Physician CDI Preparation for ICD-10 Timothy N. Brundage, MD, CCDS Certified Clinical Documentation Specialist Physician CDI Preparation for ICD-10

Clinical Documentation Integrity Program: “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

Why does CDI Matter? Utilization Quality Medical legal Reimbursement Clinical Medicine Medical Record Physician Profiles & Hospital Report Cards Data Coded Physician documentation in the medical record is an important instrument in the economics of healthcare

Why does CDI Matter? Medicine Under The Microscope Cost per patient Resource utilization Length of stay Complication Rates Morbidity Scores Mortality Scores Outcome Analysis Audits

In this World of Documentation 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”

ICD Versions ICD-9 ICD-10 ICD-11 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

Differences Between ICD-9-CM and ICD-10-CM/PCS ICD-9-CM diagnosis 3–5 characters Allows for 1 letter (1st position); otherwise numeric ICD-9-CM procedures 4 characters only All characters are 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-10-PCS Same as ICD-10-CM except each code must have 7 characters Letter “Z” used as a placeholder

ICD-9-CM Structure – Format Numeric or alpha (E or V) Numeric 5 E V 4 X 1 X 4 X . . X X Category Etiology, anatomic site, manifestation 3–5 characters 8

ICD-10-CM Structure – Format Additional characters Alpha (except U) 2–7 numeric or alpha . . M S A X 3 X X 2 X 1 X X X A Category Etiology, anatomic site, severity Added code extensions (7th character) for obstetrics, injuries, and external causes of injury 3–7 characters

Physician Buy In to CDI The most challenging aspect of CDI How do you motivate physicians to educate themselves?

Teach Physicians about Quality Data 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) 11

Physician Profiling 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)

Healthgrades.com

Physician Quality Ratings 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.

ICD-10 Physician Education Don’t need to turn doctors into coders Need good documentation habits Need specialty specific documentation education Begin the process of education now for ICD-9 and incorporate ICD-10 issues into the education

Questions? Email DrBrundage@Gmail.com