The Impact of ICD-10-CM upon Hospital and Physician ... · Hospital and Physician Quality Measurement A Primer for Physicians and Hospitals ... Code Type ICD-9-CM ICD-10-CM ... Anuria

The Impact of ICD-10-CM upon

Hospital and Physician

Quality Measurement

A Primer for Physicians and Hospitals

James S. Kennedy, M.D., C.C.S.

2

Faculty

James S. Kennedy, M.D., C.C.S.

Medical School: University of Tennessee, 1979

Residency: Internal Medicine

University of Tennessee, 1980-82

Board Certification: Internal Medicine

Coding Certification: CCS – AHIMA, 2001

Publications:

Physician Query Handbook, 2009

Severity-Adjusted DRGs: an MS-DRG Primer, 2008

Hypovolemia & Dehydration, JAHIMA, 2006

Letter – Annals of Internal Medicine 2006

615-479-7021

3

Goals

• Review the state of the art of physician and hospital profiling

• Explore ICD-10-CM‟s role in severity and risk adjustment

• Define clinical indicators ICD-10-CM coded diagnoses and treatments

• Develop a strategy that improves physician and hospital ICD-10-CM data quality

Like the Phone Book

Interesting Characters – Terrible Plot

Dictionary without

Definitions

ICD-10 Implementation Date

October 1, 2015

5

Diagnoses Procedures

ICD-10-CM

(Clinical Modification)

All entities - providers and

facilities

for diagnoses in all settings:

– Hospital inpatients

– Hospital outpatients

– Physicians offices

– Emergency department

– Home health

– Long-term care

– Rehabilitation facilities

ICD-10-PCS

(Procedure Coding System)

Used by inpatient facilities ONLY

• Includes outpatient facility services

rendered within the prior 72 hours

of writing the inpatient order

• Very different than ICD-9-CM or

CPT

CPT • Physician and

outpatient/observation facility

services still utilize CPT

• CPT does not change!!

ICD-10-CM/PCS Basics

• ICD-10-CM/PCS (and ICD-9-CM) are NOT clinical languages (like SNOMED) – ICD-9-CM and ICD-10-CM/PCS are useful for classifying

healthcare data for administrative purposes, including reimbursement claims, health statistics, and other uses where data aggregation is advantageous

• ICD-10-CM/PCS is based ONLY on provider documentation of clinical language, not on a patient‟s clinical characteristics that are abstracted by a data analyst (e.g. like STS, NCDR, or ATS databases) – The provider must use the magic words that drive ICD-10-

CM/PCS code assignment based upon patient circumstances

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• Coding is based only on provider

documentation

• If there is a difference between the attending‟s

notes and a consultant‟s notes, particularly at

the time of discharge, the attending‟s

documentation takes precedent in coding.

ICD-10-CM/PCS Basics

• Inpatient coders cannot code from EKG, laboratory, X-ray or pathology reports, even if interpreted by a board-certified physician – Results must be documented as diagnoses in the

physician‟s notes

• Arrow up (h) or down (i) with labs cannot be interpreted as abnormal i Na of 120 meq/liter ≠ hyponatremia i Hct ≠ Anemia

• Physicians must completely describe and document conditions as to be coded

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ICD-10-CM/PCS Basics

What‟s Old?

ICD-9-CM

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What‟s New

ICD-10-CM

10

ICD-9 and ICD-10

Diagnoses and Procedures

Code Type ICD-9-CM ICD-10-CM

ICD-10 PCS

Diagnosis 14,567 codes 69,832 codes

GU Diagnosis* 200 codes 594 codes

Inpatient

Procedures 3,878 codes 71,920 codes

*Codes only in the genitourinary section of ICD-9-CM and ICD-10-CM.

Interrelated conditions (e.g. hyperlipidemia, diabetes mellitus) not included

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Overall Changes

• 34,250 (50%) are related to the musculoskeletal system

• 17,045 (25%) are related to fractures

• 10,582 (62%) of fracture codes to distinguish „right‟ vs. „left‟

• ~25,000 (36%) of all ICD-10 codes to distinguish „right‟ vs. „left‟

Clinical Changes

Expansions and Deletions • Marked expansion of codes

– Trauma, overdoses, or complications treatment phases

– Office encounters

– Asthma

– Diabetes mellitus

– Obstetrics (trimesters)

– Non-pressure ulcer staging

– Myocardial infarction timing and vessel involvement

– Open fractures staging

– Cerebral hemorrhage location

– Ischemic stroke vessel involvement

– Coma (Glasgow Coma Scale)

– Atrial flutter and fibrillation

– Drug underdosing

• Deletion of MD language, such as: – Urosepsis

• Must say “sepsis due to UTI”

– SIRS due to infection • Must say “sepsis” or

“severe sepsis”

– Accelerated or malignant hypertension

• Must describe the organ dysfunction caused by hypertension to measure severity

MD progress notes and DC summaries

must use ICD-10-CM’s language (Index

or Table) as to defend the assigned code

Differences from

ICD-9-CM to ICD-10-CM

ICD-9-CM

Diagnosis Codes ICD-10-CM

Diagnosis Codes

Laterality No Laterality

Laterality –

Right or Left account for 35-40% of codes

Code Construction

3-5 digits 7 digits

First digit is alpha (E or V) or numeric

Digit 1 is alpha; Digit 2 is numeric

Digits 2-5 are numeric Digits 3–7 are alpha or numeric

Decimal is placed after the third character

Decimal is placed after the third character

Placeholders No placeholder characters “X” placeholders

# of Codes 14,000 codes 69,000 codes

Severity Limited Severity Parameters Extensive Severity Parameters

Combination Limited Combination Codes Extensive Combination Codes

Excludes Notes

1 type of Excludes Notes 2 types of Excludes Notes

New Changes

Excludes Notes Excludes1 - A type 1 Excludes note is a pure excludes.

– It means 'NOT CODED HERE!'

– An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note.

– An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.

Excludes2 - A type 2 excludes note represents 'Not included here'.

– An excludes2 note indicates that the condition excluded is not part of the condition it is excluded from but a patient may have both conditions at the same time.

– When an Excludes2 note appears under a code it is acceptable to use both the code and the excluded code together.

Excludes1 and Excludes2

Notes

Note that any acute renal

failure or ATN after trauma

codes to T79.5 (per the

Excludes1 note), even if no

anuria occurs

This appears to contradict

the Excludes2 note for

N17.9 which allows S37.0

and N17.9 to be used

together

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New Severity Levels

Emphasis Upon Laterality ICD9 ICD9 Title ICD10 ICD-10 Title

86600 Injury to kidney without mention of open

wound into cavity, unspecified injury

S37001A Unspecified injury of right kidney, initial encounter

S37002A Unspecified injury of left kidney, initial encounter

S37009A Unspecified injury of unspecified kidney, initial encounter

86601

Injury to kidney without mention of open

wound into cavity, hematoma without

rupture of capsule

S37011A Minor contusion of right kidney, initial encounter

S37012A Minor contusion of left kidney, initial encounter

S37019A Minor contusion of unspecified kidney, initial encounter

S37021A Major contusion of right kidney, initial encounter

S37022A Major contusion of left kidney, initial encounter

S37029A Major contusion of unspecified kidney, initial encounter

86602 Injury to kidney without mention of open

wound into cavity, laceration

S37031A Laceration of right kidney, unspecified degree, initial encounter

S37032A Laceration of left kidney, unspecified degree, initial encounter

S37039A Laceration of unspecified kidney, unspecified degree, initial encounter

S37041A Minor laceration of right kidney, initial encounter

S37042A Minor laceration of left kidney, initial encounter

S37049A Minor laceration of unspecified kidney, initial encounter

S37051A Moderate laceration of right kidney, initial encounter

S37052A Moderate laceration of left kidney, initial encounter

S37059A Moderate laceration of unspecified kidney, initial encounter

86603

Injury to kidney without mention of open

wound into cavity, complete disruption of

kidney parenchyma

S37061A Major laceration of right kidney, initial encounter

S37062A Major laceration of left kidney, initial encounter

S37069A Major laceration of unspecified kidney, initial encounter

S37091A Other injury of right kidney, initial encounter

S37092A Other injury of left kidney, initial encounter

S37099A Other injury of unspecified kidney, initial encounter

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Meditech 5.67

18

Combination Codes

5920 Calculus of kidney N202 Calculus of kidney with

calculus of ureter

I10

combines 2

or more I9

codes

5921 Calculus of ureter N202 Calculus of kidney with

calculus of ureter

I10

combines 2

or more I9

codes

V420 Kidney replaced by transplant Z4822 Encounter for aftercare

following kidney transplant

I10

combines 2

or more I9

codes

V5844 Aftercare following organ

transplant Z4822

Encounter for aftercare

following kidney transplant

I10

combines 2

or more I9

codes

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Codes with Placeholders

ICD9 ICD9 Title ICD10 ICD-10 Title

27402 Chronic gouty arthropathy without mention of

tophus (tophi)

M1A30X0 Chronic gout due to renal impairment, unspecified

site, without tophus (tophi)

M1A38X0 Chronic gout due to renal impairment, vertebrae,

without tophus (tophi)

M1A39X0 Chronic gout due to renal impairment, multiple

sites, without tophus (tophi)

27403 Chronic gouty arthropathy with tophus (tophi)

M1A30X1 Chronic gout due to renal impairment, unspecified

site, with tophus (tophi)

M1A38X1 Chronic gout due to renal impairment, vertebrae,

with tophus (tophi)

M1A39X1 Chronic gout due to renal impairment, multiple

sites, with tophus (tophi)

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General Equivalence Mapping

http://www.stjhs.org/documents/ICD-10/2014-ICD-9-CM-to-ICD-10-CM-GEMS.pdf

This exercise will NOT capture new ICD-10 specificities

Validate all mappings using ICD-10 Index, Table, and Guidelines

General Equivalence Mapping

Combination Codes with Hematuria

General Equivalence Mapping

Acute GNTS w/Proliferative Dz

This exercise will NOT capture all new ICD-10 specificities

Validate all mappings using ICD-10 Index, Table, and Guidelines

ICD9 ICD9 Title ICD10 ICD-10 Title

5800

Acute glomerulonephritis with

lesion of proliferative

glomerulonephritis

N000 Acute nephritic syndrome with minor glomerular

abnormality

N001 Acute nephritic syndrome with focal and segmental

glomerular lesions

N002 Acute nephritic syndrome with diffuse membranous

glomerulonephritis

N003 Acute nephritic syndrome with diffuse mesangial

proliferative glomerulonephritis

N004 Acute nephritic syndrome with diffuse endocapillary

proliferative glomerulonephritis

N005 Acute nephritic syndrome with diffuse mesangiocapillary

glomerulonephritis

N006 Acute nephritic syndrome with dense deposit disease

N007 Acute nephritic syndrome with diffuse crescentic

glomerulonephritis

General Equivalence Mapping

Acute GNTS – Rapidly Progressive ICD9 ICD9 Title ICD10 ICD-10 Title

5804 Acute glomerulonephritis with lesion of

rapidly progressive glomerulonephritis

N010 Rapidly progressive nephritic syndrome with minor

glomerular abnormality

N011 Rapidly progressive nephritic syndrome with focal

and segmental glomerular lesions

N012 Rapidly progressive nephritic syndrome with diffuse

membranous glomerulonephritis

N013 Rapidly progressive nephritic syndrome with diffuse

mesangial proliferative glomerulonephritis

N014 Rapidly progressive nephritic syndrome with diffuse

endocapillary proliferative glomerulonephritis

N015 Rapidly progressive nephritic syndrome with diffuse

mesangiocapillary glomerulonephritis

N016 Rapidly progressive nephritic syndrome with dense

deposit disease

N017 Rapidly progressive nephritic syndrome with diffuse

crescentic glomerulonephritis

N018 Rapidly progressive nephritic syndrome with other

morphologic changes

N019 Rapidly progressive nephritic syndrome with

unspecified morphologic changes

Membranous GNTS

5810 Nephrotic syndrome with lesion of

membranous glomerulonephritis

N021 Recurrent and persistent hematuria with

focal and segmental glomerular lesions

N022 Recurrent and persistent hematuria with

diffuse membranous glomerulonephritis

N023

Recurrent and persistent hematuria with

diffuse mesangial proliferative

glomerulonephritis

N041 Nephrotic syndrome with focal and

segmental glomerular lesions

N042 Nephrotic syndrome with diffuse

membranous glomerulonephritis

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Nephrotic Syndrome w/

Membranoproliferative GNTS

26

Chronic GNTS

• Emphasis

upon

pathology

27

Meditech 5.67

28

Acute Kidney Failure

Chronic Kidney Disease

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Acute Kidney Failure

Note that any acute renal

failure or ATN after trauma

codes to T79.5 (per the

Excludes1 note), even if no

anuria occurs

This appears to contradict

the Excludes2 note for

N17.9 which allows S37.0

and N17.9 to be used

together

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Acute Kidney Injury in Meditech

5.67

Acute Kidney Insufficiency

Support Text

Main Term(s) Support Text

acute renal

insufficiency [elevated BUN/creatinine only] [qualifying as acute kidney injury]

azotemia [due to] [hypovolemia] [heart failure]

Elevated blood

urea nitrogen [acute tubular necrosis] [acute interstitial

nephritis] [chronic nephropathy]

High blood urea

nitrogen [shock] [urinary

obstruction] [other] Oliguria

Anuria

Low urine output

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Acute Kidney Injury

2012 AKI Network

http://www.kdigo.org/clinical_practice_guidelines/pdf/KDIGO%20AKI%20Guideline.pdf

Published 2012

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Acute Renal Failure (MCC)

vs. Azotemia/Insufficiency (not a CC)

• Many physicians document azotemia or

renal insufficiency (an elevation of the

BUN and creatinine) in settings of AKI or

ARF

– “Pre-renal” – due to renal hypoperfusion

– “Renal” – due to intrinsic renal disease

– “Post-renal” – due to renal outflow

obstruction.

Physician definition and documentation is mandatory

Meditech 5.67

35

Urine Microscopy

• Short of a kidney biopsy, urine

microscopy or prolonged AKI best

supports the diagnosis of ATN

http://www.tinyurl.com/ATNdiagnosis

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Physician Documentation Issues Contrast-Induced Nephropathy

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39

Chronic Kidney Disease

Term CCr Usual Serum Cr*_____

• 585.9 – Chronic Renal Insufficiency OR Failure NOS

• 585.1 – CKD Stage 1 > 90 <0.9

• 585.2 – CKD Stage 2 60-89 1.0-1.3

• 585.3 – CKD Stage 3 30-59 1.4-2.5

• 585.4 – CKD Stage 4 15-29 2.5-4.5

• 585.5 – CKD Stage 5 <15 >4.5

• 585.6 – ESRD – Administrative Term

* Serum Cr. for a 170 lb white male, age 65

Source:http://www.kidney.org/professionals/kdoqi/guidelines_ckd/p4_class_g1.htm

Avoid the term

“CRI”, “CRF”

or CKD w/o

Staging

Calculated Cr clearances are on the lab reports

Diagnoses

ICD-10-CM Official Guidelines

• An essential reference that must be read over and over and over again. Available for free at:

• http://www.tinyurl.com/2015ICD10CMguidelines

2015 ICD-10-CM Official Guidelines

Chronic Kidney Disease

• Hypertensive Chronic Kidney Disease – Assign codes from category I12, Hypertensive chronic kidney disease,

when both hypertension and a condition classifiable to category N18, Chronic kidney disease (CKD), are present. Unlike hypertension with heart disease, ICD-10-CM presumes a cause-and-effect relationship and classifies chronic kidney disease with hypertension as hypertensive chronic kidney disease.

• Chronic kidney disease and kidney transplant status – Patients who have undergone kidney transplant may still have some

form of chronic kidney disease (CKD) because the kidney transplant may not fully restore kidney function.

• Therefore, the presence of CKD alone does not constitute a transplant complication. Assign the appropriate N18 code for the patient‟s stage of CKD and code Z94.0, Kidney transplant status.

– If a transplant complication such as failure or rejection or other transplant complication is documented, see section I.C.19.g for information on coding complications of a kidney transplant.

• If the documentation is unclear as to whether the patient has a complication of the transplant, query the provider.

Meditech 5.67

42

Heart Failure - Hurst

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Fluid Overload due to

Dialysis Noncompliance • The Coding Clinic Second Quarter 2001 advised to assign code 428.0,

Congestive heart failure, as the principal diagnosis for a patient admitted in

congestive heart failure (CHF) due to fluid overload and noncompliance with

dialysis treatment.

• More recent advice recommended the assignment of code 276.6, Fluid

overload, as principal diagnosis for a patient admitted in fluid overload due

to missed dialysis treatments because the patient had no history or

evidence of CHF.

• At our facility, we had a case where a patient with end stage renal disease

was admitted for treatment of fluid overload due to dialysis noncompliance.

This patient had a history of congestive heart failure. However, the

provider documented, "The patient was successfully dialyzed and had

no evidence of cardiac or pulmonary decompensation other than that

of fluid overload due to dialysis and dietary noncompliance." How

would this case be coded?

Source: Coding Clinic for ICD-9-CM, 3rd Quarter 2007, page 11

Answer

• Assign code 276.6, Fluid overload, as the principal diagnosis. Codes

428.0, Congestive heart failure, unspecified; 585.6, End stage renal

disease; V45.1, Renal dialysis status; and V15.81, Noncompliance

with medical treatment, should be assigned as additional diagnoses.

Assign code 39.95, Hemodialysis, for the dialysis.

• In this case, fluid overload is reported as principal diagnosis since the

provider indicated that the fluid overload was noncardiogenic in

nature and the congestive heart failure was not decompensated. The

provider has clearly addressed the distinction between fluid overload

and CHF in his or her documentation.

Consequently, coders must know if fluid

overload is cardiogenic or noncardiogenic if

the patient has chronic CHF

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ICD9 CMS CC MSDRG CC TITLE

4280 CMS CC CHF NOS (decomp – R Hrt Fail)

4281 CMS CC MSDRG CC LEFT HEART FAILURE

42820 CMS CC MSDRG CC SYSTOLIC HRT FAILURE NOS

42821 CMS CC MSDRG MCC AC SYSTOLIC HRT FAILURE

42822 CMS CC MSDRG CC CHR SYSTOLIC HRT FAILURE

42823 CMS CC MSDRG MCC AC ON CHR SYST HRT FAIL

42830 CMS CC MSDRG CC DIASTOLC HRT FAILURE NOS

42831 CMS CC MSDRG MCC AC DIASTOLIC HRT FAILURE

42832 CMS CC MSDRG CC CHR DIASTOLIC HRT FAIL

42833 CMS CC MSDRG MCC AC ON CHR DIAST HRT FAIL

42840 CMS CC MSDRG CC SYST/DIAST HRT FAIL NOS

42841 CMS CC MSDRG MCC AC SYST/DIASTOL HRT FAIL

42842 CMS CC MSDRG CC CHR SYST/DIASTL HRT FAIL

42843 CMS CC MSDRG MCC AC/CHR SYST/DIA HRT FAIL

4289 CMS CC (Acute) HEART FAILURE NOS

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Systolic - Diastolic

Cardiomyopathies • Systolic

– EF usually <40%

– “Dilated” Heart

• Diastolic

– EF usually >40%

– Hypertrophic heart

– HF with preserved systolic function is not coded as diastolic heart failure

• Most patients have both at one time or another

– OK to say “probable systolic-diastolic failure

• Dysfunction ≠ Failure

• Decompensated Systolic or Diastolic CHF can be coded as “Acutely decompensated”

– Does not apply to decompensated CHF not stated as systolic or diastolic

• State the cardiomyopathy

– Hypertensive

– Diabetic

– Alcoholic

– Toxic

– If ischemic, please also state if the others are present

Heart Failure in Meditech 5.67

Altered Mental Status

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ICD-9-CM and Physician – Pertinent

Disease Categorizations – MUSIC Manifestation

– Nonspecific – Altered Mental Status; Altered Level of Consciousness

– More specific – Delirium, Dementia, Psychosis Stupor, Coma

Underlying Cause – Encephalopathies – Global Brain Dysfunction – (e.g. hypertensive, hepatic)

– Structural Brain Diseases – Neoplasms, Hydrocephalus, Cerebral Laceration

– Ischemic Disease – Transient Ischemic Attack vs. Stroke vs. Late Effect

– Neurodegenerative Disorders – Alzheimer's Disease, Pick‟s Disease

Specificity or Severity – Acute, chronic, or acute on chronic decompensation

Instigating or Precipitating Causes – Acute reasons why the underlying cause or stable conditions get worse

– Includes drug overdoses, head trauma,

Consequences – Acute (on chronic) respiratory failure, Syndrome of Inappropriate Anti-diuretic

Hormone, Rhabdomyolysis, Neurogenic Bladder with incontinence, Aphasia.

Once one element is considered, look for the other four; Linking adds synergy in risk adjustment. Ex: Acute Delirium due to toxic encephalopathy due to levofloxacin given in therapeutic doses resulting in urine incontinence requiring foley catheterization.

17

Acute Altered Mental States

or Levels of Consciousness

• Clouded State – Minimally reduced wakefulness or

awareness

– May include hyperexcitability alternating with drowsiness

• Delirium – Misperceptions of sensory stimuli

and, often, visual hallucinations

– DSM-IV • Disturbance of consciousness with

reduced ability to focus, sustain, or shift attention.

• A change in cognition that is not due to an established or evolving dementia

– Disoriented first to time, then to place, and then to person.

• Psychosis – Loss from reality – delusions,

hallucinations

• Obtundation – Means mental blunting.

– Mild or moderation reduction in alertness.

• Stupor – Deep sleep or similar

unresponsiveness

• Coma – State of unresponsiveness in

which the patient lies with eyes closed and cannot be aroused, even with vigorous stimulation.

• Locked-In Syndrome – A fully conscious individual with

paralysis of all four limbs and lower cranial nerves

– Able to move eyelids and move eyes vertically.

51 Source: Posner, et. al. Plum and Posner‟s Diagnosis of Stupor and Coma. 2007.

Underlying Causes

Encephalopathy

• No universal definition of the term.

• NIH Definition: – Encephalopathy is a term for any diffuse disease of

the brain that alters brain function or structure. Encephalopathy may be caused by infectious agent (bacteria, virus, or prion), metabolic or mitochondrial dysfunction, brain tumor or increased pressure in the skull, prolonged exposure to toxic elements (including solvents, drugs, radiation, paints, industrial chemicals, and certain metals), chronic progressive trauma, poor nutrition, or lack of oxygen or blood flow to the brain. The hallmark of encephalopathy is an altered mental state.

Available at: http://tinyurl.com/encephalopathy

52

Physician Literature

http://www.tinyurl.com/TMEncephalopathy

53

Toxic/Metabolic Encephalopathies

Definitions • Toxic and metabolic

encephalopathies are a group of neurological disorders characterized by an altered mental status – That is, a delirium, defined as a

disturbance of consciousness characterized by a reduced ability to focus, sustain, or shift attention

• that cannot be accounted for by preexisting or evolving dementia and that is caused by the direct physiological consequences of a general medical condition.

MS-DRG MCC

APR-DRG

– SOI – 3 of 4

– ROM – 3 of

4

HCC

– No relative

weight

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Encephalopathy Codes

• 348.3 Encephalopathy, not elsewhere classified – 348.30 Encephalopathy,

unspecified

– 348.31 Metabolic encephalopathy

• Septic encephalopathy

Excludes:

toxic metabolic encephalopathy (349.82)

– 348.39 Other encephalopathy

Excludes

• encephalopathy:

– alcoholic (291.2)

– hepatic (572.2)

– hypertensive (437.2)

– toxic (349.82)

– 349.82 Toxic encephalopathy

• Toxic metabolic encephalopathy

• Use additional E code to identify cause

55

Thank You

Questions?