2010 UBO/UBU Conference Health Budgets & Financial Policy 1 Briefing: Above and Beyond ICD-9- CM – The DoD Extender Codes Date: 24 March 2010 Time: 1610–1700

2010 UBO/UBU Conference Turning Knowledge Into Action Objectives Find out if anyone in the class is using the data provided by some of the DoD extenders (and realize that some of these really do help the patients) Be aware of the variety of DoD extenders (if you don’t even know it exists, how do you know to look for it) Be able to give an example of when the creation, marketing and extra work to collect would be worth the data collected 2

2010 UBO/UBU Conference Turning Knowledge Into Action How the Class Will Work On the desk is a quiz – fill it out A segment of DoD Extenders will be introduced I’ll bore you with details If you have an applicable joke, raise your hand – Puns and dry humor are appreciated Anyone who may fall asleep, put your head down so you won’t fall over when you do fall asleep The next segment of DoD Extenders will be introduced At the end we will awaken the sleepers 3

2010 UBO/UBU Conference Turning Knowledge Into Action DoD Extenders Why How Who uses Who collects DoD Extender Management – ask requestor annually – 1. There could be a better way to collect (e.g., CPT category II codes, ICD-9-CM code request) – 2. Are the data are still needed – 3. Are the data are providing the information that was anticipated – 4. Is the cost to collect worth the resources to collect 4

2010 UBO/UBU Conference Turning Knowledge Into Action Viral Hepatitis 070xxx Possible extenders: – 0 - Lab test confirmed – 1 - Lab test not reported or negative – 2 - Lab test not performed Are not used for the other than viral (found in the liver part of the ICD-9-CM around 571) hepatitis Will not be needed when the Ancillary SADR laboratory feed includes results – In the next couple of years, before ICD-10, hopefully HEDIS measures are only for Hepatitis C 5

2010 UBO/UBU Conference Turning Knowledge Into Action Viral Hepatitis Show of hands – do you know what organization needs/uses these data? Let’s run the questions – 1. There could be a better way to collect (e.g., CPT category II codes, ICD-9-CM code request) – 2. Are the data are still needed – 3. Are the data are providing the information that was anticipated – 4. Is the cost to collect worth the resources to collect What about the CPT category II hepatitis codes? Jokes? Stories? 6

2010 UBO/UBU Conference Turning Knowledge Into Action Kawasaki vs. Other Acute Febrile Mucocutaneous Lymph Node Syndrome Possible extenders: – 0 - Kawasaki – rare, usually in children 2-5 years old, usually male, inflammation of blood vessels, usually initial treatment is in the hospital – 9 - Other acute febrile mucocutaneous lymph node syndrome In FY09 SIDR (Standard Inpatient Data Record), with a 446.1x diagnosis in 1 st, 2 nd, 3 rd, 4 th, or 5 th diagnosis - there were – 39 total 446.1x dispositions – 38 were – 1 was (a 4 year old male with a 3-day length of stay) 7

2010 UBO/UBU Conference Turning Knowledge Into Action Kawasaki vs. Other Acute Febrile Mucocutaneous Lymph Node Syndrome Show of hands – do you know what organization needs/uses these data? – 1. There could be a better way to collect (e.g., CPT category II codes, ICD-9-CM code request) – 2. Are the data are still needed – 3. Are the data are providing the information that was anticipated – 4. Is the cost to collect worth the resources to collect 8

2010 UBO/UBU Conference Turning Knowledge Into Action Asthma 493xx Possible extenders: – 0 – Unspecified; 1 – Mild; 2 – Mild Persistent; 3 – Moderate; 4 - Severe Needed IN THE PAST for HEDIS measures – (Healthcare Effectiveness Data and Information Set) Even though there is space, these are not in ICD-10-CM – Could it be that the CPT category II suffice? HEDIS concerned with “Appropriate Medications for People with Asthma” – Looking for persistent asthma patients with appropriate medications prescribed 9

2010 UBO/UBU Conference Turning Knowledge Into Action Asthma 327,000 outpatient encounters in FY09 for asthma 1005F,1038F,1039F,4015F (the CPT asthma Category II) only coded 1,291 times in FY09; but as you can see, 327,916 asthma codes… 10

2010 UBO/UBU Conference Turning Knowledge Into Action Asthma 1005F – Asthma symptoms evaluated (includes physician documentation of numeric frequency of symptoms or patient completion of an asthma assessment tool/ survey/ questionnaire) – Coded 1,147 times in FY F – Persistent asthma (mild, moderate or severe) – Coded 49 times in FY09 (but the persistent modifier was used 90,000 times) 1039F – Intermittent asthma – Coded 33 times in FY F – Persistent asthma, preferred long term control medication or an acceptable alternative treatment, prescribed – Coded 106 times in FY09 11

2010 UBO/UBU Conference Turning Knowledge Into Action Reactive Airway Disease Possible extenders: – 0 – Other diseases of lung, NEC – 1 – Reactive airway disease Needed to separate from asthma as pilots are grounded for asthma, but not reactive airway disease 12

2010 UBO/UBU Conference Turning Knowledge Into Action Elective Termination of Pregnancy 635 Possible extenders: – 0 - Elective – 1 - Therapeutic – 2 - Elective, terminated elsewhere – 9 - Unspecified Of the 9 inpatients with 635x in FY09, 7 were “elective, terminated elsewhere” ICD-10-CM does not collect the data in the extenders Was told a report needed to be sent to Congress – is this still the case? 13

2010 UBO/UBU Conference Turning Knowledge Into Action Attempted Termination of Pregnancy 638 Possible extenders: – 0 - Elective – 1 - Therapeutic – 9 - Unspecified ICD-10-CM does not separate elective and therapeutic FY09 outpatient encounters – 8, and all were elective 14

2010 UBO/UBU Conference Turning Knowledge Into Action Stress Fracture/Reaction 733 Multiple configurations of extenders: – Fracture vs. Reaction – Tibia vs. Fibula – Pelvis, inferior pubic rami, superior pubic rami, pubic rami In FY09, of the 166 admissions for stress fracture/reaction, 3 are for reactions ICD-10-CM does not collect fracture vs. reaction Why do we collect this? Who uses it? How? 15

2010 UBO/UBU Conference Turning Knowledge Into Action Persian Gulf War Possible extenders: – 1 - Persian Gulf War Vet – 2 - PGW Family Member – 8 - Not PGW Syndrome, Other Unknown or Unspecified Cause of Morbidity or Mortality Persian Gulf War (2 Aug 1990 – 28 Feb 1991 ~ 20 years ago) 16

2010 UBO/UBU Conference Turning Knowledge Into Action Persian Gulf War Persian Gulf War Vet PGW Family Member Not PGW Syndrome, Other Unknown or Unspecified Cause of Morbidity or Mortality 17

2010 UBO/UBU Conference Turning Knowledge Into Action Persian Gulf War – 3,136 of the 3,824 FY09 SADR with in the 2nd position are 0-35 years old – 2,243 of the 3,400 FY09 SADR with in the 3 rd position are 0-35 years old – 7,925 of the 9,882 FY09 SADR coded with Persian Gulf War Vet are for individuals 0-35 years old (21 are younger than 1 year) 18

2010 UBO/UBU Conference Turning Knowledge Into Action Not Persian Gulf War Other Unknown and Unspecified Causes of Morbidity and Mortality, Not Persian Gulf War – 40,711 in 1 st diagnosis in FY09 SADR – 24,759 in 2 nd diagnosis – 13,557 in 3 rd diagnosis – 4,455 in 4 th diagnosis – Total of 83,000 of 101,000 are coded with “Not Persian Gulf War” Persian Gulf War Syndrome is not a diagnosis in ICD- 10-CM 19

2010 UBO/UBU Conference Turning Knowledge Into Action Infection and Inflammatory Reaction Due to Vascular Device, Implant, and Graft Infection and inflammatory reaction due to vascular device, implant, and graft Possible extenders: – 0 NOS – 1 Jugular vein – 2 Subclavian vein – 3 Femoral vein – 4 Other specified vein – 5 Vein NOS 2,060 discharges in FY09 SIDR with in 1 st. 2 nd, 3 rd, 4 th, or 5 th diagnosis 20

2010 UBO/UBU Conference Turning Knowledge Into Action Infection and Inflammatory Reaction Due to Vascular Device, Implant, and Graft 86% of the 2,060 FY09 SIDR with in 1 st, 2 nd, 3 rd, 4 th, 5 th diagnosis – no extender ICD-10-CM does not have specificity of complications of vascular devices, implants, and grafts (jugular, subclavian, femoral veins) 21

2010 UBO/UBU Conference Turning Knowledge Into Action Infection and Inflammatory Reaction Due to Vascular Device, Implant, and Graft Requested to determine if there was a variation on which vein to use for the vascular device 22

2010 UBO/UBU Conference Turning Knowledge Into Action Personal History of TBI, GWOT or Not V15.59 Other Personal History Presenting Hazards to Health, Other Possible extenders: – 0 – root code – 1 – Global War on Terrorism (GWOT), unknown – 2 – GWOT, TBI mild – 3 – GWOT, TBI moderate – 4 – GWOT, TBI severe – 5 – GWOT, penetrating intracranial wound – 6 – Not GWOT, unknown – 7 – Not GWOT, mild – 8 – Not GWOT, moderate – 9 – Not GWOT, severe – A – Not GWOT, penetrating – B – Unknown if GWOT, unknown – C – Unknown if GWOT, mild – D – Unknown if GWOT, moderate – E – Unknown if GWOT, severe – F – Unknown if GWOT, penetrating 23

2010 UBO/UBU Conference Turning Knowledge Into Action Personal History of TBI, GWOT or Not FY09 SIDR, 380 patients with V15.59 x in diagnoses 1, 2, 3, 4, 5 (unconfirmed are not included) 24

2010 UBO/UBU Conference Turning Knowledge Into Action Hearing Conservation Profile V41.2 Possible modifiers: – 0 Other and unspecified problems with hearing – 1 Profile H-1 – 2 Profile H-2 – 3 Profile H-3 – 4 Profile H-4 14,326 FY09 SADR with hearing conservation profiles 25

2010 UBO/UBU Conference Turning Knowledge Into Action Hearing Conservation Profile Profiles are not a civilian sector issue, the is no similar code in ICD-9-CM 26

2010 UBO/UBU Conference Turning Knowledge Into Action Acquired Absence of Breast V45.71 Possible extenders: – 1 Left – 2 Right – 3 Bilateral Need for HEDIS – for identifying patients needing mammograms 27

2010 UBO/UBU Conference Turning Knowledge Into Action Acquired Absence of Genital Organs V45.77 Possible extenders – 0-9, A and B ICD-10-CM does not have the entire list (e.g., uterus, uterus with cervix, ovaries, prostate) Needed for HEDIS? HEDIS CPT measures – 3014F Screening mammography results documented and reviewed 28

2010 UBO/UBU Conference Turning Knowledge Into Action Acquired Absence of Genital Organs FY09 SADRs 29

2010 UBO/UBU Conference Turning Knowledge Into Action Other Health Impact/Case Management V49.89 Possible extenders: 0 – NOS, 1 – Not Case Mngt, 2 – CM start, 3 – CM continue, 4 – CM end, 5 – CM other Needed to track case management Not in ICD-10-CM 30

2010 UBO/UBU Conference Turning Knowledge Into Action Alcohol and Substance Abuse Education V65.42 Possible extenders: – 0 – Alcohol education – 1 – Substance abuse counseling ICD-10-CM has separate codes Mental Health community wanted to know if alcohol or substance abuse education 31

2010 UBO/UBU Conference Turning Knowledge Into Action Counseling V65.49 Possible extenders: 0-9, A, B ICD-10-CM has separate codes Used 891,912 times in SADRs in FY09 – 264,790 by nurses (provider specialty code 600) Mostly with chronic conditions, e.g., diabetes – 88,553 by technicians (PSC 900) Mostly with preventive health assessments (V70.5x) – 76,521 by PAs (PSC 901) Mostly PHAs (25,471) and well women – Common 1 st listed dx = 7,247; = 12,351; V03-V07.9 = 15,278 V20.2 = 13,460; V22-V23.9 = 36,291; V H = 111,110 32

2010 UBO/UBU Conference Turning Knowledge Into Action Counseling V65.49 x Extenders 33

2010 UBO/UBU Conference Turning Knowledge Into Action Counseling V65.49 x Many multiple types of counseling on single encounter Most commonly on Military Related Physicals/Preventive Health Assessments 34

2010 UBO/UBU Conference Turning Knowledge Into Action Health Exams of Defined Subpopulation V70.5 V70.5 x Possible extenders: 0-9 and A-H 592,916 encounters with V70.5 x in at least one of the 4 diagnosis positions 478,111 encounters with V70.5 x in first listed diagnosis position (so for 114,805 V70.5 is NOT the first listed) 35

2010 UBO/UBU Conference Turning Knowledge Into Action V70.5 x First Listed, Not First Listed If these are health assessments, they should be first listed except… 36

2010 UBO/UBU Conference Turning Knowledge Into Action Observation Following Accident – Head Injury V71.4 Observation Following Other Accident – 0 – head injury ruled out – 9 – injury (not head) ruled out 2,531 encounters – First dx/Second / Third / Fourth 1,362 / 112 / 23 / 11 V head injury r/o 909 / 77 / 23 / 14 V other injury r/o 37

2010 UBO/UBU Conference Turning Knowledge Into Action Observation Following Other Inflicted Injury V71.6 x – 0 – head injury ruled out – 9 – injury (other than head) ruled out – Coded 171 times in FY09 SADR 38

2010 UBO/UBU Conference Turning Knowledge Into Action Exam for Hearing Exam Following Failed Hearing Screening V72.11 coded 20,480 times in FY2009 on SADRs Possible extenders: – 0 – root code – 1 – otoscopic exam done – 2 – otoscopic exam not done 39

2010 UBO/UBU Conference Turning Knowledge Into Action Exam for Hearing Exam Following Failed Hearing Screening Most of them coded are with an otoscopic exam 40

2010 UBO/UBU Conference Turning Knowledge Into Action Other Exam of Ears and Hearing V72.19 Possible extenders – 0 – root code – 1 – otoscopic exam done – 2 – otoscopic exam not done 41

2010 UBO/UBU Conference Turning Knowledge Into Action Other Exam of Ears and Hearing V – Other exam of ears and hearing V – Exam of ears/hearing, otoscopic exam done V – Exam of ears/hearing, otoscopic exam not done Basically, if no otoscopic exam done, just using the root code 42

2010 UBO/UBU Conference Turning Knowledge Into Action Special Screening, Neurologic V80.0 (is now V80.09 as V80.01 Screening for Traumatic Brain Injury was added in FY2010) Possible extenders: – 0 – No diabetic foot check – 1 – Diabetic foot check 43

2010 UBO/UBU Conference Turning Knowledge Into Action Special Screening, Neurologic V80.0 extender is not necessary as the CPT 2028F has been around for years. 2028F Foot examination performed (includes examination through visual inspection, sensory exam with monofilament, and pulse exam – report when any of the 3 components are completed) 44

2010 UBO/UBU Conference Turning Knowledge Into Action Special Screening, Other Eye Condition V80.2 Special screening, other eye condition (not to include glaucoma) Possible extenders: – 0 not including diabetic eye check – 1 including diabetic eye check Coded 37,733 times in FY09 SADR – Including 2,067 times by nurses and 2,957 times by technicians – V coded 9,372 times – V coded 28,362 times 45

2010 UBO/UBU Conference Turning Knowledge Into Action Special Screening, Other Eye Condition V80.2 Special screening, other eye condition (not to include glaucoma) Not necessary to have extender – have CPT codes – 2022F Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed – 2024F 7 standard field stereoscopic photos with interpretation by an ophthalmologist or optometrist documented and reviewed – 2026F Eye imaging validated to match diagnosis from 7 standard field stereoscopic photos results documented and reviewed 46

2010 UBO/UBU Conference Turning Knowledge Into Action 47 Summary We probably need to “clean up” the extenders We need an annual review of all extenders to ensure they are all needed Before asking for an extender, see if there is a better way Traumatic Brain Injury will continue to be stressed as the incidence is increasing and they involve long term care

2010 UBO/UBU Conference Turning Knowledge Into Action 48 Quiz Why isn’t the DoD making more use of the CPT category II codes?

2010 UBO/UBU Conference Turning Knowledge Into Action 49 Q&A Questions?