. If the physician simply states "osteoarthritis of the hip" and makes no further qualifying statement, then we recommend that you use "unspecified coxarthrosis".

19. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 Did the chart clearly stated that there was no underlying cause? Chart does state: No injury Pain, hips and other knee = Favouring? Previous infection not documented? Previous avascular necrosis? Can not assume … physician education Let’s wait and see what CIHI coded………….

20. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 Anemia – D62 or D64.9 Query # 20941 Question: I am continuing to struggle with coding post-operative anemia. Our doctors will frequently document "post-operative anemia" following orthopedic procedures (mostly hip replacements), but they never specify the cause of the anemia. When the post-op anemia meets the criteria to be considered a diagnosis type 2, our facility has been using the code D64.9 Anemia, unspecified, with an additional external cause code of Y83.1 to identify the fact that the anemia was post-operative. In this case, we are assuming that "anemia" is a post-procedural sign, although it is not listed under post-procedural signs/symptoms on page 200 of the Coding Standards. Are we coding post-op anemia appropriately in this case?

21. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 Answer to Query 20941 First of all we would suggest that a diagnosis of “postoperative anemia” following hip replacement surgery, in the absence of any other stated cause, would be indicative of anemia due to acute blood loss and coded to D62 Acute posthemorrhagic anaemia. We do not currently have a coding standard on the coding of postoperative anemia; therefore, you may wish to verify this with the physician. Hemorrhagic anemia is defined as anemia caused by the sudden and acute loss of blood. Since the physician specifically documents this as “postoperative” anemia you would also select Y83.1.

22. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 Answer to Query 20941 Secondly, the fact that the patient has acute posthemorrhagic anemia does not imply that there was a hemorrhage complicating the procedure but rather that the patient is suffering from anemia due to expected blood loss that occurred during the procedure. Every intervention would have a certain amount of expected blood loss, some interventions (i.e. hip replacments) being greater than others. T81.0 Haemorrhage and haematoma complicating a procedure, not elsewhere classified should only be selected when the physician identifies it as such. Some interventions, by their very nature, are associated with a large amount of blood loss that may sometimes result in posthemorrhagic anemia.

23. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 BUT…………….. If postoperative anemia is documented in the absence of indications that it is due to surgical blood loss, then you would default to D64.9 Anemia, unspecified. Your physician is the best source for clarification of postoperative anemia as the situation and threshold for blood loss is different for every patient. This is why it is so difficult to make a standard on postoperative anemia. Note also that anemia is included in the listing on page 10 of the 2005 Coding Standards. These listings are not meant to be exhaustive. ---------------------------------------------------------------------------------- CIHI will be undating this query to remove the confusion How did CIHI Code this chart……..

24. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 CIHI Response to Diagnosis ICD-10-CA CODE DESCRIPTION CODESDx type DAD ABSTRACT T84.04Mechanical complication of knee prosthesisM T84.04Mechanical complication of knee prosthesis2 T81.0Haemorrhage and haematoma complicating a procedure, not elsewhere classified 3 or not coded D64.9Anaemia, unspecified2 Y83.1Surgical operation with implant of artificial internal device as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure 9 M17.9Gonarthrosis, unspecified1 I10.0Benign hypertension1 K59.0Constipation3 or not coded E03.9Hypothyroidism, unspecified3 or not coded K21.9Gastro-oesophageal reflux disease without oesophagitis3 or not coded E66.9Obesity, unspecified3 or not coded

25. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 DIAGNOSIS DISCUSSION??

26. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 CCI CODES Hospital AHospital BHospital CHospital D 4-Jan 1.VG.53.LA-PP-N S = 0 L = R E = 3 9-Jan 1.VG.73.JA L = R 1.VG.03.JA-SR 1.VG.03.JA-FQ L = R S = R L = R 11-Jan 1.VG.53.LA-PM1.VG.53.LA.PP1.VG.53.LA-PM S = R L = R E = 1 E = 3E = 1 1.VS.80.WU 1.VG.73.JA L = R

27. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 CCI CODES Hospital EHospital FHospital GHospital H 4-Jan 1.VG.53.LA-PP-N S = 0 L = R E = 3 9-Jan 1.VG.73.JA L = R 1.VG.03.JA-FQ 11-Jan 1.VG.53.LA-PM1.VG.53.LA-PM-N1.VG.53.LA-PP-N1.VG.53.LA-PM S = R L = R E = 1 1.VS.80.WU S = R L = R

28. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 CCI CODES Hospital I 4-Jan 1.VG.53.LA-PP-N S = 0 L = R E = 3 9-Jan 1.VG.73.JA L = R 1.VG.03.JA-FQ 11-Jan 1.VG.53.LA-PM S = R L = R E = 1 1.VS.80.WU L = R

29. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 Calculating Dx Consensus 4-Jan 9 1.VG.53.LA-PP-N 9 S = 0 9 L = R 9 E = 3 9-Jan 9 1.VG.73.JA 8 L = R 3 1.VG.03.JA-FQ 11-Jan 6 1.VG.53.LA-PM 6 S = R 6 L = R 6 E = 1 9 1.VS.80.WU

30. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 CCI CONSENSUS 4-Jan 1.VG.53.LA-PP-N Implantation of internal device, knee joint tri component prosthetic device with synthetic material (e.g. bone paste, cement, Dynagraft, Osteoset) Status = 0 Location = R Extent = 3 9-Jan 1.VG.73.JAReduction, knee joint using closed (external) approach Location = R 1.VG.03.JA-FQImmobilization, knee joint using cast immobilization alone 11-Jan 1.VG.53.LA.PMImplantation of internal device, knee joint, single component prosthetic device, uncemented Status = R Location = R Extent = 1 1.VS.80.WU Repair, tendons of lower leg [around knee] simple repair (without graft or transfer involved) using tenodesis technique [tendon looped or sutured to or through bone] Status = R Location = R

31. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 Other CCI Codes Used 9-Jan 2 1.VG.03.JA-SR Immobilization, knee joint using splinting device [e.g. supportive and corrective] immobilization alone L = R 11-Jan 1 1.VG.53.LA.PP Implantation of internal device, knee joint, tri component prosthetic device, uncemented 1 1.VG.53.LA-PM-N Implantation of internal device, knee joint, single component prosthetic device, with synthetic material (e.g. bone paste, cement, Dynagraft, Osteoset) 1 1.VG.53.LA-PP-N Implantation of internal device, knee joint, tri component prosthetic device, with synthetic material (e.g. bone paste, cement, Dynagraft, Osteoset) 1 Extent = 3

32. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 Standards say for Revision…. A revision may be due to mechanical failure, dehiscence, poor functional outcome or any other complication of healing at the anatomy site(s) involved in the initial intervention. It does not matter what the previous surgery was; if a current problem at the old operative site exists, Code the actual intervention that is now being performed and designate it with a status attribute of ‘R’ for revision. Standards, page 43

33. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 Components vs Compartments Components = hardware used excluding nail, screws, wires Compartments = area in which components are being implanted Unicompartmental = medial or lateral Bicompartmental = medial and lateral Tricompartmental = medial, lateral and patellofemoral

34. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 medial lateralcondyle Tibia Femur medial lateral condyle Compartments

35. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 Instructions in CCI under rubric 1.VG.53.^^…. A partial knee replacement involves just a single compartment (medial or lateral) of the joint. More than one prosthetic component is typically used because the medial (or lateral) aspect of both the tibia and femur are replaced. Sometimes a plastic support bearing is also used to act as the meniscus joining the tibial tray and the femoral component -- three components but one compartment.

36. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 Revision Surgery, Jan 11th Plastic Tibial articular surface replaced Single component Bicompartmental = this single component is placed across both the medial and lateral compartments

37. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 Revision could be….. In the case of a revision arthroplasty, a single component may be removed and replaced. This is considered a revision of a total knee replacement (bicompartmental or tricompartmental) using a single component prosthetic device.

38. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 And……… A total knee replacement always involves both the medial and the lateral compartments (bicompartmental, bycondylar) but may also involve the patellofemoral compartment (tricompartmental). When a bicompartmental knee replacement is performed, two prosthetic components will be used and when a tricompartmental knee replacement is performed, three prosthetic components will be used. All attributes are mandatory to support the Canadian Joint Replacement Registry [CJRR] reporting requirements. We will let Dr. Naudie explain this further

39. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006

42. CIHI response to CCI Codes CCI CODE DESCRIPTION CODESATTRIBUTES DAD ABSTRACT 4-Jan-06 1.VG.53.LA-PP-NImplantation of internal device, knee joint, tri component prosthetic device with synthetic material (e.g. bone paste, cement, Dynagraft, Osteoset) Status O Location R Extent 3 9-Jan-06 1.VG.73.JAReduction, knee joint using closed (external) approach Location R 1.VG.03.JA-SRImmobilization, knee joint using splinting device [e.g. supportive and corrective] (optional) 11-Jan-06 1.VG.53.LA-PMImplantation of internal device, knee joint, single component prosthetic device, uncemented Status R Location R Extent (medial&lateral) 1.VS.80.WURepair, tendons of lower leg [around knee] simple repair (without graft or transfer involved) using tenodesis technique [tendon looped or sutured to or through bone] 9-Jan-06 3.KR.30.DCUltrasound, veins of leg NEC with doppler (optional)

43. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 INTERVENTION DISCUSSION??

44. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006

45. A couple more neat websites: www.kneereplacementinfo.com/knee/ www.hipreplacementinfo.com/hip/

46. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 Coding Quality Task Force Committee ‘100%’ volunteer Deb Tetreault, Chair Sandra Lariviere, Privacy Officer Nancy Seers, Secretary Diane Carrothers, Donations Alison Temple, Membership Services Agnes VanderVecht, Coding Support Yvonne Peekhaus, Coding Support Darlene Cambridge, Technical Support Lynne Hopper, OHIMA Representative

47. Coding Quality Task Force Orthopedic Workshop, Sept 22, 2006 Let’s fill the donation tin Your donation goes to pay the expenses to put on this Workshop. The remainder of the money goes to the ‘Charity of Choice’ of the Physician doing the chart review. Dr. Naudie has choosen the ‘Brain Tumor Foundation of Canada’ Let’s thank Dr. Naudie by showing your support to his charity