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Why it is important and how it affects you as a physician. Jeni Smith, CPC.

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Presentation on theme: "Why it is important and how it affects you as a physician. Jeni Smith, CPC."— Presentation transcript:

1 Why it is important and how it affects you as a physician. Jeni Smith, CPC

2  Quality Report Suffers  It will not paint an accurate picture of the severity of the illnesses  Severity of illness is a measure of the patient's overall health status reflected by the resources necessary for care and the risk of morbidity and mortality  “severity of illness is understated 8%-15% of the time. Mortality is understated 15%-25% of the time.” (For the Record, page 11)  Reporting comorbidities and illness severity will help better define quality of care and medical necessity for that care.

3  RAC Audits  85% of Medicare RAC audit identified overpayments have been directly related to coding, determination of medical necessity and/or a need to enhance detailed documentation gathered in support of submitted claims.  RAC took back over $900 Million from hospitals (Took 3 Mil. from AGH)  More MCC, can lead to increased level of visit  Increases in morbidity, mortality, and length of stay will not correlate with the documented severity of illness which could lead to red flags

4  Transfer to ICD-10 System Inevitable  ICD-10 offers more detailed information and the ability to expand specificity  Greater specificity and clinical information, which results in: Improved ability to measure health care services Increased sensitivity when refining grouping and reimbursement methodologies

5  A code is invalid if it has not been coded to the full number of digits required for that code.  Provider reports the full ICD-9-CM  ICD-9 codes may have three to five digits depending on their category.  Each digit provides important information about the patient's condition.

6 ICD- D 9-CM Diagnosis Code Descripition (Can be found on lab sheet) 585.1Stage 1 585.2Stage 2 (mild) 585.3Stage 3 (moderate) 585.4Stage 4 (severe) 585.5Stage 5 585.6End Stage Renal Disease 585.9Chronic Kidney Disease, (unspecified)

7 250.13, uncontrolled type 1 diabetes with ketoacidosis. Choosing the most specific code means coding only what you know to be a fact.  The three-digit code (in this case, 250) represents the diagnostic category.  The fourth digit identifies complications associated with diabetes  The fifth digit describes the type of diabetes and its level of control. To correctly code an encounter with a patient who has uncontrolled type 1 diabetes complicated by ketoacidosis, you should use all five digits.

8  Patient, follow-up of benign essential hypertension = 401.1 ( The fourth digit identifies the disease as benign and thus is the most specific description of your patient's condition)  However, patient also has benign hypertensive heart disease, include a fifth digit = 402.10 or 402.11 ( depending on the absence or presence, respectively, of congestive heart failure)

9  You must always code to the highest number of digits that best describe your patient's condition  Physicians are legally responsible for the codes selected and submitted to payers.  Coding to the highest specificity allows for more accurate report of quality of care and will prepare you for possible RAC audits and the implementation of ICD-10-CM.

10  Heart Failure – Systolic or Diastolic  COPD – Need to state acute exacerbation  Sepsis – If code as 599.0, translates to UTI -Need to state Sepsis due to UTI  CVA – State with Residual or presenting symptoms  Anemia – Chronic, Acute blood loss, iron deficiency  Pneumonia – Which Bacteria  DM – Need type and whether controlled/uncontrolled  Morbid Obesity – Must state BMI, can increase reimbursement by thousands (Already calculated on MAR)

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