Medicine Under the Microscope

Value Based Purchasing, Changes for ICD-10 and the Future of Urology Robert S. Gold, MD

Medicine Under the Microscope
Morbidity Mortality Cost per patient Resource utilization Length of stay Complications Outcomes ARE YOU SAFE – avoiding harm, avoidable readmissions?

Value-Based Purchasing Program
Beginning in FY 2013 and continuing annually, CMS will adjust hospital payments under the VBP program based on how well hospitals perform or improve their performance on a set of quality measures. The initial set of 13 measures includes three mortality measures, two AHRQ composite measures, and eight hospital-acquired condition (HAC) measures. The FY 2012 IPPS final rule (available at includes a complete list of the 13 measures.

Where Does This Data Come From?
Documentation leads to identification of diagnoses and procedures Recognition of diagnoses and procedures lead to ICD codes – THE TRUE KEY ICD codes lead to APR-DRG assignment APR-DRG assignment massaged to “Severity Adjustments Severity adjusted data leads to morbidity and mortality rates

World Health Organization and ICD Codes
Semantics Coding guidelines and conventions Use of signs, symbols, arrows Accuracy and specificity Relationship between accuracy and specificity of code assignment and Complexity of Medical Decision Making

Is There a Diagnosis? 82 yo WF altered mental status, shaking chills, fevers, decr UO, T = 103, P = 124, R = 34, BP = 70/40 persistent despite 1 L NS, on Dopamine, pO2 = 78 on non-rebreather, pH = 7.18, pCO2 = 105, WBC = 17,500, left shift, BUN = 78, Cr = 5.4, CXR – Right UL infiltrates, start Cefipime, Clinda, Tx to ICU. May have to intubate – full resusc.

Is There a Diagnosis? Assessment/Plan
82 YO F patient presented to ER with: 1. Sepsis, 2. Septic Shock, 3. Acute Hypercapnic Respiratory Failure, 4. Acute Renal Failure due to #2, (don’t forget CKD and stage, if present) 5. Aspiration Pneumonia, 6. Metabolic Encephalopathy Will transfer to ICU, continue Dopamine and monitor respiratory status for possible ARDS, renal status with hydration and initiate Cefapime/clindamycin for possible aspiration pneumonia CC time 1hr 45 minutes John Smith MD

So What’s the Difference?
Principal Diagnosis Chills and Fever Sepsis Secondary Diagnoses Altered mental status Septic Shock Acute Respiratory Failure Aspiration Pneumonia Acute Renal Failure (or AKI) Respiratory Acidosis Metabolic Encephalopathy Medicare MS-DRG 864 Fever w/o CC/MCC Septicemia or severe Sepsis w/o MV 96+ hrs w/ MCC APR-DRG 722 Fever 720 Septicemia & Disseminated infection APR-DRG Severity Illness 1 – Minor 4 – Extreme APR-DRG Risk of Mortality 4 - Extreme Medicare MS-DRG Rel Wt 0.8153 1.8437 APR DRG Relative Weight 0.3556 2.9772 National Mortality Rate (APR Adjusted) 0.04% 62.02%

What Is An Index?

What Is An Index? Mortality index Complication index
Length of stay index Cost per patient index Observed Rate of Some Thing Severity Adjusted Expected Rate of That Thing =1

Profiles Come from Severity Adjusted Statistics
<1; preferred provider –  significantly better =1; as good as the next guy Observed mortality Expected mortality From severity adjusted DRGs >1; excessive mortality; find another provider - 

Patient Safety

Surgery Bundling Test Model
Disclosed May 16, 2008 ACE (Acute Care Episode) project Combine Part B payments with Part A “Value Based Centers” started with Texas, Oklahoma, New Mexico and Colorado Value based purchasing 28 cardiac and 9 orthopedic inpatient surgical services Gainsharing also permitted here Based on severity adjusted financial outcomes

Florida Blue and Mayo Clinic Introduce Knee Replacement Bundled Payment Program
Friday, December 14, 2012 JACKSONVILLE, Fla. — Florida Blue and Mayo Clinic jointly announce a new collaboration aimed at providing the utmost in quality care for knee replacement patients in Florida. The two Florida health care leaders are teaming up to create a bundled payment agreement specific to the treatment of knee replacement surgery. Knee replacement surgery is the most common joint replacement procedure. According to the Agency for Healthcare Research and Quality, health care professionals perform more than 600,000 knee replacements annually in the United States.

Florida Blue and Holy Cross Create Accountable Care Arrangement
Jacksonville and Fort Lauderdale, Fla. – Florida Blue, Florida’s Blue Cross and Blue Shield Company, and Holy Cross Physician Partners are pleased to announce that effective January 1, 2013, Holy Cross Physician Partners will participate in the Florida Blue Accountable Care Program. “Florida Blue is excited to expand our relationship with Holy Cross surrounding this exciting new partnership,” said Dr. Jonathan Gavras, chief medical officer and senior vice president for Florida Blue. “In the age of reform, both organizations realize the importance of moving away from the fee-for-service model to one that focuses on quality outcomes that will benefit our members in South Florida.”

Aetna, Baptist Memorial Health Care Announce Collaborative Care Agreement
Thursday, April 25, :11 pm EDT MEMPHIS, Tenn.--(BUSINESS WIRE)--Aetna (NYSE: AET) and Baptist Memorial Health Care today announced a collaborative care agreement to bring a new health care model to Aetna members and introduce Aetna Whole HealthSM, a commercial health care product. This collaboration will give employers and their workers access to highly coordinated care from physicians and facilities in the Baptist Select Health Alliance. The Baptist Select Health Alliance is a clinically integrated group of physicians focused on tracking outcomes, sharing data and measuring clinical standards to improve quality and efficiency. In collaborative care models, a group of health care providers delivers more coordinated care for patients to drive better quality and lower overall costs. Through Baptist Memorial Health Care, Aetna members will receive an enhanced level of coordinated care in addition to the member benefits of their current Aetna plan.

Getting Studies Paid For Laboratory/Radiographic
Bundled payment modes rely on payment being made for lab or x-ray studies Validation of reason for performing any procedure or test depends on Medical Necessity Local Medical Review Policies (LMRPs), Local or National Coverage Determinations (LCDs, NCDs) Not giving a reason for a test you order (symptom or diagnosis) could result in: Advance Beneficiary Notification (ABN) saying patient may have to pay for the test Somebody bugging you for a reason for the test

Readmissions Initiative
Identify hospitals with excess readmissions for certain selected conditions beginning in FY 2013 for discharges on or after October 1, 2012. Acute myocardial infarction (i.e., heart attack) Heart failure Pneumonia Definition of readmission: “occurring when a patient is discharged from the applicable hospital and then is admitted to the same or another acute care hospital within a specified time period from the time of discharge from the index hospitalization.” The specified time period would be 30 days. 20 20

Clinical Integration CMS proposes to pay separately for complex chronic care management services starting in 2015. "Specifically, we proposed to pay for non-face-to-face complex chronic care management services for Medicare beneficiaries who have multiple, significant, chronic conditions (two or more)." Rather than paying based on face-to-face visits, CMS would use "G-codes" to pay for revision of care plans, communication with other treating professionals, and medication management over 90-day periods. These code payments would require that beneficiaries have an annual wellness visit, that a single practitioner furnish these services, and that the beneficiary consent to this arrangement over a one-year period.

Patient Safety Indicators
Hospital acquired preventable diagnoses Hospital falls that lead to patient damage (fractures, etc.) Mediastinitis post-CABG Catheter-associated UTIs – Foley, suprapubic cystostomy, nephrostomy, ureteral stents Vascular catheter associated infections Pressure ulcers Iatrogenic pneumothorax following central line insertion Object accidentally left in patient Air embolism Reaction from blood incompatibility

What Does This Mean? Properly identify complication of care when complication – specify when due to a disease We don’t want to assign complication codes when not complication If event due to disease, not a complication If even doesn’t exist, not a complication Don’t use the word “post-op” in the post-op period!

Is an Adverse Event Always a Complication?
Not at all. Stuff happens. Diseases cause adverse effects Anemia due to blood loss is usually due to the disease and not to the surgery State so: anemia of chronic blood loss due to right renal cell carcinoma; anemia of acute blood loss due to femur fracture Adverse effects are easily explained and defended in a patient with more risk factors. If you didn’t name these, you lose.

NOT Acute Respiratory Failure
Patients being purposely maintained on the ventilator after surgery because of weakness, chronic lung disease, massive trauma are NOT in acute respiratory failure – unless they are Patients being purposely maintained on the ventilator after extensive surgery in the face of morbid obesity or COPD are NOT in acute respiratory failure – unless they are. Prevention of acute respiratory failure from angioedema, stroke, trauma when patient does NOT HAVE acute respiratory failure when intubated for airway protection

Goals of Implementation – Prove You Are Value Based
Competitive severity adjusted mortality and morbidity statistics Low incidence of HACs Reasonable occurrence of PSIs Lower than average Readmissions for Pneumonia, Heart Failure, AMI Cooperation with quality initiatives Decent responses to a new questionnaire on discharge

Documentation Needs: What’s The Surgery For?
Provide the diagnosis for which the surgery is being performed Tell why it’s necessary for that diagnosis DON’T just say that the patient is being admitted for the surgery (Admitted for radical suprapubic prostatectomy) DON’T just provide signs and symptoms Tell the story of the workup that led to the diagnosis

Documentation Needs: Complexity of Patient
Name other diseases patient has coming through the door – chronic, stable conditions Avoid “Resume home meds” unless you identify each disease being treated Permit other physicians to follow serious co-morbidities, but name each at least ONCE, especially in discharge summary

ACS NSQIP Data Collection Overview
The ACS NSQIP collects data on 136 variables, including preoperative risk factors, intraoperative variables, and 30-day postoperative mortality and morbidity outcomes for patients undergoing major surgical procedures in both the inpatient and outpatient setting.

Surgical Risk Stratification
NSQIP databases depend on identification of risk factors Heart – failure? MI? Lungs – chronic? Nutrition – over? mal? Diabetes – cont? Renal status – chr, ac. Malignancy? Smoking, ETOH? Stroke – residua? Hepatic fxn – name it Encephalopathy? Immunocomp – how? Sepsis? Org fail? Use ster, insul, chemo Periph vasc?

Risk Stratification for Pulmonary Complications
Age Obstructive sleep apnea Chronic lung disease Impaired sensorium Cigarette use Surgical site Congestive heart failure Elective vs emergency ASA Class of comorbids Prolonged surgery Functional dependence General anesthesia Obesity Transfusion > 4 units

Modified NSQIP Data Sheet

The Mayo Model of PreOperative Medical Evaluation
Initial medical evaluation for risk stratification – fill out POME Lab and radiographic studies as indicated – fill out POME Consultative visits and tests as needed – fill out POME Visit to Anesthesiology with recommendations and results – fill out preop anesthesia forms Visit to surgeon with all needed risk factors complete – complete H&P Eliminate cancelled surgeries, delays

Was It Present on Admission?
Patient safety indicators may give us a black eye if it’s not documented! Ileus from perforated bowel or from peritonitis – was it present on admission? DVT in patient from nursing home – was it present on admission? Decubitus ulcer – is it an ulcer - was it present on admission? Atelectasis in a morbidly obese patient – was it present on admission? If we don’t document it, we get charged with it!

Change in the Entire System
ICD-9 ICD-10

Notable Changes ICD-9 has maximum of 5 digits with rare alphanumeric codes (V-, E-) limiting breakdown for specificity or addition of categories; ICD-10 has three to seven alphanumeric places ICD-9: 14,000 codes; ICD-10: 73,000 codes ICD-9 has no specificity as to which side of the body (e.g., percent burn on right or left arm or leg, side of paralysis after stroke)

Don’t Wait Till Tomorrow for ICD-10

(stages II, III, IV, unspecified have 6th digits 2, 3, 4, 9)
Example - Integration ICD-9 – Multiple codes – Chronic skin ulcer, lower back – Pressure ulcer, stage I No code for which side ICD-10 – Single code L – Pressure ulcer right lower back, stage I (stages II, III, IV, unspecified have 6th digits 2, 3, 4, 9)

Example Specificity - Location
M67.4 Ganglion M67.41 shoulder M67.411, right M67.412, left M67.419, unspecified M67.42 elbow M67.43 wrist M67.44 hand M67.45 hip M67.46 knee M67.47 ankle and foot Sixth digits 1 – right 2 – left 9 - unspecified

How Close Are We?

Specificity is NOT Always Possible
Sign/Symptom/Unspecified Codes In both ICD-9-CM and ICD-10-CM, 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. When sufficient clinical information isn’t known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate “unspecified” code (e.g., a diagnosis of pneumonia has been determined, but not the specific type). In fact, unspecified codes should be reported when they are the codes that most accurately reflects what is known about the patient’s condition at the time of that particular encounter. 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. Source: Cooperating Parties for ICD-10-CM/PCS and ICD-9-CM Coding, May 2013.

Renal Malignancies ICD-9
189.0 Kidney, except pelvis (Includes Wilms tumor, renal cell carcinoma, urothelial cell ca) 189.1 Renal pelvis 189.2 Ureter 189.3 Urethra 189.4 Paraurethral glands 189.8 Other specified sites of urinary organs Malignant neoplasm of contiguous or overlapping sites of kidney and other urinary organs whose point of origin cannot be determined 189.9 Urinary organ, site unspecified

Renal Malignancies ICD-10
C64.1 Malignant neoplasm of right kidney, except renal pelvis (includes all cell types) C64.2 Malignant neoplasm of left kidney, except renal pelvis (includes all cell types) C64.9 Malignant neoplasm of unspecified kidney, except renal pelvis (includes all cell types) C65 Malignant neoplasm of renal pelvis C65.1 Malignant neoplasm of right renal pelvis C65.2 Malignant neoplasm of left renal pelvis C65.9 Malignant neoplasm of unspecified renal pelvis C66Malignant neoplasm of ureter C66.1 Malignant neoplasm of right ureter C66.2 Malignant neoplasm of left ureter C66.9 Malignant neoplasm of unspecified

Similarities and Differences
Now identify right or left kidney, pelvis, ureter Same differentiation by part of renal system No breakdown as to cell types Do we need this? Wilms tumor (nephroblastoma) Renal cell carcinoma Urothelial cell carcinoma

Mets to Bone ICD-9 198.5 Bone and bone marrow ICD-10 C79.51 Bone
C79.52 Bone marrow

Stones in 9 and 10 592.0 Calculus of kidney Nephrolithiasis NOS
Renal calculus or stone Staghorn calculus Stone in kidney Excludes: uric acid nephrolithiasis (274.11) 592.1 Calculus of ureter Ureteric stone Ureterolithiasis 592.9 Urinary calculus, unspecified N20.0 Calculus of kidney Nephrolithiasis NOS Renal calculus Renal stone Staghorn calculus Stone in kidney N20.1 Calculus of ureter Ureteric stone N20.2 Calculus of kidney with calculus of ureter N20.9 Urinary calculus, unspecified

Benign Prostatic Disease – ICD-9
600.0 Hypertrophy (benign) of prostate Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptoms (LUTS) Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS) 600.1 Nodular prostate Nodular prostate without obstruction Nodular prostate with urinary obstruction 600.2 Benign localized hyperplasia prostate Benign localized hyperplasia of prostate without urinary obstruction and other lower urinary tract symptoms (LUTS) Benign localized hyperplasia of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS) 600.3 Cyst of prostate Use additional code to identify symptoms: incomplete bladder emptying (788.21) nocturia (788.43) straining on urination (788.65) urinary frequency (788.41) urinary hesitancy (788.64) urinary incontinence ( ) urinary obstruction (599.69) urinary retention (788.20) urinary urgency (788.63) weak urinary stream (788.62)

Benign Prostatic Disease ICD-10
N40.0 Enlarged prostate without lower urinary tract symptoms N40.1 Enlarged prostate with lower urinary tract symptoms N40.2 Nodular prostate without lower urinary tract symptoms N40.3 Nodular prostate with lower urinary tract symptoms No code for benign localized hyperplasia prostate N42.83 Cyst of prostate Use additional code for associated symptoms, when specified: incomplete bladder emptying (R39.14) nocturia (R35.1) straining on urination (R39.16) urinary frequency (R35.0) urinary hesitancy (R39.11) urinary incontinence (N39.4-) urinary obstruction (N13.8) urinary retention (R33.8) urinary urgency (R39.15) weak urinary stream (R39.12)

Adhesions Specify in females if due to pelvic inflammatory diseases or post uterine or adnexal surgery General adhesions, male or female, due to other than diseases of the female pelvic organs are assigned the same code Distinguish with or without obstruction

Endocrine Complications or Metabolic Disorders After Endocrine Surgery or Other Surgery
Postop hypoadrenalism, hypothyroidism, hypoparathyroidism, hypopituitrism, ovarian failure (symptomatic or asymptomatic) Specify when these are desired outcomes of (integral to) the surgery performed Identify accidental puncture or laceration and hematoma or hemorrhage in renal, adrenal surgeries

Nephritis Identify cause (disease) and if hereditary
Identify when acute Identify when rapidly progressive With or without persistent hematuria Identify when chronic Identify when with nephrotic syndrome

Nephritic Syndrome (acute)
1. Hematuria 2. Oliguria 3. Azotemia 4. Hypertension Nephrotic Syndrome (chronic) 1. Massive proteinuria 2. Hypoalbuminemia 3. Edema 4. Hyperlipidemia/hyperlipiduria

Cystitis Provide specificity
Acute cystitis Interstitial cystitis Trigonitis Radiation cystitis Specify if with or without hematuria and microscopic or gross hematuria

Urethral Stricture Identify cause
Posttraumatic Postinfectious Other Identify sex of patient – in female, if due to childbirth Identify part of urethra involved as appropriate Meatus Bulbous urethra

Urinary Incontinence Stress incontinence Urge incontinence
Incontinence without sensory awareness Post-void dribbling Nocturnal enuresis Continuous leakage Mixed incontinence (stress and urge)

GU Surgery Complications
Urethral stricture Vaginal adhesions, prolapse Postop pelvic adhesions from pelvic surgery Complications of cystostomy, other external or internal stoma of urinary tract (hemorrhage, infection, malfunction) Hemorrhage, hematoma, accidental puncture or laceration in genitourinary surgery–specify if identified during or after surgery

KDIGO Kidney Disease Improving Global Outcomes
Stage GFR Description Treatment stage 1 90+ Normal kidney function but urine or other abnormalities point to kidney disease Observation, control of blood pressure 2 60-89 Mildly reduced kidney function, urine or other abnormalities point to kidney disease Blood pressure control, monitoring, find out why. 3 30-59 Moderately reduced kidney function More of the above, and probably diagnosis, if not already made. 4 15-29 Severely reduced kidney function Planning for endstage renal failure. 5 14 or less Very severe, or endstage kidney failure (established renal failure) See treatment choices for endstage renal failure.

AKI or ARF Insufficiency is NOT a synonym
Stg Serum creatinine criteria Urine output criteria 1 Increase in serum creatinine of more than or equal to 0.3 mg/dl or increase to more than or equal to 150% to 200% from baseline Less than 0.5 ml/kg per hour for more than 6 hours 2 Increase in serum creatinine to more than 200 – 300% from baseline Less than 0.5 ml/kg per hour for more than 12 hours 3 Increase in serum creatinine to more than 300% from baseline or serum creatinine of more than or equal to 4.0 mg/dl with an acute increase of at least 0l5 mg/dl Less than 0.3 ml/kg per hour for 24 hours or anuria for 12 hours

Caveat The writings of the AKIN state that, in cases of dehydration (and dehydration is still, truly the number one cause of acute renal failure in the US), it is imperative to NOT CALL changes in creatinine AKI until the patient has been volume repleted for at least six hours. If creatinine bump persists after fluid resuscitation, there was likely AKI. If not, there was NOT AKI. “Acute kidney injury should be both abrupt (within 1–7 days) and sustained (more than 24 hours).”

Respiratory Failure in ICD-10
Document acute or chronic or both Specify if hypoxemic or hypercapnic respiratory failure for either acute or chronic Without specificity, defaults to unspecified, with least severity

Diabetes Juvenile (IDDM) –Type 1 diabetes occurs in a state of insulin deficiency resulting from pancreatic beta cell destruction Adult (NIDDM) – Type 2 diabetes results from increased resistance to the effects of insulin. These patients may require insulin for control.

Diabetes Identify type 1, type 2, due to other secondary cause, gestational In type 2 or secondary cause, identify when using insulin long term Identify all body systems affected by the diabetes (neuropathy and its manifestation, retinopathy and proliferative or nonproliferative, nephropathy and stage of CKD, dermopathy, vasculopathy, periodontopathy) Identify all manifestations (ulcer, coma, gangrene, osteomyelitis, etc.)

Hypertension – ICD-10 Essential hypertension (I10) – includes high blood pressure, hypertension, malignant hypertension, accelerated hypertension, benign hypertension Secondary hypertension (I15) I15.0 – renovascular I15.1 – hypertension secondary to other renal disorders I15.2 – hypertension secondary to endocrine disorders (carcinoid, pheochromocytoma, etc.) I15.8 – other secondary hypertension I15.9 – secondary hypertension, unspecified

Hypertension – ICD-10 Hypertensive heart disease - I11
I with heart failure I without heart failure Hypertensive kidney disease - I12 I with stage 5 CKD or ESRD I with CKD stages 1–4 N18.1, 2, 3, 4, 5, 6, 9 for CKD stages 1, 2, 3, 4, 5, ESRD, unspecified

Nutritional Status Malnutrition – dietary consult or estimate
Mild (<10% loss) Moderate (10-20% loss) Severe (>20% weight loss) Consider the acute malnutrition of surgery, trauma and sepsis Morbid obesity and all of its manifestations and risks for surgery and anesthesia GER - Obesity Hypoventilation Syndrome - Hypertension Sleep apnea - Secondary hypercoagulable state - Diabetes with … Cellulitis - Hypertensive heart disease - Chronic cor pulmonale

Primary and Metastatic Cancer
Tell where the primary is (was) and if it was previously removed or treated and treatment is over or currently under treatment State where the metastatic sites are and if they (any) are symptomatic and if they are currently under treatment State if new site is found and if it led to the symptoms that required admission – ALWAYS LINK SYMPTOMS TO THE CANCER, when you can

The Future Must Be Started Now
ICD-9-CM Sepsis (SIRS due to infection without organ dysfunction Severe sepsis (SIRS due to infection with organ dysfunction SIRS due to noninfection without organ dysfunction SIRS due to noninfection with organ dysfunction ICD-10-CM ***** R65.20 Severe sepsis without septic shock R65.21 Severe sepsis with septic shock R65.10 SIRS due to noninfection without organ dysfunction R65.11 SIRS due to noninfection with organ dysfunction

Conditions Related to …
SIRS due to: Hemorrh pancreatitis Burns (not infected) Pulmonary embolism (clot, fat, amniotic fluid) Multiple trauma Allergy None are infections! Sepsis due to: UTI Pneumonia Cholangitis Decubitus Osteomyelitis Infected dialysis cath Subphrenic abscess All are infections!

Severe Sepsis Sepsis with distant organ failure:
Acute renal failure (due to sepsis) ARDS or acute respiratory failure Acute hepatic failure (due to sepsis) Encephalopathy (metabolic – due to sepsis) DIC (Disseminated intravascular coagulopathy) Critical care myopathy Circulatory system failure – inability to maintain a blood pressure to perfuse vital organs – CALLED SEPTIC SHOCK

What We Are Seeing BAD ARI CHF CRF Na Hb – 6.8 BP MODS
Transaminitis NEEDED Acute renal failure Chronic systolic failure CKD stage 3 Hyponatremia Anemia – cause? Shock – cause? The names of the failed organs Acute liver failure

Anemia and Complexity of Medical Decision Making
Non Specific Anemia Specific Anemia DUE TO chronic renal failure Anemia DUE TO chronic blood loss from a fungating cecal lesion Anemia DUE TO acute blood loss from a hip fracture Anemia DUE TO chronic osteo/hepatitis Anemia DUE TO antineoplastics

Encephalopathies Metabolic encephalopathy G93.41
Includes due to sepsis, hyper and hyponatremia, uremic encephalopathy Hepatic encephalopathy K72 Toxic encephalopathy G92 Lead encephalopathy, bromidism Polypharmacy over prolonged periods leading to CNS damage

Encephalopathies Hypoxic ischemic encephalopathy
P91.61 mild, P91.62 moderate, P91.63 severe Other encephalopathy G93.49 Lyme encephalopathy + A69.21 Lyme disease Wiernicke’s nutritional encephalopathy E51.2 Alcoholic (Wiernicke-Korsakoff psychosis) F10.26 Hypertensive encephalopathy I67.4

Post-Op Progress Notes
We were all taught to examine certain parts of the body on every post-op visit. No matter how many times you did it, if you don’t document it, YOU DIDN’T DO IT. VS, labs, I&O, mental status, chest, belly, legs, wound, ambulation, bowel activity – every visit.

Post-Op Progress Notes
Prosecuting attorneys LOVE: 6/17 Doing well 6/18 No new problems 6/19 Events of last night noted 6/20 Called to see patient in full code. Pronounced dead at 17:15.

Handling the Problem List
It’s an Epic Task

Is the EHR a Friend or Foe?
State that the programs are ready for ICD-9, ICD-10 and SnoMED State that they provide “meaningful use” State that they aid with “pick lists” State that they help with “problem lists” State that they help with physician professional billing because you can cut and paste

Example Changes in Epic to Support ICD-10
Diagnosis Calculator For providers who directly enter diagnoses (encounter diagnoses, charge capture, order-association), guides users to more specific code by prompting for laterality, acuity, etc. Updating Documentation Tools To facilitate documentation of needed detail for the coders Epic builders will work with you to update SmartTexts, SmartPhrases, Note templates, etc. Questions: Contact Dr. Jason Lyman, ICD-10 Physician Champion,

Progress Note Management
Copy and paste of massive amounts of trash leads to useless notes, inability of others to determine what is wrong with the patient NOW inability to validate that ANYTHING YOU DID WAS EFFECTIVE! And inability to assign ICD codes – what was ruled out what was ruled in

Beware of cloned documentation
RACs and other auditors are on the lookout for cloned documentation, often a problem in teaching hospitals and large academic medical centers. "Auditors look for instances when the attending physician cuts and pastes from the resident's note into his own," says Nguyen. CMS requires documentation of each encounter so that the note stands on its own and represents the actual services provided by the attending physician for each date of service or encounter. Data, including vital signs, may not be copied from one visit to the next. CMS states that note cloning raises concerns about the medical necessity of continued hospitalization.

The U.S. Department of Health & Human Services
and the Department of Justice have promised to come down hard on providers who misuse electronic health records to financially game the healthcare system. HHS Secretary Kathleen Sebelius and U.S. Attorney General Eric Holder warned that law enforcement agencies are keeping an eye out for fraud and "will take action where warranted," in a letter sent to the American Hospital Association, Association of Academic Health Centers, Association of American Medical Colleges and others Sebelius and Holder point to potential cloning of medical records as one of several indications that fraud could be on the rise. Medicare administrative contractor National Government Services earlier this month issued a notice, stating that cloned documents from EHRs mostly likely would result in payment denials.

Progress Note Needs What was the problem that brought the patient to your attention (one to two sentences) What did you see today? Labs, x-rays, physical findings, consults, other tests What are the diagnoses? What has changed? Worse? Better? More specific? Ruled in or ruled out? What are you going to do today?

Three Major Sections Active diseases, decompensated for which inpatient care required – update as issues resolve Chronic stable conditions that are currently under treatment Past Medical Historical conditions, not currently affecting health status nor being treated (appy age 12, s/p hysterectomy, Gr3/Para3, left hip replaced)

If the docs don't get it, nothing else matters!

Paint the picture of the patient properly with WORDS
what you might get. What you want… may not be… So the coder can paint the same picture with codes.

Motto For The Age “If you don’t look good, we don’t look good” Vidal sassoon, ca 1985 Father of modern medical economics

Questions and Answers Your Ideas and Comments

Question #1 – Which is True?
ICD-10 shows a totally different appreciation of diseases than ICD-9 ICD-10 codes are exact walkovers from the ICD-9 codes – they just look different ICD-10 codes may look different but the diseases didn’t change – proper documentation will lead to proper code assignment ICD-10 codes are different from ICD-9 only by adding the differentiation of Right vs Left

Question #2 – Which is False?
Value of purchasing of healthcare is dependent on data streams derived from ICD codes Specific documentation of diseases in ICD-9 will be all that is necessary for specific code assignments in ICD-10 Bundled payments for healthcare will lead to cooperation between practitioners and facilities We are the only country in the world billing for healthcare by ICD codes

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