Good Samaritan Advocate Hospitalists, Internal Medicine Family Practice April 15 11 am Thomas C Kravis MD © 3M 2015 - 3M Confidential - For Customer's.

Good Samaritan Advocate Hospitalists, Internal Medicine Family Practice April am Thomas C Kravis MD © 3M M Confidential - For Customer's Internal Review Only.explaiFurther use or disclosure requiresexplain apr and inpatint prior approval from 3M.

Clinical Documentation Improvement Goals and Objectives
ICD-10 General Awareness Session – Intro & Physician Leader 4/22/2017 Clinical Documentation Improvement Goals and Objectives Clear concise accurate documentation Capture the severity of illness (SOI) and the Risk of Mortality (ROM) Support hospital and physician reimbursement Improve quality report cards hospital , physician Prepare for ICD-10 Focused examples: OB/Gyn, Radiology,Psychiatry,Pediatrics, Trauma, Internal Medicine and Surgery

Value of Accurate and Complete Documentation
MD and Hospital Quality Reports Core Measures POA HACs ICD-9-CM ICD-10 Preventable Readmission Complications PSIs Compliance Fraud Abuse RAC Value Base Purchasing 2 MIDNIGHT RULE Care Coordination Team E&M Pro fees Denial related claims Medical Necessity

Documentation & Coding Issues at Advocate
Two separate languages Physician Document in CLINICAL terms Documentation for coding, profiling & compliance requires specificity in DIAGNOSIS terms This gap will be increased with ICD-10 Documentation Improvement can help bridge the gap

Clinical Diagnostic Unable to Code Able to Code
Multi-system organ failure Severe respiratory distress Hemodynamically unstable Will rehydrate “Urosepsis” ↓ K = 2.0, will give KCL Chest X infiltrate ↓ Platelets ↓ Wbc ↓Hct ↓ HgB 5.2, Transfuse Altered Mental Status Emaciated, Total Protein/Albumin Low Liver failure, renal failure, resp failure Respiratory failure : acute, acute on chronic Hypotension, shock-cardiogenic/septic Dehydration, hypovolemia Simple UTI Hypokalemia Pneumonia Left Lower Lobe Pancytopenia secondary to Chemotherapy Acute/Chronic Blood Loss Anemia Coma, Encephalopathy Protein Calorie Malnutrition On the left, is an example of documented statements that leave a coder unable to code the diagnosis. The diagnoses on the right would contribute significantly to the final assignment of severity and/or risk of mortality.

ICD-10 Documentation Tips
Use adjectives Acute, chronic, acute on chronic, mild, moderate, severe, persistent Example: Mild persistent asthma with exacerbation Example: Acute on chronic systolic heart failure Indicate cause and effect Use “due to” or “secondary to” Example: Pneumonia due to Klebsiella; Pseudomonas pneumonia Be specific about aspects of the disease Use current terminology Example: Atypical or type II atrial flutter or persistent atrial fibrillation Be specific about anatomical site and laterality Example: Pressure ulcer of right heel, stage 3;AMI probable LAD Use exact dates Example: “Myocardial infarction 3/10/2015” and not “MI last month” In your documentation of patient care, CONSIDER THE use of adjectives, LINK THE cause and effect OF EACH CONDITION, be specific about aspects of a disease and each anatomical site AND document the organism when known or suspected. Remember that the coding professional is not allowed to glean this information from laboratory results; therefore, this information must be recorded in your notes in order for it to be captured and reported. Ask yourself what else could I add in my notes about this patient’s condition that would better communicate how sick the patient is which in turn better communicates the resources needed for patient care? Incorporating these aspects into your documentation will result in an accurate picture of your patients’ severity of illness and risk of mortality. This in turn will result in accurate public reporting on quality and outcomes. And…..it will help reduce the number of queries you receive to clarify your documentation.

Physician and advanced practioners role
Focus remains on patient care Real time 3M 360 :Natural Language Processing Respond to query and document in the EMR Do not need to learn coding Minimal impact on day-to-day routine Clinical Documentation Specialists – a resource to the physician 7

When should a physician be queried regarding clinical documentation?
“ whenever there is conflicting, ambiguous, or incomplete information in the health record regarding any significant reportable condition or procedure” AHIMA Practice Brief “Managing an Effective Query Process” October 2008 © 3M All Rights Reserved.

Impact of Responding to Query
Query: “The magnesium level is 1.6 and the patient is receiving magnesium sulfate” “Please provide a corresponding diagnosis ” Physician documents: “hypomagnesemia” Cranial Procedure Impact w/o Response to Query RW = GLOS = 8.98 SOI = 2 Moderate ROM = 2 Moderate Impact w/ Response to Query RW = GLOS = 8.98 SOI = 3 Major ROM = 2 Moderate

All Patient Refined DRG
APR-DRG 3M™ Subdivide into subclasses Severity of Illness Subclasses Minor Moderate Major Extreme Risk of Mortality Subclasses Minor Moderate Major Extreme Why 3 M?3M created the APR DRGs ( and addition tools such as PPRs and PPCs) and they reflect the Quality of care provided at .We own these tools and know how best to engage our physician colleagues to use them .. The APRs are broken down into subclasses by severity and risk. We understand those cormorbid conditions when present and then documented can drive both severity of illness- as well as ROM and quality. In this slide we illustrate that if you are sick enough to die at Union or your CAC facility the physicians documentation should support a level 4---if your patients are dying at level 1,2 or 3 then this implies: either a quality issues, a coding problem ---or documentation. In our experience it is the physician documentation is the most common factor or reason!! Mortality at < 4 Quality Coding Documentation

Principal Diagnosis "XYZ" Impact of Secondary Diagnosis
Among the most powerfull slides based on MD feedback after presenting ( the XYZ is changed for each specialty presentation) Invite and “engage” a member of audience to share an example of a current patient in the hospital

Risk-Adjusted Mortality Analysis: Quality Measure
Advocate Data based on all cases using selection criteria. No inference is made or conclusion can be drawn about the significance of actual to expected mortality variance without further study. GS Hopital

APR DRG 194, HEART FAILURE RISK OF MORTALITY Quality Documentation or
Coding

Heart Failure Kidney failure
Acuity Acute, chronic, acute on chronic/exacerbation Type Systolic and/or diastolic heart failure Etiology If known or suspected: Ischemia Anemia Hypertension Myocarditis Kidney failure Structural heart disease Supraventricular tachycardia Cardiomyopathy : Alcoholic congenital, congestive, constrictive, dilated, endomyocardial, idiopathic hypertrophic sub aortic stenosis ,nonobstructive hypertrophic, obstructive hypertrophic, restrictive

Acute Kidney Failure – Impact of Documentation
Insufficient documentation Acute renal insufficiency SOI 1; ROM 1 Acute kidney injury (AKI) SOI 3; ROM 3 Acute kidney failure SOI 3; ROM 3 Preferred specificity if clinically appropriate Acute kidney failure due to: Acute tubular necrosis SOI 4; ROM 4 Cortical necrosis SOI 4; ROM 3 Medullary (papillary)necrosis SOI 4; ROM 3 You should avoid using the term ‘acute renal insufficiency’ when you mean ‘acute renal failure’ as insufficiency is assigned to a generic or non-specific code in ICD-10 which will not do justice in explaining your patient’s severity of illness and risk of mortality.

Heart Failure Sample Physician: SOI less than Peers
Training objective: Respond to query Document the drivers of SOI Treat underlying cause: clinical effectiveness Sample Physician: SOI less than Peers Target for training Lower SOI

Probable, Possible, Suspected Diagnosis Uncertain Diagnosis
Inpatient application only: These conditions may be coded as though they exist Applies to hospital setting only If condition is ruled out, it may not be coded Outpatient application: Must code signs/symptoms, not the suspected condition Supports appropriate E&M professional component 17

Possible/Probable Cause of Chest Pain ICD-10
Cardiac Cath MS-DRGs 286/287 RW = GERD Gastritis MS-DRGs 391/392 RW = Chest Pain MS-DRG 313 RW = Anterior CP Pleuritic CP Chest Wall Pain MS-DRG 204 RW = Costochondritis Tietze’s Disease MS-DRGs 205/206 RW = Pulmonary Embolism MS-DRGs 175/176 RW = Cardiac Arrhythmia MS-DRGs 308/309/310 RW = Angina MS-DRG 311 RW = CAD MS-DRGs 302/303 RW = Shingles MS-DRGs 595/596 RW = Psychogenic Chest Pain MS-DRG 882 RW = Pleurisy MS-DRGs 193/194/195 RW = Psychogenic Angina Pericarditis MS-DRGs 314/315/316 RW = Anxiety MS-DRG 880 RW = Biliary Colic MS-DRGs 444/445/446 RW = 18

Documentation for Pulmonary Embolism ICD-10
Specify if related to any other condition such as: Atrial fibrillation DVT (specify site and laterality) Hypercoagulable state Malignancy/Orthopedic surgery/Sepsis/Trauma Not POA and after an operative episode is considered a patient safety indicator (PSI 12) A hospital acquired condition (HAC) when following certain orthopedic procedures Cor pulmonale (acute /chronic) Document acuity: Acute Chronic Healed/old Specify meaning of “history of PE” Chronic PE being treated no longer has the condition “chronic pulmonary embolism” /“healed PE” or “old PE” Specify type: Saddle Septic Postprocedural or due to a vascular device “History of PE” can be interpreted to mean the patient has had the condition for a while, such as in “history of hypertension,” or interpreted to mean the patient no longer has the condition. Documentation of “chronic pulmonary embolism” versus “healed or old PE” makes a clear distinction and assures that the severity of illness of your patient is reported accurately. Severity of illness is increased when a patient has a chronic pulmonary embolism but there is no impact on severity of illness when the patient has a personal history of pulmonary embolism.

Acute Coronary Syndrome (ACS)
ACS or “acute ischemic heart disease” translates in ICD-10-CM to a nonspecific code Document a diagnosis which may more accurately describe the patient's condition such as: Intermediate or insufficiency coronary syndrome Demand ischemia Unstable angina Coronary slow flow syndrome Myocardial infarction Other condition?

ICD-10 Myocardial Infarction ICD-10-CM :
Type of infarction (STEMI or NSTEMI) Specific site of myocardium involved ( anterior wall, inferior wall) Coronary artery involved (LAD, RCA, LMCA, LCx) New MI within 4 weeks of a previous MI Specify date of onset) ICD-10 April 5, 2006 21

Syncope Alternatives”: “possible” “probable”
Arrhythmia MS-DRGs 308/309/310 RW = Syncope MS-DRG 312 RW = .7215 Stroke or CVA MS-DRGs 64/65/66 RW = Anemia MS-DRGs 811/812 RW = Dehydration MS-DRGs 640/641 RW = Heart Failure MS-DRGs 291/292/293 RW = Hypotension MS-DRGs 314/315/316 RW = Alcohol Abuse MS-DRGs 896/897 RW = Dig Poisoning MS-DRGs 917/918 RW = . 22

Transient Ischemic Attack
“TIA” = unspecified code If known or suspected, document more specific diagnosis or cause: Amaurosis fugax Carotid artery stenosis Carotid artery syndrome Precerebral artery syndrome Transient global amnesia Vertebro-basilar artery syndrome Other cerebral ischemic attacks and syndromes Documentation of “TIA” results in the reporting of an unspecified code… as it did in ICD-9. In ICD-10, that code is G45.9. If known or suspected, document the etiology of the patient’s symptoms, such as vertebro-basilar artery syndrome or carotid artery stenosis.

Cerebral Infarction Specify etiology or cause of the infarct:
Thrombosis Embolism Occlusion or stenosis Document specific artery involved and laterality: Precerebral arteries which include: Carotid artery Basilar artery Vertebral artery Cerebral arteries which include: Anterior cerebral artery Cerebellar artery Middle cerebral artery Posterior cerebral artery

Sepsis Sepsis is classified by the bacteria causing the infection
Streptococcal sepsis (group A, group B, Streptococcus pneumoniae, other streptococcal) or Other sepsis (e.g., MRSA, pseudomonas) Severe sepsis is associated with organ dysfunction/failure Document the specific associated organ dysfunction (not MOD) and Document presence of septic shock Sepsis is classified to one of two categories in ICD-10; either Streptococcal Sepsis or Other Sepsis. Streptococcal sepsis is further specified as being due to group A or group B streptococcus, Streptococcus pneumoniae, or other streptococcal infection. As mentioned earlier, the professional coding staff cannot simply read the laboratory results such as a blood culture to code an organism responsible for an infectious proces and it is therfore necessary for you to indicate a cause and effect relationship between the organism and the sepsis, if known, or suspected, in your notes. There are now combination codes for severe sepsis or SIRS due to an infectious process with acute/multi-organ dysfunction with or without septic shock. It is important to document shock as well as any associated organ dysfunction such as acute respiratory failure, acute renal failure, acute hepatic failure, disseminated intravascular coagulopathy, and so forth as they support the appropriate use of resources to provide good patient care and they are important indicators of severity of illness and risk of mortality in the critically ill patient. Sometimes we use the terms ‘sepsis’, ‘ bacteremia’, ‘septicemia’ and ‘severe sepsis’ interchangeably or indiscriminately in records. Make certain to clearly document the term that accurately describes your patient’s condition and update it should the patient progress along the sepsis continuum as the condition is treated or resolved. On another note, should you have a patient with SIRS due to a non-infectious process such as trauma, ICD-10 requires you to document if there is associated acute organ dysfunction.

Respiratory Failure Acute/chronic/acute on chronic
Etiology :pneumonia,COPD,drug,trauma If following surgery was it POA ( PSI ) or due to underlying pulmonary condition, failure to wean Signs :RR> 26, accessory muscles use, altered mental status Arterial blood gas and pH: pH of <7.30 or >7.50 pCO2 of >50 pO2 of <60 (impacted by hemoglobin level) Type I Hypoxemic : pO2 60 mm Hg normal or low pCO2 Type II Hypercapnic: pH < 7.30 and increased bicarbonate;pCO2 >50 Chronic : As above and low flow 02 at home; polycythemia ;cor pulmonale; heart failure

Diabetes Document Type Type 1 Type 2 Drug or chemical induced
Cause :Cushing's syndrome Cystic fibrosis malignant neoplasm malnutrition or Pancreatitis Other specified diabetes mellitus :Genetic defects of beta-cell function Genetic defects in insulin action or postpancreatectomy diabetes mellitus postprocedural diabetes mellitus Manifestations Cause and effect link between the diabetes and the condition “Chronic osteomyelitis of the left ankle due to type 2 diabetes” “Type 1 moderate nonproliferative diabetic retinopathy with macular edema” Control status: “Diabetes with hyperglycemia” “Diabetes out of control” Diabetes The look and feel for codes describing diabetes have changed but the level of detail describing the disease remains mostly the same. Therefore, your documentation doesn’t need to change as long as you are currently documenting the type of diabetes as type 1 or type 2, and any associated complications.

Bronchitis What’s New If chronic, specify:
Combination codes for acute bronchitis due to specific organisms If chronic, specify: Simple Mucopurulent Mixed (both simple and mucopurulent) Bronchitis (Bullet 1 and code box on screen) ICD-10 provides combination codes to capture acute bronchitis due to 8 different organisms. Document the specific organism causing the acute bronchitis when known or suspected by using “due to” or “secondary to,” to indicate cause and effect. (grey arrow on screen) Note that you must document the word “acute” when your intended diagnosis is in fact acute bronchitis. (2nd blue box on screen) Otherwise, a diagnosis of “bronchitis” is assigned to a code describing “bronchitis, not specified as acute or chronic.” Chronic bronchitis has it’s own classification. If you can further specify the type of chronic bronchitis, such as simple, mucopurulent, or both, a unique code describing the specific type will be reported.

Asthma Document type Document acuity Mild intermittent
Mild, moderate, or severe persistent Document acuity With acute exacerbation With status asthmaticus Asthma The classification of asthma is an example of the use of updated terminology in ICD-10. Bullet 1: Asthma is now classified as mild intermittent or mild, moderate, or severe persistent. Bullet 2: Documentation of acuity remains unchanged from ICD-9. You should continue to document the presence of an acute exacerbation or status asthmaticus. (box to come on screen as the following is read) For example, a diagnosis of severe persistent asthma with acute exacerbation is classified to J45.51.

“Postoperative” Diagnosis: Two Definitions
Clinical Definition “A condition occurring in the postoperative period”. Coder Definition “A diagnosis related to the surgical procedure” Complication-900 code “Coder cannot make the determination if it is a complication or an expected outcome” (Coding Clinic 4/27/2011) .

Examples Complication
Postop ileus ( ) Ileus secondary to surgery ( ) Post op atelectasis ( ) Post op anemia ( ) Non-Complication Ileus Prolonged ileus Expected ileus Incidental atelectasis Atelectasis Acute blood loss anemia 3131

Impact of Documentation and Quality
MS-DRG Bowel Procedure with CC PDx: Colon cancer SDx: Dehydration Post-op ileus (codes to ) “Ulcer/Wound” noted by RN PPx: Left hemicolectomy MS-DRG Bowel Procedure with MCC PDx: Colon cancer SDx: Acute Renal Failure – ATN Expected ileus (560.1) Pressure Ulcer, site unspecific PPx: Left hemicolectomy MS-DRG Bowel Procedure with MCC PDx: Colon cancer SDx: Acute Renal Failure – ATN Expected ileus (560.1) Pressure Ulcer Stage IV on Sacrum PPx: Left hemicolectomy Highest MS-DRG payment APR DRG: 221 SOI Level: 2 APR Weight: ROM Level: 1 Peer Group 0.0% APR DRG: 221 SOI Level: 3 APR Weight: ROM Level: 3 Peer Group 2.5% APR DRG: 221 SOI Level: 4 APR Weight: ROM Level: 4 Peer Group 24.2%

Procedures ICD-10

ICD-9 vs. ICD-10 Structural Changes
ICD-10 General Awareness Session – ICD-10 Overview 4/22/2017 ICD-9 vs. ICD-10 Structural Changes ICD-9 (Diagnoses) # Category etiology, site, manifestation 3-5 characterst Here we will show the comparison of ICD-9 to ICD-10. In ICD-9 most of the characters are numeric, (exceptions are the V-codes and the E-codes). The decimal point is after the 3rd digit. Press ENTER. In comparison, in ICD-10, the first digit is always alpha, the second character is always numeric, characters 3 – 7 can be either alpha or numeric. The decimal point is also after the 3rd character, as in ICD9. You will notice in ICD-10 there’s an additional character to allow for additional specificity of the codes in the etiology, site and manifestation. (Point to this on the slide) Finally, there is the addition of the 7th character. This is new to ICD-10 which is called an extension character. This character is used in certain conditions to identify the type of encounter and status of the condition. The importance of complete, specific documentation in the medical record cannot be overemphasized. Without complete documentation, the coder will be unable to assign a code upon initial review of the chart and a query may have to be created in an effort to clarify documentation for coding purposes. You may receive query’s from both professional coders as well as from the Clinical Documentation Specialists. ICD-10 (Diagnoses) 3-7 characters a # a/# Category etiology, site, manifestation extension

ICD-10 General Awareness Session – ICD-10 Overview
4/22/2017 ICD-10 Diagnosis Code Code Example Fracture Femur S 7 2 4 K Fracture of the femur Head & Neck Base of Neck Displaced fracture left Subsequent encounter for closed fx with nonunion To show the complexity of the new structure of ICD-10, let’s build an ICD-10 code. Press ENTER. The first three characters indicate that this is a fracture of the femur. Press ENTER. The next character indicates the anatomical section of the head and neck. Press ENTER. The next character gives further specificity of the base of neck. Press ENTER. The next character adds a new component in ICD-10 which is that the fracture is displaced in addition to the laterality. Press ENTER. The final character tells us whether it was the initial encounter or subsequent encounter. If it was a subsequent encounter we need to identify whether it was for routine healing, non-healing, nonunion, malunion or for sequela. All of this is new information and will need to be documented in the medical record in order for the chart to be coded.

ICD-10 Documentation Requirements for Procedures
Laterality of site Left Right Bilateral Specificity of approach Open Percutaneous Percutaneous endoscopic Via natural or artificial opening Via natural or artificial opening- endoscopic Open with percutaneous endoscopic assistance External

Example:Angioplasty with Stent Procedures
Objective of the procedure Root operation “dilation” is defined as “expanding an orifice or the lumen of a tubular body part” Vessel and laterality Approach Open Endoscopic Percutaneous endoscopic Type of stent inserted Drug-eluting intraluminal device Non-drug-eluting stent Bare metal stent

Fracture Treatment Reduction: open vs. closed
Fixation: internal vs. external vs. no fixation device Reduction = “reposition” in ICD-10-PCS Example “Closed reduction with percutaneous internal fixation of right femoral neck fracture” ICD-10 coding of fracture treatment doesn’t necessarily require additional documentation from you since you would typically document all elements needed to determine the ICD-10 code, These elements are: bone involved, laterality, approach, and type of fixation device, if any. If an external fixation device is applied, additional elements of documentation would be monoplanar, ring, or hybrid. Here is the table the coder will use to construct a code for fracture reduction of some of the lower bones. Note that ICD-10 uses the terminology of “reposition” instead of “reduction” to describe the procedure You won’t have to change your vocabulary; the coder will know that ICD-10 reposition operations include fracture reduction. For example, the code for closed reduction with percutaneous internal fixation of a right femoral neck fracture is 0-Q-S Z.

ICD-10 Trauma Documentation Tips
Cause and effect Subarachnoid hemorrhage secondary to fall during skiing accident Specific Salter Harris Type I physeal fracture proximal left femur Anatomical site and laterality Displaced fracture of olecranon process with intraarticular extension of right ulna Encounter Initial vs. subsequent vs. sequela In your documentation of patient care, CONSIDER THE use of adjectives, LINK THE cause and effect OF EACH CONDITION, be specific about aspects of a disease and each anatomical site AND document the organism when known or suspected. Remember that the coding professional is not allowed to glean this information from laboratory results; therefore, this information must be recorded in your notes in order for it to be captured and reported. Ask yourself what else could I add in my notes about this patient’s condition that would better communicate how sick the patient is which in turn better communicates the resources needed for patient care? Incorporating these aspects into your documentation will result in an accurate picture of your patients’ severity of illness and risk of mortality. This in turn will result in accurate public reporting on quality and outcomes. And…..it will help reduce the number of queries you receive to clarify your documentation.

ICD-10 OB/Gyn Documentation Tips
Use adjectives Acute, chronic, acute on chronic, mild, moderate, severe Example: Moderate pre-eclampsia Indicate cause and effect Use “due to” or “secondary to” Acute salpingitis secondary to Neisseria Gonorrhoeae Clinical aspects of the disease Gestational hypertension without proteinuria Patient’s trimester or number of weeks Admitted for proteinuria in 34th week of pregnancy Specify anatomical site Example: Acute salpingitis and oophoritis

ICD-10 Documentation Tips Mental Health
Adjectives Acute, chronic, acute on chronic, mild, moderate, major, severe, persistent Bipolar disorder, acute episode manic, moderate Cause and effect Dementia due to Alzheimer’s disease In your documentation of patient care, CONSIDER THE use of adjectives, LINK THE cause and effect OF EACH CONDITION, be specific about aspects of a disease and each anatomical site AND document the organism when known or suspected. Remember that the coding professional is not allowed to glean this information from laboratory results; therefore, this information must be recorded in your notes in order for it to be captured and reported. Ask yourself what else could I add in my notes about this patient’s condition that would better communicate how sick the patient is which in turn better communicates the resources needed for patient care? Incorporating these aspects into your documentation will result in an accurate picture of your patients’ severity of illness and risk of mortality. This in turn will result in accurate public reporting on quality and outcomes. And…..it will help reduce the number of queries you receive to clarify your documentation.

Good Samaritan Advocate Hospitalists, Internal Medicine Family Practice April 15 11 am Thomas C Kravis MD © 3M 2015 - 3M Confidential - For Customer's.

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Good Samaritan Advocate Hospitalists, Internal Medicine Family Practice April 15 11 am Thomas C Kravis MD © 3M 2015 - 3M Confidential - For Customer's.

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