ICD-10 Overview
Program Integrity
Code Structure & Definition
GEMS, Translation & Dual Processing
Claims Management
Provider Communications
Analytics & IT Infrastructure
ICD-10 Testing
Post Implementation Impacts & Opportunities
Mapping & Policy Remediation
ICD-10 for Provider Administrative Staff
ICD-10 for Clinicians
ICD-10 for Clinicians
January 27-30, 2015
Puerto Rico ICD-10 Implementation Assistance Site VisitTraining segments to assist Puerto Rico with ICD-10 transition
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Agenda
Health care data in a changing environment ICD-10 basics Clinical documentation – the key to data and good care Getting specific Clinical case examples Measuring coding patterns Reducing the burden of data capture
Source: Health Affairs
Japan – 8.5% of the GDP (2008)US – 16% of the GDP (2008)
Healthcare ExpendituresUnsustainable
Japa
n
Ital
y
Spai
n
U.K
.
Aus
tral
ia
Swed
en
Bel
gium
Fran
ce
Ger
man
y
Aus
tria
Net
herlan
ds
Can
ada
Switz
erla
nd
Nor
way
U.S
.A.
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
$8,000
$2,729 $2,870 $2,902$3,129
$3,353 $3,470$3,677 $3,696 $3,737
$3,970 $4,063 $4,079
$4,627$5,003
$7,538
Total Health Expenditure per Capita, U.S. and Selected Countries, 2008
Per
Cap
ita S
pen
din
g -
PPP A
dju
sted
Source: Organisation for Economic Co-operation and Development (2013), "OECD Health Data", OECD Health Statistics (database). doi: 10.1787/data-00350-en (Accessed on 14 February 2013).
Notes: Data from Australia and Japan are 2007 data. Figures for Belgium, Canada, Netherlands, Norway and Switzerland, are OECD estimates. Numbers are PPP adjusted.
• US 38th in life expectancy• Japan 1st in life expectancy
• US infant mortality is approximately 3 times Japan
Healthcare Data
Health Data Consulting © 20125
A Cornerstones of Healthcare Information
Patient Provider
Condition Service
Source: Health Data Consulting
Source: Health Data Consulting
Source: Health Data Consulting
Source: Health Data Consulting
Getting from Data to Information
Health Data Consulting © 20126
Understanding the whole picture
Getting from Data to Information
Health Data Consulting © 20127
Source: Health Data Consulting
Data
Standards
Information
Source: Health Data Consulting
Source: Health Data Consulting
ICD10 Quick Facts
Health Data Consulting © 20128
ICD-10 international version– Adopted by WHO in 1990– Most countries other than the US currently use ICD-10– ICD-10 (International version) ~ 12,500 diagnostic codes– ICD-10 used for mortality reporting in the US - 1999
ICD-10-CM (US version) – ~ 69,000 diagnostic codes– Final rule published – 2009– Compliance date – Oct 1, 2015
ICD-10-PCS– ~72,000 codes– Not part of an international standard– Inpatient procedures only– Compliance date – Oct 1, 2015
Source: Health Data Consulting
Source: Health Data Consulting
Same Condition – Different Codes
September 2015
Health Data Consulting © 20129
What’s the Difference?
October 2015
ICD-9 ICD-1082111:
Open fracture of Shaft of FemurS72351C:
Displaced comminuted fracture of shaft of right femur, initial encounter for open fracture type IIIA, IIIB, or IIIC
All codes for femur fractures = 16 All codes for femur fractures = 1530
Source: Health Data Consulting
Source: Health Data Consulting
Nature of the ChangesDiagnosis Codes – Clinical Example
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A patient is admitted as the result of [rupture of the cardiac wall without bleeding into the pericardium]. The patient is [within 4 weeks] of a [myocardial infarction].
ICD9 Code Description
42979Certain sequelae of myocardial infarction, not elsewhere
classified, other
ICD10 Code Description
I233Rupture of cardiac wall without hemopericardium as current
complication following acute myocardial infarction
Source: Health Data Consulting
Nature of the ChangesDiagnosis Codes – Clinical Example
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A patient is admitted as the result of [rupture of the cardiac wall without bleeding into the pericardium]. The patient is [within 4 weeks] of a [myocardial infarction].
ICD9 Code Description
42979Certain sequelae of myocardial infarction, not elsewhere
classified, other
ICD10 Code Description
I233Rupture of cardiac wall without hemopericardium as current
complication following acute myocardial infarction
Source: Health Data Consulting
Why are there so many diagnosis codes?
34,250 (45%) of all ICD-10-CM codes are related to the musculoskeletal system
17,045 (25%) of all ICD-10-CM codes are related to fractures
~25,000(36%) of all ICD-10-CM codes to distinguish ‘right’ vs. ‘left’
Health Data Consulting © 201012
Example
Source: Health Data Consulting
Source: Health Data Consulting
Varying Code Volume By clinical area
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Clinical Area ICD-9 ICD-10
Fractures 747 17099
Poisoning and toxic effects 244 4662
Pregnancy related conditions 1104 2155
Brain Injury 292 574
Diabetes 69 239
Migraine 40 44
Bleeding disorders 26 29
Mood related disorders 78 71
Hypertensive Disease 33 14
End stage renal disease 11 5
Chronic respiratory failure 7 4
13 Source: Health Data Consulting
Nature of the ChangesCode Distribution
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5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100%0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
Total Charges by Diagnosis Code (ICD-9)3years - $10 Bill
Charge %
14 Source: Health Data Consulting
Changing Reimbursement Models
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Source: Health Data Consulting
*Source: Modern Healthcare – June 2014
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Why is good documentation important?
Bad Mojo is not a diagnosis
Supports proper payment and reduced denials
Assures accurate measures of quality and efficiency
Addresses the issue of accountability and transparency
Provides better business intelligence
Supports clinical research
Supports interoperable sharing of data
It’s just good care!
Health Data Consulting © 201317
DocumentationWhy is it Important?
Source: Health Data Consulting
Source: Health Data Consulting
18 Health Data Consulting © 2013
Documentation1889
Source: Health Data Consulting
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Documentation1889
Source: Health Data Consulting
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Documentation1889
Source: Health Data Consulting
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Documentation1889
Source: Health Data Consulting
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Progress?
Documentation2011
Source: Health Data Consulting
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History
Physical ExamInternal Record Review
External Record Review
Assessment/Diagnosis
Studies
Documentation and CodingWhere it all begins
Source: Health Data Consulting
Clinical / Business/Coding RelationshipsCreating a new working relationship
1. The role of the clinician is to document as accurately as possible the nature of the patient conditions and services done to maintain or improve those conditions.
2. The role of the coding professional is to assure that coding is consistent with the documentation
3. The role of the business manager is to assure that all billing is accurately coded and supported by the documented facts.
24 Source: Health Data Consulting
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Getting Specific
Defining and measuring specificity
Source: Health Data Consulting
Poorly Specified Coding
Health Data Consulting © 2013
A proposed definition
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Source: Health Data Consulting
Source: Health Data Consulting
Source: Health Data Consulting
“Coding that does not fully define important parameters of the patient condition that could otherwise be defined given
information available to the observer (clinician) and the coder.”
Coding specificity
Health Data Consulting © 2013
A place for “unspecified” codes
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Source: Health Data Consulting
Source: Health Data Consulting
Source: Health Data Consulting
Sometimes unspecified makes sense…–The patient may be early in the course of
evaluation–The claim may be coming from a provider who is
not directly related to diagnosis of the patients condition
–The clinician seeing the patient may be more of a generalist and not able to define the condition at a level of detail expected by a specialist
Coding specificity
Health Data Consulting © 2013
No place for “unspecified” codes
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Source: Health Data Consulting
Source: Health Data Consulting
Source: Health Data Consulting
If there is sufficient information available to more accurately define the condition
For basic concepts such as:– Laterality (Right, Left, Bilateral, Unilateral)– Anatomical locations– Trimester– Type of diabetes– Known complications or comorbidities – Description of severity, acute or chronic or other known parameters…
Where care is implemented that demands a more specific level of detail
At specialty level that should be able to define the detail required
Coding ICD-10 CM
Health Data Consulting © 2013
Suspected, probable, likely and other condition qualifiers
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Source: Health Data Consulting
Source: Health Data Consulting
Source: Health Data Consulting
The use of terms like “suspected”, “probable”, “likely” and other qualifications of conditions have different guidelines for coding in the inpatient vs. the outpatient setting.
Health Data Consulting © 201330
DocumentationWhat they taught us in medical school
Source: Health Data Consulting
Type of condition– Condition categories i.e. Type I or Type II diabetes
Onset– When did it start?
Etiology / Cause– Infectious agent– Physical agent– Internal failure– Congenital
30 Source: Health Data Consulting
Health Data Consulting © 201331
DocumentationWhat they taught us in medical school
Source: Health Data Consulting
Anatomical location– Which anatomical structure
– Proximal, distal, medial, lateral, central, peripheral, superior, inferior,
anterior, posterior…
Laterality– Right side or left side
Severity– Mild, moderate or severe
Environmental factors– Smoking
– Geographic location31 Source: Health Data Consulting
Health Data Consulting © 201332
DocumentationWhat they taught us in medical school
Source: Health Data Consulting
Time parameters– Intermittent/Paroxysmal
– Recurring
– Acute or chronic
– Post-op, post delivery
Comorbidities or complications– Diabetes with neuropathic joint
– Intracranial injury
Manifestations– Hypoxia, Hypercapnia (Respiratory Failure)
– Loss of consciousness32 Source: Health Data Consulting
Health Data Consulting © 201333
DocumentationWhat they taught us in medical school
Source: Health Data Consulting
Healing level– Routing healing, delayed healing, non-union, malunion…
Findings and symptoms– Fever
– Hypoglycemia/hyperglycemia
– Wheezing
External causes– Motor vehicles, injury locations
– Assault, accidental, work related, intentional self harm
Type of encounter– Initial encounter, subsequent encounter, encounter for condition sequela,
routine evaluation, administrative encounter33 Source: Health Data Consulting
Medical Concepts
Health Data Consulting © 2013
Expressing the patient condition in codes
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Source: Health Data Consulting
Medical Scenario: A [27 year old] [male] patient is seen in [follow-up] for a [Smith’s fracture] on the [right] that was exposed through an [open wound] with [minimal opening and minimal tissue damage]. The fracture has [not healed after 6 months].Though not explicitly stated in this scenario certain expressions imply other concepts:“Smith’s fracture” >> [fracture], [radius], [distal], [dorsal angulation], [extra-
articular], [displaced]
“minimal opening and minimal tissue damage” >> [Gustilo classification I]
“not healed after 6 months” >> [nonunion]
Source: Health Data Consulting
Source: Health Data Consulting
Source: Health Data Consulting
Pulmonary Disease COPD
Chronic BronchitisAsthma
ICD-10 Relevant Documentation
Health Data Consulting © 2013
Chronic Pulmonary Disease Concepts:
Caused by : Chemical or environmental agents
– Define agent…
Smoking– Exposure to environmental tobacco smoke– History of tobacco use– Occupational exposure to environmental tobacco smoke– Tobacco dependence– Tobacco use
Allergic/non-allergic
Source: Health Data Consulting
37 Source: Health Data Consulting
ICD-10 Relevant Documentation
Health Data Consulting © 2013
Chronic Pulmonary Disease Concepts:
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Temporal Factors: Acute Chronic Intermittent Persistent
Severity: Mild Moderate Severe
Source: Health Data Consulting
Source: Health Data Consulting
ICD-10 Relevant Documentation
Health Data Consulting © 2013
Chronic Pulmonary Disease Concepts:
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Bronchitis Specific: Simple Mucopurulent Mixed simple and mucopurulent Tracheitis Tracheobronchitis
Source: Health Data Consulting
Source: Health Data Consulting
ICD-10 Relevant Documentation
Health Data Consulting © 2013
Chronic Pulmonary Disease Concepts:
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Emphysema Specific: Unilateral pulmonary emphysema
– MacLeod’s syndrome– Swyer-James syndrome– Unilateral hyper-lucent lung– Unilateral pulmonary artery functional hyperplasia– Unilateral transparency of lung
Panlobar emphysema– Panacinar emphysema
Centrilobar emphysema
Source: Health Data Consulting
Source: Health Data Consulting
ICD-10 Relevant Documentation
Health Data Consulting © 2013
Chronic Pulmonary Disease Concepts:
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Emphysema Specific: Other emphysema
– Bullous emphysema (lung)(pulmonary)– Emphysema (lung)(pulmonary) NOS– Emphysematous bleb– Vesicular emphysema (lung)(pulmonary)
Source: Health Data Consulting
Source: Health Data Consulting
ICD-10 Relevant Documentation
Health Data Consulting © 2013
Chronic Pulmonary Disease Concepts:
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Other COPD: With acute lower respiratory infection
– Define infectious agent… With exacerbation
– Decompensated COPD Other COPD
– Chronic obstructive airways disease– Chronic obstructive lung disease
Source: Health Data Consulting
Source: Health Data Consulting
ICD-10 Relevant Documentation
Health Data Consulting © 2013
Chronic Pulmonary Disease Concepts:
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Asthma Specific - Types : Detergent asthma Eosinophilic asthma Lung diseases due to external agents Miner's asthma Wheezing Wood asthma Exercise induced bronchospasms Cough variant asthma Atopic asthma
Source: Health Data Consulting
Source: Health Data Consulting
ICD-10 Relevant Documentation
Health Data Consulting © 2013
Chronic Pulmonary Disease Concepts:
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Asthma Specific - Types (alternate terms): Allergic (predominantly) asthma Allergic bronchitis Allergic rhinitis with asthma Atopic asthma Extrinsic allergic asthma
Source: Health Data Consulting
Source: Health Data Consulting
ICD-10 Relevant Documentation
Health Data Consulting © 2013
Chronic Pulmonary Disease Concepts:
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Asthma Specific - Types (alternate terms): Hay fever with asthma Idiosyncratic asthma Intrinsic non-allergic asthma Non-allergic asthma Asthmatic bronchitis Childhood asthma Late onset asthma
Source: Health Data Consulting
Source: Health Data Consulting
ICD-10 Relevant Documentation
Health Data Consulting © 2013
Chronic Pulmonary Disease Concepts:
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Asthma Specific: Uncomplicated
or with (acute) exacerbation
or with status asthmaticus
Source: Health Data Consulting
Source: Health Data Consulting
ICD-10 Relevant Documentation
Health Data Consulting © 2013
Code examples - COPD:
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ICD-10 Code ICD-10 Description
J418 Mixed simple and mucopurulent chronic bronchitis
J431 Panlobular emphysema
J432 Centrilobular emphysema
J440 Chronic obstructive pulmonary disease with acute lower respiratory infection
J441 Chronic obstructive pulmonary disease with (acute) exacerbation
J4521 Mild intermittent asthma with (acute) exacerbation
J4552 Severe persistent asthma with status asthmaticus
J45990 Exercise induced bronchospasm
Source: Health Data Consulting
Source: Health Data Consulting
Measuring Performance
Coding Specificity
Health Data Consulting © 201349
Unspecified (NOS), Other (NEC) or Symptom/Finding Codes
Source: Health Data Consulting
Code Type Claims Total Charges %Claims %Charges
All Professional Claims 15,352,056 $ 4,030,052,634 100% 100%
‘Unspecified’ (and not ‘Other’ or ‘Symptom or Finding’) 2,902,691 $ 709,765,341 19% 18%
‘Other’ 1,917,163 $ 509,694,935 12% 13%
‘Symptom or Finding’ 3,530,464 $ 675,662,073 23% 17%
Total 'Unspecified', 'Other' and 'Symptom or Finding' 8,350,318 $ 1,895,122,349 54% 47%
Source: Health Data Consulting
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Source: Health Data Consulting
Measuring Performance
Differences in coding distribution by condition (injury and poisoning) for these two previous providers
Source: Health Data Consulting
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Source: Health Data Consulting
Measuring Performance
Differences in coding distribution by condition (injury and poisoning) for these two previous providers
Source: Health Data Consulting
Coding Pattern Comparisons
Health Data Consulting © 201352
Obstetrical providers
Source: Health Data Consulting
Source: Health Data Consulting
Coding Pattern Comparisons
Health Data Consulting © 201353
Obstetrical providers
Source: Health Data Consulting
Source: Health Data Consulting
Coding Pattern Comparisons
Health Data Consulting © 201354
Obstetrical providers
Source: Health Data Consulting
Source: Health Data Consulting
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Capturing Key Medical ConceptsReducing the burden of documentation
Source: Health Data Consulting
There are a limited number of clinical concepts – For each clinical condition there are a finite clinical parameters that need to
be captured from the perspective of ICD-10
– Most of these condition parameters recur in many codes
The physician does not need to capture everything– He/she must review and agree with data captured in other ways in the office
Use other resources to capture data– Patient intake forms
– Trained nursing and medical assistance interviews
Prompting for the right stuff– Documentation requirement are condition specific
– Forms or templates can help remind what is neededSource: Health Data Consulting
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Source: Health Data Consulting
GEM Mapping Tool
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Source: Health Data Consulting
GEM Mapping Tool
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GEM Mapping Tool
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GEM Mapping Tool
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GEM Mapping Tool
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Source: Health Data Consulting
GEM Mapping Tool
Questions?
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