ICD-10 The Provider Perspective Presented by: Joe Nichols MD Date: May 3, 2014

Agenda ICD-10, the basic facts How is ICD-10 different? What are the business impacts? Clinical documentation.  What’s needed to support proper coding in ICD-10? What do I need to do to prepare?

Source: Health Data Consulting ICD-10 What is it?

Health Data Consulting © 2012 ICD10 Quick Facts 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, 2014 ICD-10-PCS ~72,000 codes Not part of an international standard Inpatient procedures only Source: Health Data Consulting Health Data Consulting © 2012

ICD-9 Diagnosis Codes vs. ICD-10-CM (Diagnosis Codes) 3 to 5 digits Alpha “E” and “V” on 1st character No place holder characters Terminology Index and Tabular Structure Coding Guidelines Approximately 14,000 codes Severity parameters limited Does not include laterality Combination codes limited 7 digits Alpha or numeric for any character Include place holder characters (‘x’) Similar Some what similar Approximately 69,000 codes Extensive severity parameters Common definition of laterality Combination codes common Purpose of the slide: This slide illustrate some key differences between ICD-9 and ICD-10 Talking Points: 7 digits are allow allowable in ICD-10 but as little as 3 characters may be valid. A code is only valid if there are no more detailed subcategories or codes underneath it. Currently the first character is always ‘alpha’ and the second character is ‘numeric’ but that could change over time. A place holder ( ‘x’ character) is used to assure that when a code is needed in the 5th ,6th or 7th position that the position of that code is maintained. An example will be given later assuming that the more details presentation is done Emphasize that the unlike the PCS codes the overall terminology and documentation structure is quite similar to ICD-9 Coding guidelines have similarities but there are a number of specific changes that will be discussed in the coding module Severity parameters will be illustrated in the leveraging ICD-10 module Combination codes are codes that contain multiple clinical concepts within a single code. This is the subsequent slides comparing a clinical example of a clinical example in Icd-9 and ICD-10-CM Health Data Consulting © 2012

Same Condition – Different Codes What’s the Difference? September 2014 October 2014 Source: Health Data Consulting ICD-9 ICD-10 82111: Open fracture of Shaft of Femur S72351C: 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 Health Data Consulting © 2012

ICD9 Comparison to ICD10-CM Diagnosis Codes – Clinical Example A patient is seen in the emergency room with. [severe] [persistent] [asthma] with [acute exacerbation]. ICD9 Code Description 49312 Intrinsic asthma with (acute) exacerbation ICD10 Code Description J4551 Severe persistent asthma with (acute) exacerbation Purpose of the slide: This illustrate the best ICD-9 code and the best ICD-10 code to represent this clinical scenarios. This slide focuses on ICD-9 Talking Points: The bracketed items in red are clinical concepts represented in the ICD-9 code Source: Health Data Consulting Health Data Consulting © 2012

ICD9 Comparison to ICD10-CM Diagnosis Codes – Clinical Example A patient is seen in the emergency room with. [severe] [persistent] [asthma] with [acute exacerbation]. ICD9 Code Description 49312 Intrinsic asthma with (acute) exacerbation ICD10 Code Description J4551 Severe persistent asthma with (acute) exacerbation Purpose of the slide: This illustrate the best ICD-9 code and the best ICD-10 code to represent this clinical scenarios. This slide focuses on ICD-9 Talking Points: The bracketed items in red are clinical concepts represented in the ICD-9 code Health Data Consulting © 2012

ICD9 Comparison to ICD10-CM Diagnosis Codes – Clinical Example 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 42979 Certain sequelae of myocardial infarction, not elsewhere classified, other ICD10 Code Description I233 Rupture of cardiac wall without hemopericardium as current complication following acute myocardial infarction Purpose of the slide: This illustrate the best ICD-9 code and the best ICD-10 code to represent this clinical scenarios. This slide focuses on ICD-9 Talking Points: The bracketed items in red are clinical concepts represented in the ICD-9 code Health Data Consulting © 2012

ICD9 Comparison to ICD10-CM Diagnosis Codes – Clinical Example 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 42979 Certain sequelae of myocardial infarction, not elsewhere classified, other ICD10 Code Description I233 Rupture of cardiac wall without hemopericardium as current complication following acute myocardial infarction Purpose of the slide: This illustrate the best ICD-9 code and the best ICD-10 code to represent this clinical scenarios. This slide focuses on ICD-9 Talking Points: The bracketed items in red are clinical concepts represented in the ICD-9 code Health Data Consulting © 2012

Nature of the Changes Volume Diagnosis Procedure Source: Health Data Consulting Health Data Consulting © 2012

“There are too many Codes” There are lots of words in the dictionary, but that doesn’t seem to trouble authors… 34,250 (50%) of all ICD-10CM codes are related to the musculoskeletal system 17,045 (25%) of all ICD-10CM codes are related to fractures 10,582 (62%) of fracture codes to distinguish ‘right’ vs. ‘left’ There are over 1800 codes for fractures of the radius (forearm) but only ~ 50 concepts used repeatedly in different patterns Only a very small percentage of the codes will be used most providers Health Data Consulting © 2012

Current Distribution of ICD-9 diagnosis codes 3 Years of Data - All claims - All lines of business - 1million Lives Health Data Consulting © 2012 Source: Health Data Consulting

Lots of Codes, Lots of Repetition 2466 codes for fractures of the femur

Documentation Requirements Recurring Concepts Concept Number of Codes Initial Encounter 13,932 Subsequent Encounter 21,389 Sequela 11,974 Right 12,704 Left 12,393 Routine Healing 2,913 Delayed Healing Nonunion 2,895 Malunion 2,595 Assault 1096 Self-harm 1057 Accidental 1262 Health Data Consulting © 2013

Health Data Consulting © 2012 Varying Code Volume By Clinical Area Clinical Area ICD-9 Codes ICD-10 Codes 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 Health Data Consulting © 2012 Source: Health Data Consulting

Other Key Changes Code Example – Down’s Syndrome ICD-9 Code ICD-9 Description 7580 Down’s Syndrome ICD-10 Code ICD-10 Description Q909 Down syndrome, unspecified Q900 Trisomy 21, nonmosaicism (meiotic nondisjunction) Q901 Trisomy 21, mosaicism (mitotic nondisjunction) Q902 Trisomy 21, translocation Health Data Consulting © 2012

Other Key Changes Code Examples – Benign neoplasms of the colon: ICD-9 Code ICD-9 Description 2113 Benign neoplasm of colon ICD-10 Code ICD-10 Description D120 Benign neoplasm of cecum D121 Benign neoplasm of appendix D122 Benign neoplasm of ascending colon D123 Benign neoplasm of transverse colon D124 Benign neoplasm of descending colon D125 Benign neoplasm of sigmoid colon D126 Benign neoplasm of colon, unspecified K635 Polyp of colon Health Data Consulting © 2012

Other Key Changes Code Examples – Leukemia: ICD-9 Code ICD-9 Description 20501 Acute myeloid leukemia, in remission ICD-10 Code ICD-10 Description C9201 Acute myeloblastic leukemia, in remission C9241 Acute promyelocytic leukemia, in remission C9251 Acute myelomonocytic leukemia, in remission C9261 Acute myeloid leukemia with 11q23-abnormality in remission C92A1 Acute myeloid leukemia with multilineage dysplasia, in remission Health Data Consulting © 2012

Current Physician thinking on ICD-10 The Challenge Current Physician thinking on ICD-10

“There are a bunch of dumb codes that make no sense.” Clinician organizations have used codes like; “Hit by a spacecraft” or “Suicide by paintball gun” as examples of the “stupidity” of the ICD-10 codes. Interesting to note however is that the codes noted above are ICD-9 codes and have been around for a long time. The bottom line; don’t use the codes that don’t make sense or don’t accurately represent your patient’s condition. They may mean something to someone, but shouldn’t bother you. Health Data Consulting © 2012

“ICD-10 won’t help me take care of my patients.” Difficult to make the case about how ICD-10 will help Dr. Smith with his encounter with Mary Jones Healthcare goes crosses the boundary of time and providers Improving healthcare requires a broad understanding of what works and what doesn't work Clinicians should be leaders in the healthcare industry by providing accurate data, accurate analysis of the data and change in healthcare to continuously improve the value their patients receive

“Documentation for ICD-10 is an unnecessary burden.” The number and type of new concepts required for ICD-10 are not foreign to clinicians The focus of documentation is good patient care Patients deserve to have accurate and complete documentation of their conditions If other industries understand the value of accurate and complete documentation of data about encounters; shouldn’t we? Health Data Consulting © 2013

“ICD diagnosis codes are irrelevant to my business.” ICD-10 codes are likely to factor into: Changes in reimbursement based on both “what” was done and “why” Managing financial risks for contracted populations (ACO’s) Changes in reimbursement based on more robust models of payment adjusted for risk and severity More sophisticated weighting of payments based on DRGs, episodes or other groupers of care. Health Data Consulting © 2013

It’s bigger than you think Business Impacts It’s bigger than you think

Business Impacts Coding Contracting Billing EHR updates Super Bill??? Training Coding software Contracting Scope of services Case rates Carve outs Billing Billing code updates Charge masters Billing Edits Benefits and coverage determinations View of the structure of PCS codes

Business Impacts (Cont.) Compliance HIPAA Reporting National State Regional Initiatives Contract requirement Accreditation Reimbursement Pay for performance POA, “never events”, re-admissions, HACs, tiered payment models Network inclusion Denials Audits RAC Fraud and abuse Coding Health Data Consulting © 2013

Coding ICD-10-CM - Challenges Getting there Example look up for “Coronary Artery Disease” + “Angina” Purpose of the slide: Illustrate the challenges in looking up a common condition “Coronary Artery Disease + Angina” in the standard ICD-10 alphabetical index Talking Points: Coding guidelines suggest going first to the index to search for a code and then to the tabular index. Health Data Consulting © 2012

Coding ICD-10 CM - Challenges Same concept in many places Condition Tabular Category Number of codes Hypertension Hypertensive Disease 14 Other Categories (14) 115 Pneumonia Influenza and Pneumonia 38 Other Categories (18) 42 Genitourinary Disorders Diseases of the Genitourinary System 587 535 Health Data Consulting © 2012

Coding ICD-10 CM - Challenges Relevant Quote "If you don't find it in the index, look very carefully through the entire catalogue."        -- Unknown

Health Data Consulting © 2010 Business Impacts Coding EHR updates Super Bill??? Training Coding software Contracting Scope of services Case rates Carve outs Billing Billing code updates Charge masters Billing Edits Benefits and coverage determinations View of the structure of PCS codes Health Data Consulting © 2010

Business Impacts Compliance Reimbursement Audits HIPAA Reporting National State Regional Initiatives Contract Accreditation Reimbursement Pay for performance POA, “Never Events”, Tier Models Network inclusion Denials Audits RAC Fraud and abuse Coding View of the structure of PCS codes

Quality Measures Impacts AMI example Definition of acute myocardial infarction (MI) has changed ICD-9 – Eight weeks from initial onset ICD-10 – Four weeks from initial onset Subsequent vs. Initial episode of care ICD-9 – Fifth character defines initial vs. subsequent episode of care ICD-10 – No ability to distinguish initial vs. subsequent episode of care Subsequent (MI) ICD-9 – No ability to relate a subsequent MI to an initial MI ICD-10 – Separate category to define a subsequent MI occurring within 4 weeks of an initial MI Health Data Consulting © 2013

Fraud Waste and Abuse If you can’t stop expenditures upfront … 4/13/2017 Fraud Waste and Abuse If you can’t stop expenditures upfront … Fraud, Waste and Abuse Enough money to take care of a lot of need. The Office of Management and Budget estimates that every $1 invested to fight fraud results in approximately $17 in savings. Purpose of the slide To answer some of the basic questions about ICD-10: what, why, who, and when. Talking Points The National Health Care Anti-Fraud Association estimates that fraud amounts to at last three percent of total health care spending, or more than $60 billion per year. Increases funding for the Health Care Fraud and Abuse Control fund to fight fraud in public programs. The Office of Management and Budget estimates that every $1 invested to fight fraud results in approximately $17 in savings. $60,000,000,000/Year Source: National Health Care Anti-Fraud Association / OMB

Coding: The Prime Directive The goal of coding is to reflect as accurately as possible key parameters of the patient health condition and/or the procedures done to maintain or improve that condition. Coding focused on maximizing payment over accurate definition of the condition begins to cross the boundary of fraud and abuse. Health Data Consulting © 2012

Fraud, Waste and Abuse Medicare Definition Source: CMS

Fraud, Waste and Abuse Don’t get caught in the trap… With increasing challenges to control cost, the intensity of audits related to fraud, waste and abuse is increasing. In the “Justification of Estimates for Appropriations Committees” CMS states: “Although the ICD-10 code set will not eliminate all fraud, waste, and abuse, CMS believes that its increased specificity will make it much more difficult for fraud, waste and abuse to occur.” Source: CMS

Fraud, Waste and Abuse Don’t get caught in the trap… 4 Billion Recovered in 2013 Source: CMS

Healthcare on the “RAC” Getting tighter… Source: CMS Health Data Consulting © 2012

Health Data Consulting © 2010 The Super Bill Not That Super Really… [Note] For all codes related to fractures of the radius: ICD-9 codes = 33 ICD-10 codes = 1818 Health Data Consulting © 2010

Health Data Consulting © 2012 Cash Flow Impacts inbound and outbound Coding Challenges Payment Delays Increased Cost Health Data Consulting © 2012

Health Data Consulting © 2012 Cash Flow Impacts inbound and outbound Source: CMS Health Data Consulting © 2012

Documentation and Coding – The Patient Interface Where it all begins Physical Exam Internal Record Review History External Record Review Studies Assessment/Diagnosis

Bad Mojo Documentation is not a diagnosis It could be better… Bad Mojo is not a diagnosis Poor quality documentation is bad for Payers, Providers and Patients. Billing accuracy Quality measures Population management Risk management Healthcare analytics Patient Care

Documentation 1889

Documentation 1889

Documentation 1889

Documentation 1889

Documentation 2013 Progress?

Health Data Consulting © 2012 Documentation Why is it important? Supports proper payment reduced denials Assures accurate measures of quality and efficiency Assures accountability and transparency Captures the level of risk and severity Provides better business intelligence Supports clinical research Enhances communication with hospital and other providers It’s just good care! Source: Health Data Consulting Health Data Consulting © 2012

Health Data Consulting © 2012 Good patient data It’s all about good patient care… Complete observation of all objective and subjective facts relevant to the patient condition Documentation of all of the key medical concepts relevant to patient care currently and in the future Coding that includes all of the key medical concepts supported by the coding standard and guidelines Health Data Consulting © 2012

Health Data Consulting © 2012 Medical Concepts Expressing the patient condition in codes. 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] Purpose of the slide: To illustrate how medical concepts may be documented in a clinical record as well as the fact the concepts may be implied and not explicitly stated Talking Points: Point out how the following slide demonstrates how the ontology would map the medical concepts indicated in this scenario to ICD-9, ICD-10 and Snomed codes that are chosen to represent as accurately as possible the patients conditions as defined in this scenario. Health Data Consulting © 2012

Health Data Consulting © 2012

Neurologic complications Coding ICD-10 CM Diabetes Concepts Diabetes = 276 ICD-10 Codes / 83 ICD-9 Codes Unique concepts within in ICD-10 codes = 62 Diabetes Type Pregnancy Neurologic complications Type 1 diabetes First trimester Neurological complication Type 2 diabetes Second trimester Neuropathy Underlying condition Third trimester Mononeuropathy Drug or chemical induced Childbirth Polyneuropathy Pre-existing Puerperium Autonomic (poly)neuropathy Gestational Antepartum Amyotrophy Poisoning by insulin and oral hypoglycemic Postpartum Coma Adverse effect of insulin and oral hypoglycemic Underdosing of insulin and oral hypoglycemic Neonatal Secondary Health Data Consulting © 2012

Ophthalmologic Complications Coding ICD-10 CM Diabetes Concepts Lab Findings Renal complications Ophthalmologic Complications Ketoacidosis Nephropathy Retinopathy Hyperosmolarity Chronic kidney disease Macular edema Hypoglycemia Kidney complication Cataract Hyperglycemia Ophthalmic complication Mild nonproliferative retinopathy Moderate nonproliferative retinopathy Severe nonproliferative retinopathy Proliferative retinopathy Background neuropathy Health Data Consulting © 2012

Vascular Complications Coding ICD-10 CM Diabetes Concepts Vascular Complications Skin Complications Joint Complications Circulatory complications Dermatitis Neuropathic arthropathy Peripheral angiopathy Foot Ulcer Arthropathy Gangrene Skin complications Skin ulcer Health Data Consulting © 2012

Coding ICD-10 CM Diabetes Concepts Oral Complications Diabetic Control Encounter Other Concepts Oral complications Diet-controlled Initial encounter Complications Periodontal disease Insulin controlled Subsequent encounter Right Uncontrolled Sequela Left Controlled Accidental Intentional self-harm Assault Family history Personal history Screening Health Data Consulting © 2012

Health Data Consulting © 2012 Source: Health Data Consulting Otitis Media Health Data Consulting © 2012

ICD-10 Relevant Documentation Otitis Media Concepts: Type: Serous Supparative or non-supparative Tubotympanic Atticoantral Allergic Mucoid Health Data Consulting © 2012

ICD-10 Relevant Documentation Otitis Media Concepts: Type (alternate terms): Sanguinous Seromucinous Exudative Transudative Secretory with effusion (non-purulent) Catarrhal Purulent Myringitis Health Data Consulting © 2012

ICD-10 Relevant Documentation Otitis Media Concepts: Associated with: With spontaneous rupture of the TM Without spontaneous rupture of the TM Infectious or other external agent… Smoking Exposure to environmental tobacco smoke History of tobacco use Occupational exposure to environmental tobacco smoke Tobacco dependence Tobacco use Allergic or non-allergic Health Data Consulting © 2012

ICD-10 Relevant Documentation Otitis Media Concepts: Temporal Factors: Acute or subacute or chronic Recurrent Laterality: Left or right Bilateral or unilateral Health Data Consulting © 2012

ICD-10 Relevant Documentation Code Examples – Otitis Media: ICD-10 Code Description B053 Measles complicated by otitis media H6501 Acute serous otitis media, right ear H65113 Acute and subacute allergic otitis media (mucoid) (sanguinous) (serous), bilateral H65194 Other acute nonsuppurative otitis media, recurrent, right ear H6532 Chronic mucoid otitis media, left ear H66012 Acute suppurative otitis media with spontaneous rupture of ear drum, left ear H6613 Chronic tubotympanic suppurative otitis media, bilateral H6622 Chronic atticoantral suppurative otitis media, left ear J1183 Influenza due to unidentified influenza virus with otitis media Health Data Consulting © 2012

Health Data Consulting © 2013 Source: Health Data Consulting Fractures Radius Femur Health Data Consulting © 2013

ICD-10 Relevant Documentation Fracture Concepts: Type of Fracture: Pathologic fracture Stress fracture Torus fracture Greenstick fracture Osteoporosis related Health Data Consulting © 2013

ICD-10 Relevant Documentation Fracture Concepts: Type of Fracture: Open or Closed Gustillo type I or II Gustillo type IIIA, IIIB, or IIIC Physeal Fracture Salter Harris I Salter Harris II Salter Harris III Salter Harris IV Health Data Consulting © 2013

Health Data Consulting © 2013 Open Fractures Gustilo Classification Grade I:         - wound less than 1 cm w/ minimal soft tissue injury;         - wound bed is clean         - bone injury is simple w/ minimal comminution;         - w/ IM nailing, average time to union is 21-28 weeks;  Grade II:         - wound is greater than 1 cm w/ moderate soft tissue injury;         - wound bed is moderately contaminated;         - fracture contains moderate comminution;         - w/ IM nailing, average time to union is 26-28 weeks; *Source: Duke Orthopedics Health Data Consulting © 2013

Health Data Consulting © 2012 Open Fractures Gustilo Classification Grade III:     - following frx automatically results in classification as type III:          - segmental frx w/ displacement          - frx w/ diaphyseal segmental loss;          - frx w/ associated vascular injury requiring repair;          - farmyard injuries or highly contaminated wounds;          - high velocity BSW;          - frx caused by crushing force from fast moving vehicle *Source: Duke Orthopedics Health Data Consulting © 2012

Health Data Consulting © 2013 Open Fractures Gustilo Classification Grade III A:          - wound less than 10 cm w/ crushed tissue and contamination;          - soft tissue coverage of bone is usually possible;          - w/ IM nailing, average time to union is 30-35 weeks;  Grade III B:          - wound greater than 10 cm w/ crushed tissue and contamination;          - soft tissue is inadequate and requires regional or free flap;          - w/ IM nailing, average time to union is 30-35 weeks; Grade III C:          - is frx in which there is a major vascular injury requiring repair for limb salvage;          - fractures can be classified using the MESS:          - in some cases it will be necessary to consider BKA following tibial frx *Source: Duke Orthopedics Health Data Consulting © 2013

Growth Plate Fractures Salter-Harris Classification Health Data Consulting © 2013

ICD-10 Relevant Documentation Fracture Concepts: Laterality: Left Right Unilateral Bilateral Spatial Localization: Proximal Distal Medial Lateral Health Data Consulting © 2013

ICD-10 Relevant Documentation Fracture Concepts: Encounter: Initial Subsequent Sequela Healing pattern: Routine Healing Delayed healing Nonunion Malunion Health Data Consulting © 2013

ICD-10 Relevant Documentation Fracture Concepts: Fracture Patterns: Displace/Non-displaced Transverse, Oblique, Spiral Simple , Comminuted, Segmental 3 part.., Intra-articular/Extra-articular Avulsion Health Data Consulting © 2013

ICD-10 Relevant Documentation Fracture Concepts: Fracture Patterns: Osteochondral or Articular Blowout Fracture Longitudinal Pilon Fracture Compression Fracture Wedge Fracture Health Data Consulting © 2012

ICD-10 Relevant Documentation Fracture Concepts - Radius: Parts of the Bone: Radius Radial Head Radial Styloid Shaft Neck Radius and ulna Radial tuberosity

ICD-10 Relevant Documentation Fracture Concepts-Radius: Named Fractures of the Radius: Colles’ Smith’s Galeazzi’s Barton’s Chauffeur’s

ICD-10 Relevant Documentation Code Example – Radial Fractures: ICD-10 Code Description M84534G Pathological fracture in neoplastic disease, left radius, subsequent encounter for fracture with delayed healing S52121B Displaced fracture of head of right radius, initial encounter for open fracture type I or II S52112P Torus fracture of upper end of left radius, subsequent encounter for fracture with malunion S52321A Displaced transverse fracture of shaft of right radius, initial encounter for closed fracture S52331J Displaced oblique fracture of shaft of right radius, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing S52549M Smith's fracture of unspecified radius, subsequent encounter for open fracture type I or II with nonunion S59111S Salter-Harris Type I physeal fracture of upper end of radius, right arm, sequela S52516K Nondisplaced fracture of unspecified radial styloid process, subsequent encounter for closed fracture with nonunion Health Data Consulting © 2013

Health Data Consulting © 2013 The Femur Anatomy Health Data Consulting © 2013

The Femur Fracture Patterns Sub Capital Inter-Trochanteric Sub-Trochanteric Oblique Transverse Supra-Condylar Spiral Medial Condylar Lateral Condylar Intra-Condylar

ICD-10 Relevant Documentation Code Example – Femur: ICD-10 Code Description M80052A Age-related osteoporosis with current pathological fracture, left femur, initial encounter for fracture M84351D Stress fracture, right femur, subsequent encounter for fracture with routine healing S72032H Displaced midcervical fracture of left femur, subsequent encounter for open fracture type I or II with delayed healing S72051P Unspecified fracture of head of right femur, subsequent encounter for closed fracture with malunion S72142K Displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with nonunion S72322A Displaced transverse fracture of shaft of left femur, initial encounter for closed fracture S72335B Nondisplaced oblique fracture of shaft of left femur, initial encounter for open fracture type I or II S72422G Displaced fracture of lateral condyle of left femur, subsequent encounter for closed fracture with delayed healing Health Data Consulting © 2013

Getting Specific When is unspecified OK? Slides 48-50 - High level discussion of the business impacts of ICD-10 Getting Specific When is unspecified OK?

Health Data Consulting © 2012 Coding specificity What’s an unspecified code? Does specificity require more than one code? When is unspecified the right choice? When should unspecified change to specified? Health Data Consulting © 2012

Poorly Specified Coding A proposed definition “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.” Health Data Consulting © 2012

Health Data Consulting © 2012 Coding specificity More than one code. Beyond the primary code, accurate representation of the patient’s health condition may require other codes to represent: Causation Infectious, chemical, physical or other agents Location of Injury External causes of injury Manifestations Comorbid condition or contributing factors Sequela Findings Multiple other factors associated with the primary condition being treated or evaluated Health Data Consulting © 2012

Coding specificity Sometimes unspecified makes sense… A place for “unspecified” codes 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 Source: Health Data Consulting

Health Data Consulting © 2012 Coding specificity No place for “unspecified” codes 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 Health Data Consulting © 2012

Clinical / Business/Coding Relationships Creating a new working relationship 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 The role of the coding professional is to assure that coding is consistent with the documentation The role of the business manager is to assure that all billing is accurately coded and supported by the documented facts. Source: Health Data Consulting Health Data Consulting © 2012

Getting your ducks in a row Slides 48-50 - High level discussion of the business impacts of ICD-10 Implementation Getting your ducks in a row

Implementation Strategy Short term goals with a long term visions What solution do I need today? Will that solution extend to tomorrows needs? Awareness of touch points with other initiatives Overlap and conflicts Down Stream Impacts What works well for one business area, may bring another business area to it’s knees Positioning for competitive advantage Can you predict risk better than you competitor? Are you perceived as a supporter and facilitator for the transition challenge to providers and other stakeholders? Can you manage the “burden of illness” of your population better than your competitors? Health Data Consulting © 2012

Health Data Consulting © 2012 Phases of Transition Assessment Inventory of impacted systems and processes Identifying risk Analysis/Planning Prioritizing focus Establishing business area specific approaches Creating specifications for mapping to support implementation Implementation and Operations Translating codes from 9 to 10 and from 10 to 9 using crosswalks Changing analytic models to support both codes Operationalization of coding to ICD10 from source information Changing processing logic to operate directly from ICD10 codes Leveraging ICD10 capabilities Using the enhanced information within ICD10 codes to improve processing and analysis based on improved concepts buried within the ICD10 codes Health Data Consulting © 2012

Scenario-Based Testing What is it? The scenario: The identification of some event or condition that we are familiar with today Recreating that event virtually through some verbal or data representation Defining a variety of assumptions and variables around this virtual representation Applying one or more of these scenarios in a Reference Implementation Model (RIM). Walk through current systems or processes using these scenarios with varying assumptions and variables to determine if expected results can be achieved and the required changes to achieve those expected results. Health Data Consulting © 2012

Health Data Consulting © 2012 Leveraging ICD10 A changing world of cost containment Accurate and complete documentation and coding provides opportunities to support the transition into a “value-based”, “accountable care” reimbursement environment. Better representation of severity and risk Recognition of varying levels of complexity Better claim information to support automated processing and more rapid reimbursement Opportunities to reduce audit risk exposure Improved business intelligence to support population risk management More accurate measures of quality and efficiency Health Data Consulting © 2012

Health Data Consulting © 2012 Summary Key Points ICD-10 will be a substantial change in the standard for defining the patient’s health state and the institutional procedures performed to maintain or improve that health state. There are significant impacts and changes to both the clinical and business side of the practice. Coding accuracy and productivity will be substantially impacted during the transition and will impact both cost and revenue. There are significant new opportunities to leverage ICD-10 in a new payment environment (ACO). Source: Health Data Consulting Purpose of the slide: Summation of key point discussed in the presentation Health Data Consulting © 2012

Health Data Consulting © 2012 Summary Action Items Establish awareness across members of your organization Clearly define strategic goals Identify internal and external dependencies Identify and prioritized key risks Clearly define all business requirements and implementation tasks Create a realistic project plan and support it as a priority Test early and often. Get started now!! Source: Health Data Consulting Purpose of the slide: Summary of important action items to consider moving forward Health Data Consulting © 2012

Questions ? Slides 48-50 - High level discussion of the business impacts of ICD-10

Online Resources CMS - https://www.cms.gov/ICD10/ Coding Documentation (Indexes, Coding Guidelines, Code Files) General Equivalency Mapping [GEM] (Mapping files, Guidelines, Procedure and Diagnosis) FAQ, Coordination and maintenance Committee minutes WEDI - http://www.wedi.org/ List serves Workgroups White papers Implementation forums Industry advocacy and issue Access to standards leaders AHIMA - http://ahima.org/ Training and certification Extensive documentation libraries Bookstore Communities of practices ICD-10 focused conferences Source: Health Data Consulting

Online Resources Blogs HIMSS- http://www.himss.org/ Vendors White papers Bookstore Webinars Vendors Consulting Organization Online news ICD-10 watch -http://www.icd10watch.com/ Blogs Source: Health Data Consulting

Online Resources Health Data Consulting white papers: ICD-10 Vendor Evaluation ICD-10 A Primer ICD-10 Physician Impacts ICD-10 Hospital Impacts Scenario Based Testing ICD-10 The Case for Moving Forward Transition to ICD-10: Getting Started Reconciling Analytics Across the ICD-10 Transition Contingency Planning http://healthdataconsulting.com/resources/white-papers/ Source: Health Data Consulting