Randy C. Roth, MD Chief Medical Officer April 1, 2016 · Randy C. Roth, MD Chief Medical Officer...

Randy C. Roth, MD Chief Medical Officer Singing River Health System April 1, 2016

“We do not believe there is anything inappropriate, unethical, or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment that is supported by documentation in the medical record.”

CMS 2008 IPPS Final Rule, http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1533-FC.pdf, page 208

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Clinical Medicine

Medical Record

Utilization

Quality

Medical Legal

Reimbursement

Physician Profiles

& Hospital Report Cards Data

Coded

Physician documentation in the medical record is an important instrument in the economics of healthcare

Cost per patient

Resource utilization

Length of stay

Complication Rates

Morbidity Scores

Mortality Scores

Outcome Analysis

Audits

Documentation reflects severity of illness (SOI) and risk of mortality (ROM) scores.

Specificity is vital, a definitive diagnosis must be documented.

Physician profiles are developed from documented information.

Golden Rule: “If it is not written in coding language, it didn’t happen.”

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ICD-10 is the biggest change in Healthcare since ICD-9 in the 1970’s.

Professional coders will transition from working with approximately 30,000 different codes to working with over 70,000 different codes.

There is unknown potential cash impact to all providers.

Physicians will be asked to improve clinical documentation or asked for additional documentation.

ICD-9 Version

Having Coffee at Home: Cup of coffee

with sugar & cream

Outcome: Cup of Coffee

ICD-10 Version

Having Coffee at Starbucks: Size: Tall, Grande, Venti

Milk: Non-fat, Low-fat, Whole

Temp: Normal Hot, Extra-Hot

Flavors: Vanilla, Hazelnut, Toffee Nut

Outcome: Grande, Non-fat, Extra-hot, Vanilla Latte

ICD-9 Version

Broken Arm September 30, 2015:

Left, Upper Arm Fracture

Outcome: Open Fracture Left Humerus

ICD-10 Version

Broken Arm October 1, 2015: Type: Traumatic, Pathologic

Location: Bone, Left/Right, Joint Involved

Nature: Open/Closed, Displaced/Non-displaced

Encounter: Initial, Subsequent, Sequela

Healing: Routine, Delayed, Nonunion, Malunion

Outcome: Initial encounter for Traumatic

Open Fracture of Left Humerus

ICD-9 1977 – Worldwide use

1979 – U.S. modification

Clinical & mortality

ICD-10 1994 – Release of full ICD-10 by WHO, published in 42 languages

1999 – Adopted for death certificates in the United States, mortality

2014 – U.S. modification, Clinical

ICD-11: 2015 – Tentative rollout worldwide

ICD-9-CM diagnosis

3–5 characters

Allows for 1 letter (1st position); otherwise numeric

ICD-10-CM

3 to 7 characters

1st character is alpha (except U); others are either alpha or numeric

Numbers 0–9; letters A–H, J–N, P–Z

Alpha characters are not case-sensitive

ICD-9-CM procedures

4 characters only

All characters are numeric

ICD-10-PCS

Same as ICD-10-CM except each code must have 7 characters

Letter “Z” used as a placeholder

Without all diagnoses documented, profiles will inappropriately reflect higher than expected mortality.

Complete documentation, reflective of the true severity of illness of patients, will justify outcomes.

Profiles are used for both commercial and public use.

Future reimbursement methods will likely incorporate profiles in the formula (e.g., pay for performance).

Hospital report cards

Healthgrades, Delta Group, Leapfrog

Medicare Physician Data (since 2007)

Federal and state regulatory agencies (e.g. OIG)

The Joint Commission (TJC)

Centers for Medicare and Medicaid Services (CMS)

Quality Improvement Organizations (QIO)

Predicted Mortality Rates for some disease processes in this case:

Community Acquired Pneumonia = 10%

Sepsis = 30%

Septic shock = 50%

If the patient survives, quality ratings will be much higher in the public reporting data because the physician took care of a “sicker” patient.

Expected mortality will be higher than actual mortality.

Need good documentation habits

Need specialty specific documentation education

Buy-In to CDI is imperative in order to survive in the conversion of ICD-9 to ICD-10

These are additional conditions, apart from principal diagnosis

Comorbid Conditions: Present on admit; chronic, but active; even if not acutely symptomatic

Complications need to be Documented: Acute blood loss anemia, thrush, hyponatremia, acute respiratory failure RW – Relative Weights: All DRGs have a weight when multiplied by the Case Rate, that determines payment to the Hospital

If two or more conditions are present and are equally addressed, either can be used as the principal diagnosis

Try not to contradict previous hospitalists

Acute systolic heart failure as primary with staph pneumonia as additional RW=1.54

vs. Staph pneumonia as primary with CHF as additional RW=2.05 This is important because .1 equals about $1,000 in Collections to the Hospital

Sepsis SIRS

Sepsis

Severe Sepsis

Septic Shock AKI (Acute Kidney Injury)

Acute and Chronic Respiratory Failure

Alzheimer’s Dementia with Behavioral Disturbances

Encephalopathy

BMI Derangements of <19 or >40

Acute Delirium

Fecal Impaction (if treat)

Hemiplegia/paresis or Functional Quadriplegia

Hyponatremia

AKI

Pickwickian Syndrome

Pathologic Fracture

Thrush

Stage 3 or 4 Decubiti Ulcer (POA and Site)

Mallory –Weiss syndrome

Functional Quadriplegic

Diverticulitis, with sigmoid resection, no other diagnoses = RW of 1.63

Diverticulitis, same resection, with documented chronic CHF = RW of 2.57

GI bleed with no other diagnoses = RW of .70 but GI bleed with acute blood loss anemia = RW of 1.01

Decubitus ulcer, chronic CHF, non-excisional debridement = RW of .99

with excisional debridement = RW of 1.49

The Higher

the RW, the

Higher the

Payment

Acute Respiratory Failure: Acute Respiratory Distress or Apnea +

ABGs (room air)

pO2 < 60 = SpO2 < 88%

pCO2 > 50 (+ pH<7.35), if COPD

While being on a Ventilator (or BiPAP) indicates the presence of acute respiratory failure, it is not mandatory.

The following cannot be coded as Respiratory Failure:

respiratory insufficiency, respiratory distress, hypoxemia.

Sepsis

SIRS due to an underlying infection

Validation that the patient “looks sick” / “septic” / “toxic”

Two or more of the following:

Fever (38.3°C/101°F) Hypothermia (36°C/96°F) Heart rate >90 Respiratory rate >20 WBC >12,000 or < 4,000 or Bands >10%

A positive blood culture is not required “Urosepsis” = UTI only

Heart Failure

“CHF” is non-specific: Do Not use it!

Must state if: SYSTOLIC heart failure DIASTOLIC heart failure COMBINED systolic and diastolic heart failure

Specify if currently Acute* vs Chronic (* including “acute exacerbation” / “acute on chronic”)

Check Echocardiogram

Pneumonia

Must specify the “possible/probable/most likely/suspected” organism.

For example: Staph; Pseudomonas; “gram-negative”; “Aspiration Pneumonia.”

Consider the antibiotic you are using: What organism(s) does it “cover”?

VAP, CAP, “nosocomial” all default to “simple” pneumonia.

Encephalopathy

Definition: Significant generalized alteration in mental function due to an underlying process

For all patients with “mental status alteration,” is it really:

TOXIC encephalopathy ? METABOLIC encephalopathy ?

If so, please indicate in medical record

Acute Renal Failure

Increase in Serum Cr by 0.5 mg/dl within 2 weeks (or by 20%, if baseline > 2.5 mg/dl)

Correction of creatinine upon rehydration = baseline

Acute Renal Failure due to dehydration

Acute renal failure occurring with dehydration is a significant risk factor for morbidity and mortality.

Acute renal failure in the presence of dehydration, coding rules instruct us to code the acute renal failure first.

Chronic Kidney Disease (Specify Stage 1-5 or ESRD)

Term GFR Approx. Serum Cr

Chronic Renal Insufficiency or Failure

CKD Stage 1 >90 <0.9

CKD Stage 2 60-89 1.0-1.3 not CC’s

CKD Stage 3 30-59 1.4-2.5

CKD Stage 4 15-29 2.5-4.5 CC

CKD Stage 5 <15 >4.5 CC

ESRD (Need for dialysis)

Major CC

Pathologic Vertebral Fracture

Pathologic Fracture of Vertebral Body Minimal/Mild trauma Due to underlying abnormal bone

Severe osteoporosis Malignancy (“lytic lesion”); Myeloma Metabolic bone disease (e.g. CKD or hyperparathyroidism)

Usually elderly, debilitated, chronic illness, immobility “Pathologic Fracture due to [underlying condition] .”

Not vertebral compression fracture

Due to trauma: MVA, fall >6 feet, other high-velocity injury Mild or no osteoporosis; no malignancy Any age

Other Key Terms

Acidosis / Alkalosis

Unstable Angina Crescendo / Pre-Infarction Angina Angina at rest

Arrhythmia (any type) Even if transient

AV-block (2nd or 3rd degree)

Atelectasis (especially post-op)

Cellulitis

Chronic Respiratory Failure Instead of severe COPD; end-stage COPD; COPD with home O2

Cor Pulmonale, acute

Pericarditis, acute

Decubitus Ulcers Even Stage 1 (non-blanching erythema) Any location

Dehydration (Is it also acute renal failure?) Drug dependence/abuse (if current

continuous-use)

GI hemorrhage

Excisional Debridement Cutting away of tissue with scalpel (not scissors) Any wound or ulcer OR, bedside, or procedure room

Ileus

Pancreatitis (acute or chronic)

Peritonitis

Hyponatremia / Hypernatremia Requiring some type of management / treatment

Not just incidental lab finding

Malnutrition Significant unintentional weight-loss

Low body weight / BMI

Physical exam findings (e.g. muscle atrophy)

Low albumin, pre-albumin, transferrin, and/or cholesterol

Phlebitis (including DVT, IV site, etc.)

Melena

Hemiplegia / Hemiparesis Including post-stroke

Schizophrenia / Bi-polar Disorder Even if controlled with medication

Major Depressive Disorder

Delirium / Hallucinations

Pt admitted for GI Hemorrhage unspecified.

Pt had a dx of rectal mass with positive findings.

Physician queried without further documentation of the adenocarcinoma found in the pathology report.

DRG without documentation of the rectal malignancy 379 GI Hemorrhage without CC/MCC RW .6937 =$3214

DRG with documentation of the rectal malignancy

378 GI Hemorrhage with CC RW 1.0029 = $4646

Revenue Difference: $1,432.00

Patient admitted due to AV Blockage w/insertion of a pacemaker

Physician discussed the abnormal BUN and Creatinine but never followed up on the abnormal labs.

Query was submitted without a response.

DRG without the Acute Renal Failure documentation

244 Permanent Cardiac Pacemaker Implant without CC/MCC RW 2.1608 = $10,010

DRG with Acute Renal Failure documented

243 Permanent Cardiac Pacemaker Implant with CC RW 2.6716 = $12,376

Revenue Difference: $ 2,366

Pt here with cellulitis of the foot. They had ESRD as an MCC.

Query was submitted and documentation was given for the sharp instruments used allowing the excisional debridement to be coded.

DRG without documentation of the excisional debridement goes to a non-excisional debridement

602 Cellulitis with MCC RW 1.4607 = $6767

DRG with documentation of the excisional debridement 570 Skin Debridement with MCC RW 2.4154 = $11,189

Revenue Difference: $4,422

Patient here for joint replacement.

Query submitted to specify the obesity and the physician documented Morbid Obesity w/BMI of 47.4.

Please note: BMI cannot be coded without an obesity diagnosis but the BMI is the actual CC.

DRG without the Obesity documentation: 484 Major Joint & Limb Reattachment procedure of Upper Extremity without CC/MCC RW 2.2298 = $10,329

DRG with the Obesity documentation:

483 Major Joint & Limb Reattachment procedure of Upper Extremity with CC/MCC RW 2.6488=$12,270

Revenue Difference: $1,941

Patient admitted for mastectomy for breast cancer. During the mastectomy a sentinel node biopsy was performed. The pathology came back positive for metastatic adenocarcinoma of the lymph node.

Query sent to add the diagnosis for the pathology findings without an answer.

DRG without the metastatic lymph node documentation

581 Other Skin, Subcutaneous tissue and breast procedures without CC/MCC RW 1.0605 = $4912

DRG with the metastatic lymph node documentation

580 Other Skin, Subcutaneous tissue and breast procedures with CC RW 1.5398 = $7133

Revenue Difference: $2,221

Negative DRG Shifts $2.96M - $8m

Productivity Impact:

Potential DRG shift:

0

5

10

AR

Day

s AR Change

Coding Payor lag Denials At Peak*

2.3 4.0 0.5 6.8

Coding Payor lag Denials At Trough*

$1.73M $3.03M $0.38M $5.14M

Estimated Maximum Increase in AR Days

Estimated Maximum Cash Deficit

*The components will not be equal to the peak due to the varied timing of the effects

CODER TRAINING

CODER TRAINING

CODER TRAINING

I10 DELAYED TO 2015

IMPACT ANALYSIS COMPELTED

FTI PHYSICIAN TRAINING

FTI PHYSICIAN TRAINING

CODER/CDI REFRESHER

HOSPITAL DUAL CODING

ICD10 PREP CLASS FOR

COMMUNITY

PHYSICIAN CALCULATOR GO LIVE

Coder & Chart Documentation Specialist Training over 100 hours of classroom and WebEx training over the last 18 months. Certifications required for all Coders by January 1, 2016 Physician Education 1.5 hrs. on ICD-10 Basics & The Affects of Documentation.

System Upgrades for Epic and 3M software. Payer Testing with BCBS, Aetna, Cigna and UHC. Testing Claims with Medicare and vendor clearinghouse.

- Weekly Work Sessions Minimum of 1.5 hrs. with Singing River Health System Clinic Coders and Office Managers through the last week of September. Weekly Review of clinical documentation for educational opportunities with physicians and nurse practitioners, etc. Continuous Payer Testing with other non governmental third party payers. ICD-10 Prep Class will be held every Wednesday evening for 2 hours (8 week class). Review Process for Hospice of Light and the use of Standing Orders.

ICD-10 is here, don’t delay any education.

Physician profiling is here, document your severity and specificity.

Part B – Physician Payment is dependent on correct descriptions, represented by ICD-10.

Part A – Hospital Payment is continuing to decline, and in order to stay in operation they must be able to capture everything the providers are treating.