1. ICD-10 for Clinicians January 27-30, 2015 Puerto Rico ICD-10 Implementation Assistance Site Visit Training segments to assist Puerto Rico with ICD-10 transition

2. Agenda 1 Health care data in a changing environment ICD-10 basics Clinical documentation – the key to data and good care Getting specific Clinical case examples Measuring coding patterns Reducing the burden of data capture

3. Source: Health Affairs Japan – 8.5% of the GDP (2008) US – 16% of the GDP (2008) Japan – 8.5% of the GDP (2008) US – 16% of the GDP (2008) Healthcare Expenditures Unsustainable

4. Source: Organisation for Economic Co-operation and Development (2013), "OECD Health Data", OECD Health Statistics (database). doi: 10.1787/data-00350-en (Accessed on 14 February 2013).doi: 10.1787/data-00350-en Notes: Data from Australia and Japan are 2007 data. Figures for Belgium, Canada, Netherlands, Norway and Switzerland, are OECD estimates. Numbers are PPP adjusted. US 38 th in life expectancy Japan 1 st in life expectancy US infant mortality is approximately 3 times Japan US 38 th in life expectancy Japan 1 st in life expectancy US infant mortality is approximately 3 times Japan

5. Healthcare Data Health Data Consulting © 2012 4 A Cornerstones of Healthcare Information PatientProviderConditionService Source: Health Data Consulting

6. Getting from Data to Information Health Data Consulting © 2012 5 Understanding the whole picture

7. Getting from Data to Information Health Data Consulting © 2012 6 Source: Health Data Consulting Data Standards Information Source: Health Data Consulting

8. ICD10 Quick Facts Health Data Consulting © 2012 7  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 - 1999  ICD-10-CM (US version) – ~ 69,000 diagnostic codes – Final rule published – 2009 – Compliance date – Oct 1, 2015  ICD-10-PCS – ~72,000 codes – Not part of an international standard – Inpatient procedures only – Compliance date – Oct 1, 2015 Source: Health Data Consulting

9. Same Condition – Different Codes September 2015 Health Data Consulting © 2012 8 What’s the Difference? October 2015 ICD-9ICD-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 = 16All codes for femur fractures = 1530 Source: Health Data Consulting

10. Nature of the Changes Diagnosis Codes – Clinical Example 9 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 CodeDescription 42979 Certain sequelae of myocardial infarction, not elsewhere classified, other ICD10 CodeDescription I233 Rupture of cardiac wall without hemopericardium as current complication following acute myocardial infarction Source: Health Data Consulting

11. Nature of the Changes Diagnosis Codes – Clinical Example 10 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 CodeDescription 42979 Certain sequelae of myocardial infarction, not elsewhere classified, other ICD10 CodeDescription I233 Rupture of cardiac wall without hemopericardium as current complication following acute myocardial infarction Source: Health Data Consulting

12. Why are there so many diagnosis codes? 34,250 (45%) of all ICD-10-CM codes are related to the musculoskeletal system 17,045 (25%) of all ICD-10-CM codes are related to fractures ~25,000(36%) of all ICD-10-CM codes to distinguish ‘right’ vs. ‘left’ Health Data Consulting © 2010 11 Example Source: Health Data Consulting

13. Varying Code Volume By clinical area 12 Source: Health Data Consulting

14. Nature of the Changes Code Distribution 13 Source: Health Data Consulting

15. Changing Reimbursement Models 14 Source: Health Data Consulting *Source: Modern Healthcare – June 2014

16. 15 Why is good documentation important?

17.  Supports proper payment and reduced denials  Assures accurate measures of quality and efficiency  Addresses the issue of accountability and transparency  Provides better business intelligence  Supports clinical research  Supports interoperable sharing of data  It’s just good care! Health Data Consulting © 2013 16 Documentation Why is it Important? Source: Health Data Consulting

18. 17 Health Data Consulting © 2013 Documentation 1889 Source: Health Data Consulting

19. 18 Health Data Consulting © 2013 Documentation 1889 Source: Health Data Consulting

20. Health Data Consulting © 2013 19 Documentation 1889 Source: Health Data Consulting

21. Health Data Consulting © 2013 20 Documentation 1889 Source: Health Data Consulting

22. Health Data Consulting © 2013 21 Progress? Documentation 2011 Source: Health Data Consulting

23. 22 History Physical Exam Internal Record Review External Record Review Assessment/Diagnosis Studies Documentation and Coding Where it all begins Source: Health Data Consulting

24. Clinical / Business/Coding Relationships Creating a new working relationship 1. 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. 2. The role of the coding professional is to assure that coding is consistent with the documentation 3. The role of the business manager is to assure that all billing is accurately coded and supported by the documented facts. 23 Source: Health Data Consulting

25. 24 Getting Specific Defining and measuring specificity Source: Health Data Consulting

26. Poorly Specified Coding Health Data Consulting © 2013 A proposed definition 25 Source: Health Data Consulting “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.”

27. Coding specificity Health Data Consulting © 2013 A place for “unspecified” codes 26 Source: Health Data Consulting  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

28. Coding specificity Health Data Consulting © 2013 No place for “unspecified” codes 27 Source: Health Data Consulting  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

29. Coding ICD-10 CM Health Data Consulting © 2013 Suspected, probable, likely and other condition qualifiers 28 Source: Health Data Consulting The use of terms like “suspected”, “probable”, “likely” and other qualifications of conditions have different guidelines for coding in the inpatient vs. the outpatient setting.

30. Health Data Consulting © 2013 29 Documentation What they taught us in medical school Source: Health Data Consulting  Type of condition – Condition categories i.e. Type I or Type II diabetes  Onset – When did it start?  Etiology / Cause – Infectious agent – Physical agent – Internal failure – Congenital 29 Source: Health Data Consulting

31. Health Data Consulting © 2013 30 Documentation What they taught us in medical school Source: Health Data Consulting  Anatomical location – Which anatomical structure – Proximal, distal, medial, lateral, central, peripheral, superior, inferior, anterior, posterior…  Laterality – Right side or left side  Severity – Mild, moderate or severe  Environmental factors – Smoking – Geographic location 30 Source: Health Data Consulting

32. Health Data Consulting © 2013 31 Documentation What they taught us in medical school Source: Health Data Consulting  Time parameters – Intermittent/Paroxysmal – Recurring – Acute or chronic – Post-op, post delivery  Comorbidities or complications – Diabetes with neuropathic joint – Intracranial injury  Manifestations – Hypoxia, Hypercapnia (Respiratory Failure) – Loss of consciousness 31 Source: Health Data Consulting

33. Health Data Consulting © 2013 32 Documentation What they taught us in medical school Source: Health Data Consulting  Healing level – Routing healing, delayed healing, non-union, malunion…  Findings and symptoms – Fever – Hypoglycemia/hyperglycemia – Wheezing  External causes – Motor vehicles, injury locations – Assault, accidental, work related, intentional self harm  Type of encounter – Initial encounter, subsequent encounter, encounter for condition sequela, routine evaluation, administrative encounter 32 Source: Health Data Consulting

34. Medical Concepts Health Data Consulting © 2013 Expressing the patient condition in codes 33 Source: Health Data Consulting 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] Source: Health Data Consulting

36. Pulmonary Disease COPD Chronic Bronchitis Asthma

37. ICD-10 Relevant Documentation Health Data Consulting © 2013 Chronic Pulmonary Disease Concepts: Caused by :  Chemical or environmental agents – Define agent…  Smoking – Exposure to environmental tobacco smoke – History of tobacco use – Occupational exposure to environmental tobacco smoke – Tobacco dependence – Tobacco use  Allergic/non-allergic Source: Health Data Consulting 36 Source: Health Data Consulting

38. ICD-10 Relevant Documentation Health Data Consulting © 2013 Chronic Pulmonary Disease Concepts: 37 Temporal Factors:  Acute  Chronic  Intermittent  Persistent Severity:  Mild  Moderate  Severe Source: Health Data Consulting

39. ICD-10 Relevant Documentation Health Data Consulting © 2013 Chronic Pulmonary Disease Concepts: 38 Bronchitis Specific:  Simple  Mucopurulent  Mixed simple and mucopurulent  Tracheitis  Tracheobronchitis Source: Health Data Consulting

40. ICD-10 Relevant Documentation Health Data Consulting © 2013 Chronic Pulmonary Disease Concepts: 39 Emphysema Specific:  Unilateral pulmonary emphysema – MacLeod’s syndrome – Swyer-James syndrome – Unilateral hyper-lucent lung – Unilateral pulmonary artery functional hyperplasia – Unilateral transparency of lung  Panlobar emphysema – Panacinar emphysema  Centrilobar emphysema Source: Health Data Consulting

41. ICD-10 Relevant Documentation Health Data Consulting © 2013 Chronic Pulmonary Disease Concepts: 40 Emphysema Specific:  Other emphysema – Bullous emphysema (lung)(pulmonary) – Emphysema (lung)(pulmonary) NOS – Emphysematous bleb – Vesicular emphysema (lung)(pulmonary) Source: Health Data Consulting

42. ICD-10 Relevant Documentation Health Data Consulting © 2013 Chronic Pulmonary Disease Concepts: 41 Other COPD:  With acute lower respiratory infection – Define infectious agent…  With exacerbation – Decompensated COPD  Other COPD – Chronic obstructive airways disease – Chronic obstructive lung disease Source: Health Data Consulting

43. ICD-10 Relevant Documentation Health Data Consulting © 2013 Chronic Pulmonary Disease Concepts: 42 Asthma Specific - Types :  Detergent asthma  Eosinophilic asthma  Lung diseases due to external agents  Miner's asthma  Wheezing  Wood asthma  Exercise induced bronchospasms  Cough variant asthma  Atopic asthma Source: Health Data Consulting

44. ICD-10 Relevant Documentation Health Data Consulting © 2013 Chronic Pulmonary Disease Concepts: 43 Asthma Specific - Types (alternate terms):  Allergic (predominantly) asthma  Allergic bronchitis  Allergic rhinitis with asthma  Atopic asthma  Extrinsic allergic asthma Source: Health Data Consulting

45. ICD-10 Relevant Documentation Health Data Consulting © 2013 Chronic Pulmonary Disease Concepts: 44 Asthma Specific - Types (alternate terms):  Hay fever with asthma  Idiosyncratic asthma  Intrinsic non-allergic asthma  Non-allergic asthma  Asthmatic bronchitis  Childhood asthma  Late onset asthma Source: Health Data Consulting

46. ICD-10 Relevant Documentation Health Data Consulting © 2013 Chronic Pulmonary Disease Concepts: 45 Asthma Specific:  Uncomplicated or  with (acute) exacerbation or  with status asthmaticus Source: Health Data Consulting

47. ICD-10 Relevant Documentation Health Data Consulting © 2013 Code examples - COPD: 46 Source: Health Data Consulting

48. Measuring Performance

49. Coding Specificity Health Data Consulting © 2013 48 Unspecified (NOS), Other (NEC) or Symptom/Finding Codes Source: Health Data Consulting Code TypeClaimsTotal Charges %Claim s%Charges All Professional Claims 15,352,056 $ 4,030,052,634100% ‘Unspecified’ (and not ‘Other’ or ‘Symptom or Finding’) 2,902,691 $ 709,765,34119%18% ‘Other’ 1,917,163 $ 509,694,93512%13% ‘Symptom or Finding’ 3,530,464 $ 675,662,07323%17% Total 'Unspecified', 'Other' and 'Symptom or Finding' 8,350,318 $ 1,895,122,34954%47% Source: Health Data Consulting

50. 49 Source: Health Data Consulting Measuring Performance Differences in coding distribution by condition (injury and poisoning) for these two previous providers Source: Health Data Consulting

51. 50 Source: Health Data Consulting Measuring Performance Differences in coding distribution by condition (injury and poisoning) for these two previous providers Source: Health Data Consulting

52. Coding Pattern Comparisons Health Data Consulting © 2013 51 Obstetrical providers Source: Health Data Consulting

53. Coding Pattern Comparisons Health Data Consulting © 2013 52 Obstetrical providers Source: Health Data Consulting

54. Coding Pattern Comparisons Health Data Consulting © 2013 53 Obstetrical providers Source: Health Data Consulting

55. 54 Capturing Key Medical Concepts Reducing the burden of documentation Source: Health Data Consulting  There are a limited number of clinical concepts – For each clinical condition there are a finite clinical parameters that need to be captured from the perspective of ICD-10 – Most of these condition parameters recur in many codes  The physician does not need to capture everything – He/she must review and agree with data captured in other ways in the office  Use other resources to capture data – Patient intake forms Patient intake forms – Trained nursing and medical assistance interviews Trained nursing and medical assistance interviews  Prompting for the right stuff – Documentation requirement are condition specific – Forms or templates can help remind what is needed Source: Health Data Consulting

56. 55Health Data Consulting © 2012 Source: Health Data Consulting GEM Mapping Tool

57. 56Health Data Consulting © 2012 Source: Health Data Consulting GEM Mapping Tool

58. 57Health Data Consulting © 2012 Source: Health Data Consulting GEM Mapping Tool

59. 58Health Data Consulting © 2012 Source: Health Data Consulting GEM Mapping Tool

60. 59Health Data Consulting © 2012 Source: Health Data Consulting GEM Mapping Tool

61. 60Health Data Consulting © 2012 Source: Health Data Consulting GEM Mapping Tool

62. Questions? 61