7/27/2012 1 CODING TEXAS STYLE! AAPC Tyler Symposium Agenda and Syllabus Saturday, August 4th 2012 Registration and Check-In 7:00 – 7:45 7:45 Welcome and opening remarks: Dr. Spain Morning Sessions: 8:00 – 9:00 Speaker: Reed Pew AAPC Chairman and CEO “The AAPC and the Future of Healthcare” 9:00 – 10:00 Speaker: Annie Boynton CPC CPC-H CPC-P CPC-I RHIT CCS CCS-P CPhT “ICD-10: Bracing for Change” Break 10:00 – 10:15 10:15 – 11:15 Speaker: Hitesh Singh MD “Oncology – Understanding Lung Cancer” 11:15 – 12:15 Speaker: Debra L Patterson MD “Medicare Contracting, Medical Review Audits, and Other Assorted Medicare ‘Stuff’ “ Lunch and Quiz 0.5 CEU!! 12:15 – 1:30 2 Afternoon Sessions: 1:30 – 2:30 Speaker: William F Turner Jr, MD, Cardiothoracic Surgeon “An Anatomical Look at Advances in Thoracic Surgery” 2:30 - 3:30 Speaker: Stephen C Spain MD FAAFP CPC “Quality Initiatives and ACO’s: What Coders Need to Know” Break 3:30 – 3:45 3:45– 4:45 Speaker: Loretta Swan CPC “Take Charge of Coding: Establishing a Review Process For Best Results” 3 4 President: Stephen C. Spain, MD, CPC Email: [email protected]Vice President: Patty Hobbs, CPC, CPMA Email: [email protected]Education Officer: Barbara Sullenbarger , CPC Email: [email protected]Treasurer: Judy Young, CPC Email: [email protected]New Member Development: Vickie Lowder, CPC Email: [email protected]Secretary: Zella Haynes, CPC Email: [email protected]The Tyler “Rose” Chapter of the AAPC Officers:
60
Embed
Saturday, August 4th 2012cloud.aapc.com/pdf/Compiled Presentations_4perPage.pdf3. Readiness Assessments Verify now if your physician’s documentation will work for ICD-10 If not,
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Implications of an ICD-10 Delay • It is important to continue moving forward with ICD-10
• Loss of momentum poses a significant risk to the entire healthcare industry
– 30 Day Public Commentary Period
• Overcome fear of change!
• ICD-10 is coming! – Proposal to delay ICD-10 until
October 1, 2014 was announced April 9, 2012.
• Treat the delay as a gift of time, additional time will help spread out costs, and allow the industry to become better prepared for ICD-10
– Better Manage the Change Process
• Strategic thinking is more critical than ever
– Planning
– Training
– Testing
ICD-10 Quick Reference Guide
Proposed Implementation deadline 10/1/2014
W58.11XA Bitten by
crocodile, initial encounter
W58.01XA Bitten by
alligator, initial encounter
Worldwide ICD-10
Adoption Timeline
United States and Italy are the last industrialized nations to implement ICD-10 for morbidity reimbursement.
7/27/2012
10
37
The ICD-10 Challenge
•ICD-10 requires a more complex business approach than HIPAA
5010. – HIPAA 5010 changes were specified by CMS by prescriptive EDI technical specifications.
CMS recommended health care payers’ use of new and modified HIPAA 5010 data
elements.
– ICD-10, on the other hand, requires health care payers to interpret the new ICD-10 code
set and determine how to modify business processes so that efficiencies can be gained
to drive organizational value and competitive differentiation.
– ICD-10 process changes will impact all physician practices and hospitals but there are
benefits too:
• Medical Management
– Medical Policy changes made to align with ICD-10 may impact business process
– Opportunity: richer code set allows for more focused Care Mgmt & Wellness Programs
• Contracting
– Updating contracts containing ICD-9 codes & references may impact business process
– Opportunity: additional detail allows for a more precise pricing structure
• Fraud & Abuse
– Richer data set available for Fraud & Abuse analytics may impact business processes
– Opportunity: greater specificity of code sets allows for more automation in reviews 38
Tran External
Reporting
Physicians
Clearinghouse EDI Transaction
Billing System
EHR
Coding Encounter
Documentation
Clearinghouse EDI Transaction
Payers
Claims
Payment Medical
Management
Fraud/Abuse
Preauthorization
Referrals
Med/Utilization Review
Case/Disease Management
Claims
Adjudication
Contract
Design
Benefit
Design
Compliance
Reporting
Quality
Analysis
Actuarial
Analysis
Network
Management
Translation
Pre-adjudication
Edits
Gateway
Call Center
Transactions
Data
Warehouse
In both Physician and Payer settings, ICD-10 represents a major impact to all business and
technology areas that utilize medical codes.
ICD-10 Impact Map
39
ICD-10-CM Diagnosis Code Example
Diagnostic Code Set - Broad Impacts
ICD-10-CM provides 50 different codes for “complications of foreign body accidentally left in body following a procedure,” compared to only one code in ICD-9-CM.
– T81 category for complications due to foreign body show how specific these ICD-10-CM codes are compared to the one general ICD-9-CM.
– ICD-10-CM codes describe the actual complication, e.g. perforation, obstruction, adhesions, as well as the actual procedure that had been done that resulted in the foreign body being left behind.
• T81.530, Perforation due to foreign body accidentally left in body following surgical operation
• T81.524, Obstruction due to foreign body accidentally left in body following endoscopic examination
• T81.516, Adhesions due to foreign body accidentally left in body following aspiration, puncture or other catheterization
40
ICD-10-PCS Procedure Code Example
Procedure Code Set - Heavily Impacts Inpatient Procedures
ICD-10-PCS provides dozens of combinations of codes for Coronary Artery Bypass Grafts compared to only 7 codes in ICD-9-CM.
− Specificity of an ICD-10-PCS code compared to the more general ICD-9-CM code
− ICD-9-CM codes 36.14 and 36.16 would be reported for this same procedure
− Each ICD-10-PCS character has a specific meaning, and there is no decimal point used in ICD-10-PCS procedure codes
– 02100Z8 Bypass, One Coronary Artery to Right Internal Mammary Artery,
Open • 0 stands for the medical-surgical section
• 2 is the heart and great vessels body system
• 1 is the root operation of bypass
• 0 is the body part – one coronary artery
• 0 is the approach, which is open for this case
• Z indicates no device was used
• 8 is a qualifier for right internal mammary artery
7/27/2012
11
41
Crosswalks are not the solution to ICD-10 deployment for the
industry, rather a tool to be used in creating the solution.
What Are Crosswalks?
• Crosswalks are a translation tool used to assign an ICD-9 code to the best possible match in ICD-10 (and potentially the reverse as well).
• Crosswalks will likely be created based on the CMS-created General Equivalency Mapping (GEM) files
– GEMs not crosswalks
– GEMs are more of 2 way translation dictionaries for diagnosis and procedure codes from which crosswalks will be developed.
– Interpretation of the GEMs will impact everything from medical necessity to reimbursement.
• The development of a crosswalk ideally should be a temporary measure used for specific purposes.
• Crosswalks should not alter the meaning of a code; rather represent the facts as accurately as possible.
• Creating a crosswalk from “scratch” will incur significant costs.
42
The Mapping Problem
•Development of a single “official”
mapping between ICD-9 and ICD-10 is a
major industry concern: – Not all of all the codes will map accurately 1:1
– All other codes will either lose information or assume information
that may not be true
– Imperfect mapping will affect processing and analytics in a way
that impacts revenue, costs, risks and relationships
– The level of impact is directly related to the quality of translation
– The anticipated quality of translation is currently an unknown
– GEMs do not provide a definitive match
– There may be multiple translation alternatives for a source system
code, all of which are equally plausible
– Some translation projects will require selection of a “best
alternative”
Why Do We Map?
43
Why Providers Map
Why Payers Map
Contracting with payers
Outdated documents and reports
containing ICD-9 codes
Lab orders need updates
New medical review edits
Quality Measurements
May need automated coding support
Contracting with providers and employers
Coverage determinations
Payment determinations
Plan structures
Statistical reporting
Actuarial projections
Fraud and abuse monitoring
Quality measurements
Source: Brian Levy, MD and Elaine King of Health Language 44
ICD-9 ICD-10
14,000 Diagnosis Codes
4,000 Procedure Codes
68,000 Diagnosis Codes
87,000 Procedure Codes
Angioplasty (procedure codes)
1 code
39.50
Angioplasty (procedure codes)
854 different codes
047K047 Specifying body part, approach and device
Pressure Ulcer Codes (diagnosis codes)
7 codes
707.00-707.99
Show location, but not depth
Pressure Ulcer Codes (diagnosis codes)
125 different codes
L89.131 Specific location, depth, severity, occurrence
No equivalent ICD 9 Code
-Indicated through notes and
other methods
Y71.3
Surgical instruments, materials and cardiovascular
devices associated with adverse incidents
Autopsy
89.8
No ICD 10 code
More than just a crosswalk
Example ICD-9 to ICD-10 changes
7/27/2012
12
45
• There may be multiple translation alternatives for a source system code, all of which are equally plausible
• Some translation projects require selection of a “best alternative”
Clinical Example:
A provider sees a patient in a [subsequent encounter] for a [non-union] of an [open] [fracture] of the [right] [distal] [radius] with [intra-articular extension] and a [minimal opening] with [minimal tissue damage].
ICD-9-CM code: 813.52 Other open fracture of distal end of radius (alone)
ICD-10-CM code: S52.571M Other intra-articular fracture of lower end of right radius, subsequent encounter for open fracture type I or II with nonunion
NOTE: For all codes related to fractures of the radius:
• ICD-9 codes = 32
• ICD-10-CM codes = 1731
ICD-10 Crosswalk Example
46
Example of Change Impact & Sensitivity – Diagnosis Related Groups (DRG)
Based
47
Benefit How Achieved
• Strategic imperative
• ICD-10 transition should be viewed more broadly than “complying with a
government regulation”; it serves as an opportunity to create differentiation
and new and incremental value for the organization.
• Positive impact to Case Mix /
Quality Reporting
• More specific diagnosis reporting
• Case mix adjustments
• More specific quality monitoring / reporting; e.g., Stent Insertion (specific
codes for open vs. subcutaneous stent insertions)
• Reduced cycle time
• Increased throughput
• Reduced administrative
expense
• Fewer claim rejections and denials due to non-specific diagnoses
• Fewer requests for clinical information
• Expectations of fewer denials from payers could result in significant reduction
of rework / administrative expense for both physicians and payers
• Positively affect patient /
community health
• More specific disease management programs
• Enhanced reimbursement • Targeted reimbursement based on revised diagnoses and procedure coding
Transitioning to ICD-10 can result in significant value realization.
Benefits of ICD-10
Implementation
48
III. Physician, Hospital, Office staff and Vendor
Readiness
A Call to Action…
7/27/2012
13
• Physicians
• Clinical Administrative Staff
• Patient Accounting
• Coders
• IT Staff
ICD-10 Impact on Providers and
Payers
49
• Coding/ Billing Workflows
• Contracting Approaches
• Prior Authorization/Notification Changes
• Reporting Analytics
• Physician/ Coder Query Process
• Claims/ Billing Systems
• System Interfaces
• Electronic Data Interchanges (Clearinghouses)
• Practice Management Systems
• EHRs
People
Process
Technology
ICD-10 Impacts on Physicians
Different types of physician practices
will experience different impacts:
– Private practice physicians (solo, small group)
– Large physician groups
– Employed & academic physicians (all models)
– Government, Researchers and other types
Physician practices are highly cost
sensitive, and are already contending
with:
– HIPAA Changes
– American Recovery and Reinvestment Act (ARRA)/Health Information Technology for Economic and Clinical Health (HITECH) meaningful use incentive drivers and penalty avoidance
Concerns/Risk Mitigation - Understand, value and invest in people - like never before
- Consider supplementing practice staff to support the initial transition - Help bridge initial decreased productivity - Better able to absorb attrition
- Reduce stress to avoid mistakes
- Too early for full staff/coder training on ICD-10 now, but not for brushing up on anatomy and
physiology, pathophysiology, pharmacology, etc (much more critical in ICD-10)
studies 1. Chemotherapy with 1 or 2 drugs better than
BSC 2. Two drug regimens are more effective than
one. 3. Two drug platinum doublet improves
survival and QOL in patients with good performance status
4. 3 drug regimens no better than 2 5. Elderly patients can be treated safely -
ELVIS
7/27/2012
24
Schiller et al 2002
First study showing certain histology is responds better to
certain chemotherapy
Scagliotti et al, 2008
Targeted therapy
Hanahan et al, 2000
Anti- VEGF - Bevacizumab
EGFR TKI - Erlotinib Alk – TKI - Crizotinib
Targeted therapy for
non-small cell, non-Sq lung
cancer Monoclonal ab
• Antibody against
Vascular Endothelial
Growth Factor
– Bevacizumab
• Extracellular
Small Molecule Inhibitor
• EGFR Tyrosine Kinase -
Inhibtor
– Erlotinib
• ALK Tyrosine Kinase
inhibtor
– Crizotinib
7/27/2012
25
Bevacizumab Stage
4,
adeno
BPC PC
Resp
Rate
35% 15%
PFS 6.4
mo
4.5 mo
OS 12.3
mo
10.3
mo
1993 - Inhibition of vascular endothelial growth factor induced angiogenesis suppresses tumour growth in vivo 1995- The effect of antibody to vascular endothelial growth factor and cisplatin on the growth of lung tumors in nude mice. 2004- Bevacizumab plus carboplatin and paclitaxel with carboplatin and paclitaxel alone in previously untreated locally advanced or metastatic non-small-cell lung- phase II
2005-Paclitaxel–Carboplatin Alone or with Bevacizumab for Non–Small-Cell Lung Cancer.
N Engl J Med 2006;355:2542-50
Indication: Stage 4- Non- small cell, Non-Sq Side effects: HTN , hemorrhage, bowel perforation
Erlotinib
• 1997_ EGFR over expression in Lung Ca
• 2004 – FDA approval for second line After failure of chemotherapy- erloyinib as single agent
• 2011: FDA approval for first line in patients with EGFR mutation , and nonsquamous only
Documentation of patient’s functional limitations or need for adaptive behavior or use of assistive devices (e.g., canes, walkers, wheelchair).
Suggested Actions
• Physicians and others who provide inpatient services must produce clinically meaningful inpatient records or supply the hospital with relevant documents from their outpatient records.
• Hospitals could proactively obtain previous diagnostic and therapeutic records from other sources
History and physical, progress notes, relevant “consultations,” from the surgeon and other treating physicians.
Physical and occupational therapist evaluations and therapy notes.
Imaging reports.
Therapeutic procedure (such as joint injection) notes.
7/27/2012
35
• DRG 227 – Cardiac defibrillator implant without cardiac catheterization
without major complications or comorbidities.
• DRG 243 – Permanent cardiac pacemaker implant with complications or
comorbidities.
• DRG 244 – Permanent cardiac pacemaker implant without complications
or comorbidities/major complications or comorbidities.
• DRG 246 – Percutaneous cardiovascular procedure with drug-eluting
stent with major complications or comorbidities or 4+ vessels/stents.
• DRG 247 – Percutaneous cardiovascular procedure with drug-eluting
stent without major complications or comorbidities.
TrailBlazer A/B Crossover Audits
•DRG 251 – Percutaneous cardiovascular procedure without coronary
artery stent without major complications or comorbidities.
•DRG 253 – Other vascular procedures with complications or
comorbidities.
•DRG 254 – Other vascular procedures without complications or
comorbidities/major complications or comorbidities.
•DRG 291 – Heart failure and shock with major complications or
comorbidities.
•DRG 292 – Heart failure and shock with complications or comorbidities.
TrailBlazer A/B Crossover Audits
• DRG 293 – Heart failure and shock without complications or
comorbidities/major complications or comorbidities.
• DRG 392 – Esophagitis, gastroenteritis and miscellaneous digestive
disorders without major complications or comorbidities.
• DRG 460 – Spinal fusion except cervical without major complications or
comorbidities.
• DRG 470 – Major joint replacement or reattachment of lower extremity
without major complications or comorbidities.
• DRG 552 – Medical back problems without major complications or
comorbidities (two days or less).
• Inpatient High Dollar Edit.
TrailBlazer A/B Crossover Audits
Take Home Message
• The quality of the information within a
document is usually more important than
the record’s volume.
• (Beware the Curse/Blessing of the EHR)
7/27/2012
36
Questions Presentation #5
William F. Turner Jr, MD
Hybrid Coronary Revascularization A Surgeon’s Perspective
William F. Turner Jr., MD
Louis and Peaches Owen Heart Hospital
Trinity Mother Frances Hospitals and Clinics
Tyler, Texas
www.heartsurgery-tyler.com
Hybrid Revascularization
Total endoscopic coronary artery bypass grafting in combination
with percutaneous catheter intervention as a simultaneous or
staged approach for the management of patients with multivessel coronary disease.
7/27/2012
37
Why “Hybrid Coronary
Revascularization?”
Complex PCI is transformed into a simpler procedure and
complex CABG is transformed into a simpler operation
Hybrid
Revascularization
Objectives
Relieve symptoms and prolong life
Achieve a durable result
Avoid Complications
Decrease Morbidity
Patient Satisfaction
Patients Don’t Want This! Patients Will Demand This !!!!
7/27/2012
38
Hybrid
Revascularization
“The Best Of Both Worlds”
No Documented Survival Benefit of
SVG over Stents (SYNTAX,EAST,BARI)
Survival Benefit of Internal Mammary
Artery Grafting to LAD
LIMA to LAD
“There is now incontrovertible evidence that
for patients with severe diffuse coronary
atherosclerosis who are candidates for
myocardial revascularization, internal
thoracic artery grafting to the left anterior
descending coronary artery is the single
most important determinant of survival
and event free survival.”
Floyd D. Loop NEJM, 1996
7/27/2012
39
Hybrid
Revascularization
Requirements
Collaboration between cardiologist and
surgeon
Education of the patient and referring
MD
Elimination of turf battles
Patient centric and not procedure
centric
Skilled operators(surgeon and
cardiologist)
Choosing The Appropriate Patient
True ostial LAD-high risk for stenting
Chronic total occlusions with
demonstrable ischemia
Left main involvement
Vessels unsuitable for TECAB can be
stented(PDA,PLB,OM3)
Multiple co-morbidities
Hybrid Revascularization
Contraindications Very large hearts (Cor bovinum)
Hemodynamic instability
(MI < 24 hrs; dysrhythmias)
Decompensated heart failure
Inaccessible artery (calcified, diffuse
disease, intramyocardial)
Morbid Obesity (BMI>40kg/m2)
Simultaneous TECAB and
PCI
Advantages
Complete revascularization in one
operative setting (hybrid suite)
Immediate quality assessment of IMA
Any graft issues corrected immediately
Shorter hospital length of stay and
faster functional recovery
No platelet inhibition during surgery
7/27/2012
40
Staged Hybrid Approach
“Who goes first?”
Surgery followed by PCI :in majority of
patients
PCI followed by surgery: acute
coronary syndrome requiring PCI
culprit vessel in multivessel disease
Staged Hybrid Approach
a
PCI interval managed according to
post op recovery from TECAB
Qualitative assessment of graft
patency
No antiplatelet agent concerns
Revascularized myocardium(LIMA-
LAD)
Hybrid Revascularization
Illustrative Case 80 yo male with occluded LAD and
• 11. Percent of PCPs who Successfully Qualify for an EHR Incentive Program Payment.
• 12. Medication Reconciliation: Reconciliation After Discharge from an Inpatient Facility.
• 13. Falls: Screening for Fall Risk.
Preventive Health
• 14. Influenza Immunization
• 15. Pneumococcal
• 16. Adult Weight Screening and Follow-up.
• 17. Tobacco Use Assessment and Tobacco Cessation Intervention.
• 18. Depression
• 19. Colorectal Cancer Screening.
• 20. Mammography
• 21. Proportion of Adults 18+ who had their Blood Pressure Measured within the preceding 2 years.
At Risk Population: Diabetes • 22. Hemoglobin A1c Control (< 8%).
• 23. Low Density Lipoprotein (< 100mg/dl).
• 24. Blood Pressure < 140/90.
• 25. Tobacco Non Use.
• 26. Aspirin Use.
• 27. Hemoglobin A1c Poor Control (> 9%).
7/27/2012
52
At Risk Populations: Hypertension
• 28. Hypertension (HTN): Blood
Pressure Control.
At Risk Populations: IVD
• 29. Ischemic Vascular Disease (IVD):
Complete Lipid Profile and LDL Control <
100 mg/dl.
• 30. Ischemic Vascular Disease. Ischemic
Vascular Disease (IVD): Use of Aspirin or
Another Antithrombotic.
At Risk Populations: Heart Failure
• 31. Heart Failure: Beta-Blocker
Therapy for Left Ventricular Systolic
Dysfunction (LVSD).
At Risk Populations: CAD
• 32. Coronary Artery Disease (CAD) Composite: All or Nothing Scoring: Drug Therapy for Lowering LDL-Cholesterol.
• 33. Coronary Artery Disease (CAD) Composite: All or Nothing Scoring: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Patients with CAD and Diabetes and/or Left Ventricular Systolic Dysfunction (LVSD).