1. 3M Health Information Systems, Inc. 3M provides these slides to better understand 3M's software and/or services. These slides contain 3M confidential information and are for customer’s internal review only. Innovating Health Language of the Innovating Health Language of the Advocate Condell Cardio Draft Thomas C Kravis MD © 3M 2015 - 3M Confidential - For Customer's Internal Review Only.explaiFurther use or disclosure requiresexplain apr and inpatint prior approval from 3M.

2. 2 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. 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 and clinical outcomes Reduce denials and queries Prepare for ICD-10

3. 3 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Value of Accurate and Complete Documentation MD and Hospital Quality Reports Care Coordination Team Medical Necessity Value Base Purchasing PSIs Core Measures Compliance Fraud Abuse RAC 2 MIDNIGHT RULE E&M Pro fees Denial related claims ICD-9-CM ICD-10 POA HACs Preventable Readmission Complications

4. 4 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. General guidelines for Documentation  Document all diagnoses and procedures  Licensed hands-on treating practitioner in the body of the EMR and discharge summary  All medications, treatments and diagnostic studies and the corresponding medical diagnoses for each and the clinical significance  Conditions cannot be coded from lab, x-ray, other diagnostic test results or symbols (↑, ↓) without practitioner documentation.  ‘Cut and pasted’ documentation must accurately reflect the clinical condition of the patient at the time of the documentation

5. 5 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Documentation & Coding Issues at Advocate Physician Document in CLINICAL terms Documentation for coding, profiling & compliance requires specificity in DIAGNOSIS terms This gap will be increased with ICD-10 Two separate languages Documentation Improvement can help bridge the gap

6. 6 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Hypomagnesemia Protein Calorie Malnutrition Dehydration, hypovolemia Acute or Chronic Blood Loss Anemia Respiratory failure, acute due to…. Acute Myocardial Infarction, LAD Atrial fibrillation, paroxysmal Severe Sepsis Pathologic fx R hip-initial encounter Unstable angina, possible AMI Diagnostic TermClinical Statement ↓ Magnesium = 2.0, will give Mg Emaciated, weight loss,↓ albumin, ↓BMI Will rehydrate ↓ Hgb 5.2, transfuse Severe respiratory distress Chest pain, ↓BP, acute changes EKG Arrhythmia “Urosepsis” Hx Ca hip, fracture Acute Coronary Syndrome Unable to CodeAble to Code

7. 7 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Pocket Card Example Clinical Terms (Documentation needs clarification) Diagnostic Statement (Accurate code may be assigned) Continue home medications such as furosemide, HCTZ, ACE inhibitor Document specific diagnosis such as chronic systolic/ diastolic heart failure, CAD, atrial fibrillation, angina, HTN History of HF, will continue home medsSpecify acuity (chronic, acute, acute on chronic); specify type (systolic, diastolic, combined systolic and diastolic) Cardiac enzymes elevated, elevated troponin, EKG positive Acute myocardial infarction (specify type such as STEMI or NSTEMI; document specific artery involved such as LAD, left circumflex; exact date of any recent AMI) Acute coronary syndrome (ACS)Clearly document intended diagnosis such as intermediate/insufficiency syndrome, unstable angina, coronary slow flow syndrome, myocardial infarction Cardiac historyClearly document specific diagnoses such as CAD, angina, old MI (document date when MI occurred) Atrial fibrillationSpecify type such as paroxysmal, persistent, chronic Atrial flutterSpecify type such as typical (type I) or atypical (type II) BP 70/40, ordered norepinephrine or dopamine for support Shock (specify type such as cardiogenic septic, hypovolemic) A code may not be assigned based on abnormal laboratory results or diagnostic report findings alone. The physician must document the corresponding diagnosis in the body of the medical record.

8. 8 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Cardiology Clinical Terms (Documentation needs clarification) Diagnostic Statement (Accurate code may be assigned) Pulmonary insufficiencyDocument acuity (acute or chronic), document cause (due to shock, surgery, trauma) SOB, paCO 2 60 mmHg, pH 7.32, O 2 sat 88%, BiPAP Respiratory failure (specify acuity, if known or suspected: acute, chronic or acute on chronic; document hypoxia, hypercapnia, if present) CT scan/MRI of brain indicative of infarction CVA/stroke/cerebral infarction (specify if due to embolism, thrombosis, occlusion, stenosis, or hemorrhage; document the clinical significance from the diagnostic findings to the current condition; document artery involved such as carotid, middle cerebral, vertebral; document laterality such as left or right; specify cause-and-effect between medical intervention and the CVA and specify intraoperative or post-procedural CVA; document any associated cerebral edema) Diabetes, blood sugar ↑360, will start insulin drip, history of PVD Specify type (type 1, type 2, drug or chemical induced, other underlying condition), document any associated complications (diabetic autonomic neuropathy, diabetic foot ulcer, PVD due to diabetes – must document a cause and effect link), document insulin control status as controlled, out of control, with hyperglycemia CXR shows chronic lung changes. Nurses’ notes indicate COPD. Home meds of inhalers noted COPD (document if with acute exacerbation or decompensated and document if oxygen dependent); Emphysema (document type such as unilateral, panlobular, centrilobular) Chronic kidney disease (CKD)Document stage (stage 1-5, ESRD) and etiology such as due to diabetes or polycystic kidney disease Acute kidney failureDocument etiology, if known or suspected (acute tubular, cortical or medullary necrosis; postprocedural; post-traumatic or drug-induced) A code may not be assigned based on abnormal laboratory results or diagnostic report findings alone. The physician must document the corresponding diagnosis in the body of the medical record.

9. 9 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. ICD-10 Cardiology Documentation Tips  Use adjectives ―Acute, chronic, acute on chronic Example: Acute on chronic systolic heart failure  Indicate cause and effect ―Use “due to” or “secondary to” Example: Congestive heart failure due to atrial fibrillation  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 ―For example, Ablation of left ventricle  Use exact dates ―Example: “Myocardial infarction 3/10/2015” and not “MI last month”

10. 10 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Physician role Clinical Documentation  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

11. 11 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Impact of Responding to Query Impact w/ Response to Query  RW = 2.9797  GLOS = 8.98  SOI = 3 Major  ROM = 2 Moderate Impact w/o Response to Query  RW = 2.9797  GLOS = 8.98  SOI = 2 Moderate  ROM = 2 Moderate Query: “ The magnesium level is 1.6 and the patient is receiving magnesium sulfate” “Please provide a corresponding diagnosis ” Physician documents: “hypomagnesemia” Cardiac Procedure

12. 12 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. When should I Document Secondary Diagnoses and What is the Impact? “ Additional conditions that affect patient care in terms of requiring at least one of the following”: 1.Clinical evaluation 2.Therapeutic treatment 3.Diagnostic procedures 4.Extended length of hospital stay 5.Increased nursing care and/or monitoring

13. 13 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Principal Diagnosis "XYZ" Impact of Secondary Diagnosis

14. 14 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Diabetic “Neuropathy” is Nonspecific in ICD-10 Diabetic neuropathy is a nonspecific code in ICD-10 (will generate a query and if not clarified, result in a missed opportunity to capture SOI and ROM) If known or suspected, document : Diabetic mononeuropathy Diabetic polyneuropathy Diabetic autonomic neuropathy Diabetic amyotrophy Type of diabetes Type 1 or Type 2 Control status Document: “Inadequately controlled,” “ Out-of-control,” or “ Poorly controlled” and “With or without hyperglycemia”

15. 15 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Provider Documentation: Quality profile and reimbursement Provider Documentation Principal & Secondary Diagnoses Principal & Secondary Procedures ICD-9-CM Codes ICD-10-CM Codes ICD-10-PS Codes DRG Assignment Severity & Risk of Mortality Classification Profiling/Reimbursement (Providers/Hospitals) © 3M 2008. All rights reserved. Copy Right 3M 2014 All Rights Reserved

16. 16 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. All Patient Refined DRG APR-DRG 3M™ Severity of Illness Subclasses 1.Minor 2.Moderate 3.Major 4.Extreme Risk of Mortality Subclasses 1.Minor 2.Moderate 3.Major 4.Extreme Mortality at < 4  Quality  Coding  Documentation Subdivide into subclasses

17. 17 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Underlying Principle of 3M™ APR DRGs High SOI and ROM are characterized by: (a) multiple (b) serious diseases and (c) the interaction among those diseases. © 3M 2015 - 3M Confidential - For Customer's Internal Review Only. Further use or disclosure requires prior approval from 3M.

18. 18 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. SOI and ROM are Independent The SOI and ROM subclass are calculated separately ROM = 1 Low Risk of Mortality SOI = 3 Significant Organ Decomposition Acute Cholecystitis

19. 19 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Severity Summary Analysis by Service Lines

20. 20 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. 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 Risk-Adjusted Mortality Analysis: Actual vs Expected Advocate

21. 21 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. 3M  APR DRG Classification System Risk-Adjusted Mortality Example APR-DRG 194, HEART FAILURE 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. Data Source: 3M APR DRG Classification System utilizing MEDPAR 2013

22. 22 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M.  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 <<< How does Advocate improve performance ? ―Structural heart disease ―Supraventricular tachycardia ―Cardiomyopathy : Alcoholic congenital, congestive, constrictive, dilated, endomyocardial, idiopathic hypertrophic sub aortic stenosis,nonobstructive hypertrophic, obstructive hypertrophic, restrictive Heart Failure Videos Specialty Semiars Case Studies 1:1 Guidance

23. 23 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. 3M™ APR Physician Dashboard – Target & Train Physician Lower SOI 3 Peer Groups: Target physician Peers

24. 24 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Heart Failure  Sample Physician: SOI less than Peers  Target for Training/guidance Training objective:  Respond to query  Document the drivers of SOI  Treat underlying cause: clinical effectiveness  Lower SOI

25. 25 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. ―Acute renal “insufficiency” SOI 1; ROM 1 ―Acute kidney injury (AKI) SOI 3; ROM 3 ―Acute kidney failure SOI 3; ROM 3 Versus ― 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 Acute Kidney Failure Documentation Impact of Appropriate Documentation on SOI and ROM and Physician Scorecard

26. 26 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Respiratory Failure  Acute/chronic/acute on chronic  Cause or 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 7.50  pCO 2 of >50  pO 2 of <60 (impacted by hemoglobin level)  Type I Hypoxemic : pO 2 60 mm Hg normal or low pCO 2  Type II Hypercapnic: pH 50  Chroni c : As above and low flow 02 at home; polycythemia ;cor pulmonale; heart failure

27. 27 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. 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

28. 28 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Possible/Probable Cause of Chest Pain GERD Gastritis MS-DRGs 391/392 RW = 1.0958 Chest Pain MS-DRG 313 RW = 0.5404 Anterior CP Pleuritic CP Chest Wall Pain MS-DRG 204 RW = 0.6472 Costochondritis Tietze’s Disease MS-DRGs 205/206 RW = 1.2566 Pulmonary Embolism MS-DRGs 175/176 RW = 1.6121 Cardiac Arrhythmia MS-DRGs 308/309/310 RW = 1.2188 Angina MS-DRG 311 RW = 0.5128 CAD MS-DRGs 302/303 RW = 0.9999 Shingles MS-DRGs 595/596 RW = 1.7691 Psychogenic Chest Pain MS-DRG 882 RW = 0.6676 Pleurisy MS-DRGs 193/194/195 RW = 1.4378 Psychogenic Angina Pericarditis MS-DRGs 314/315/316 RW = 1.7589 Anxiety MS-DRG 880 RW = 0.6191 Biliary Colic MS-DRGs 444/445/446 RW = 1.5055 Cardiac Cath MS-DRGs 286/287 RW = 1.9634

29. 29 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M.  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  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  Document presence of cor pulmonale (acute /chronic) Documentation for Pulmonary Embolism ICD-10

30. 30 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. 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: Intermediate or insufficiency coronary syndrome Unstable angina Coronary slow flow syndrome Myocardial infarction Other condition? Acute Coronary Syndrome (ACS) – A Nonspecific Code in ICD-10

31. 31 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Myocardial Infarction Myocardial infarction documentation and coding will need to include: Type of infarction STEMI NSTEMI Age of infarction If within 4 weeks coded as initial If older than 4 weeks coded as “old” Specific site of myocardium involved Anterior wall Inferior wall Coronary artery involved Initial or subsequent MI within 4 weeks ICD-9-CM Acute Myocardial Infarction 10 10 codes (410.01-410.91) ICD-10-CM Myocardial Infarction 9 5 9 codes for initial (I21) and 5 codes for subsequent (I22) © 3M 2014. All Rights Reserved.

32. 32 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Drug Underdosing  Document intentional versus unintentional or accidental ―Intentional For example, due to financial hardship ―Unintentional or accidental Age-related dementia Rheumatoid arthritis of hands

33. 33 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M.  Specify what type of coronary artery is diseased: ―Native coronary artery ―Coronary artery bypass graft Autologous vein coronary artery bypass graft Autologous artery coronary artery bypass graft Non-autologous biological coronary artery bypass graft ―Coronary artery of transplanted heart Native artery of transplanted heart Bypass graft of coronary artery of transplanted heart  Document if CAD is present with: ―Angina pectoris ―Angina pectoris and spasm ―Unstable angina ―Other forms of angina Coronary Artery Disease (CAD) Example: Atherosclerosis of coronary artery bypass graft(s) without angina pectoris - I25.810

34. 34 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. 3M  APR DRG Classification System Risk-Adjusted Mortality Example APR-DRG 720, SEPTICEMIA & DISSEMINATED INFECTIONS 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. Data Source: 3M APR DRG Classification System utilizing MEDPAR 2013

35. 35 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Sepsis  Urosepsis imprecise  No IDD-10 a code for urosepsis  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

36. 36 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. “ 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).

37. 37 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Examples Complication  Postop ileus (997.4 + 560.1 )  Ileus secondary to surgery (997.4 + 560.1)  Post op atelectasis (997.39 + 518.0)  Post op anemia (998.11 + 285.1) Non-Complication  Ileus  Prolonged ileus  Expected ileus  Incidental atelectasis  Atelectasis  Acute blood loss anemia

38. 38 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M.  Document etiology of cerebral infarction: ―Embolism ―Thrombosis ―Occlusion ―Stenosis  Specify artery involved: ―Anterior cerebral artery ―Basilar artery ―Carotid artery ―Cerebellar artery ―Middle cerebral artery ―Posterior cerebral artery ―Vertebral artery  Document the link between the occluded vessel and the CVA, if appropriate  Requires laterality distinction (left vs. right)  Intraoperative or postprocedural cerebral infarction occurring during cardiac or other type of surgery Cerebral Infarction Following Cardiac Surgery

39. 39 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. ICD-9 vs. ICD-10 Structural Changes  ICD-9 (Diagnoses) 3-7 characters a a # # a/# Category etiology, site, manifestation extension a/# ICD-10 (Diagnoses) # # # # # # # # # # Category etiology, site, manifestation 3-5 characters t

40. 40 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. 027B34Z 027B34Z Med/Surg Heart & Great Vessels Dilatation Coronary Artery Percutaneous Transluminal Device, Drug Eluting None Section Body System Body System Root Operation Root Operation Body Part Body Part Approach Device Qualifier Documentation of a procedure: Example stent ICD-10-PCS

41. 41 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M.  Objective of the procedure ― Root operation “dilation” is defined as “ expanding an orifice or the lumen of a tubular body part”  Coronary artery and the number of sites receiving treatment (e.g., one, two, three or four more sites)  Approach is open, percutaneous, or percutaneous endoscopic  Drug-eluting or non-drug-eluting device Coronary Angioplasty

42. 42 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. ICD-10-PCS Structure  ICD-10 (Procedures) 7 characters All letters except “I” and “O” No decimal point Each character is a function of its position in the code Each letter or # is called a “value” 7 characters All letters except “I” and “O” No decimal point Each character is a function of its position in the code Each letter or # is called a “value” a/# Section, Body System, Root Operation, Body Part, Approach, Device, Qualifier ICD-9 Procedure Code 00.66 (PTCA)

43. 43 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Building an ICD-10 Procedural Code PTCA with 1 DES Heart & Great Vessels Coronary Artery, One Site Perc Intraluminal Drug-eluting device No Qualifier Dilation Medical and Surgical PTCAs are always: Section 0: Medical & Surgical Body System 2: Heart & Great Vessels Root Operation 7: Dilation Body Part 0: one site 1 : (2) sites 2 : (3) sites 3 : (4+) sites Approach 0 : open 3: perc 4 : perc endoscopic Device 4: drug-elut D : non-elut T : radioactive Z : no device Qualifier 6 : bifurcating Z: no qualifier

44. 44 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M.  Specify the objective of the procedure ―Root operation “dilation” is defined as “expanding an orifice or the lumen of a tubular body part”  Specify vessel and laterality  Document the approach ―Open ―Endoscopic ―Percutaneous endoscopic  Specify type of stent inserted ―Drug-eluting intraluminal device ―Non-drug-eluting stent ―Bare metal stent Angioplasty with Stent Procedures

45. 45 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Coronary Angioplasty  Specify the number of sites  If stent inserted, drug-eluting versus non-drug eluting

46. 46 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Coronary Artery Dissection During a PTCA  In some cases, the dissection is minor, clinically insignificant and does not alter the procedure outcome  Insertion of a stent because of the dissection does not automatically indicate the dissection is clinically significant  Physician documentation of the clinical significance is necessary to support code assignment  If the dissection is considered clinically insignificant, then the dissection is not considered a complication  A query may be necessary to determine if the dissection is considered a complication of the procedure or is clinically insignificant

47. 47 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M.  Specific location of both bypass attachments  Coronary to coronary  Coronary to thoracic artery or abdominal artery  Coronary to aorta  Internal mammary, right or left  Specific graft used  Autologous venous tissue/Autologous arterial tissue  Synthetic substitute  Nonautologous tissue substitute  Number of bypass grafts  Approach  Open  Percutaneous endoscopic  Specific vein harvested for graft (greater/lesser saphenous vein: left/right) Coronary Artery Bypass Graft (CABG)

48. 48 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Heart Biopsy  Specific site of heart from which tissue is taken

49. 49 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Provide detailed description of the surgery in order to select the correct root operation  Replacement is “ putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part” Cardiac Valve Replacements

50. 50 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Approach  Open  Percutaneous  Percutaneous endoscopic Cardiac Valve Replacements

51. 51 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M.  Specify valve replaced  Aortic  Mitral  Pulmonary  Tricuspid  Clarify if cause of valvular disease is rheumatic or nonrheumatic as ICD-10 assumes rheumatic in cases of multiple valvular diseases Cardiac Valve Replacements

52. 52 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M.  Specify the type of device used in valve replacement  Autologous tissue substitute  Zooplastic tissue  Synthetic substitute  Nonautologous tissue substitute  For example: Porcine replacement of aortic valve would be reported as a zooplastic device Cardiac Valve Replacements

53. 53 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Impact of Documentation MS-DRG 330 2.4981 Bowel Procedure with CC PDx: Colon cancer SDx: Dehydration Post-op ileus (codes to 997.4 + 560.1) “Ulcer/Wound” noted by RN PPx: Left hemicolectomy MS-DRG 329 5.1396 Bowel Procedure with MCC PDx: Colon cancer SDx: Acute Renal Failure – ATN Expected ileus (560.1) Pressure Ulcer, site unspecific PPx: Left hemicolectomy APR DRG:221 SOI Level:2 APR Weight:1.7681 ROM Level:1 Peer Group 0.0% APR DRG:221 SOI Level:3 APR Weight:2.9531 ROM Level:3 Peer Group 2.5% Highest MS- DRG payment MS-DRG 329 5.1396 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 APR DRG:221 SOI Level:4 APR Weight:6.3732 ROM Level:4 Peer Group 24.2%