ICD-10 Education Session Preparing for the Change January 29th & 30th, 2015

Agenda Topic Timeframe Presenter/s Welcome 15 minutes Anupam Goel, MD Documenting for ICD-10 90 minutes Thomas Kravis, MD Clinical Informatics/Clinical Documentation Improvement (CD)/Coding- How can we help you? 30 minutes Cheryl Hager Stephen Crouch, MD & Kelly Tarpey Lou Ann Schraffenberger & Dawn Monegato Break Using CareConnection to Improve Documentation Case Examples Discussion 45 minutes

WELCOME

Housekeeping Items Sign In Sheets Restrooms Cafeteria Eureka Conference Room

ICD-10 Resources You can access the ICD-10 Website from the Advocate Home Page:

What is available? FAQ’s Documentation Tip Sheets 3M Specialty Focused Training Videos EMR Specific Videos Leadership Materials

Advocate CDI Thomas C Kravis MD January 29 and 30 2015

Clinical Documentation Improvement Goals and Objectives ICD-10 General Awareness Session – Intro & Physician Leader Clinical Documentation Improvement Goals and Objectives 4/27/2017 Clear concise accurate documentation Across the continuum of care: inpatient and outpatient Capture the severity of illness (SOI) and the Risk of Mortality (ROM) Support hospital and physician reimbursement Improve quality report cards and clinical outcomes Reduce denials and queries Prepare for ICD-10

Value of Accurate and Complete Documentation MD and Hospital Quality Reports Core Measures POA HACs ICD-9-CM ICD-10 Preventable Readmission Complications PSIs Compliance Fraud Abuse RAC Value Base Purchasing 2 MIDNIGHT RULE Care Coordination Team E&M Pro fees Denial related claims Medical Necessity

Documentation Across the Continuum of Care Pre Hospital Hospital Post Acute Care Population at Risk Ambulatory Outpatient Inpatient OP Facility/ Comprehensive OP Rehab Fac. Critical Access Hospital Outpatient Critical Access Hospital Inpatient Physician Practices Ambulatory Surgery Ctr Skilled Nursing Facility Urgent Care Ctr Free-standing Diagnosis Center Hospital - Outpatient Home Hospice Fed Qualified HC Indian Health Services Day Surgeries Emergency Clinic visits Observation Hospital-Based ancillary services Hospital – Inpatient Psych Employer Clinic Home Healthcare Community Mental Health Clinic Home Health Agency Inpatient Rehab Physician Office Clinic Rural Health Clinic Retail Clinic Hospice End Stage Renal Disease Physician Evaluation and Management

General Guidelines for Documentation Document all diagnoses and procedures Licensed hands-on treating practitioner in the body of the EMR and discharge summary All medications, treatments and diagnostic studies and the corresponding medical diagnoses for each and the clinical significance Conditions cannot be coded from lab, x-ray, other diagnostic test results or symbols (↑, ↓) without practitioner documentation. ‘Cut and pasted’ documentation must accurately reflect the clinical condition of the patient at the time of the documentation To capture SOI and ROM and assign an appropriate code a “condition” in the inpatient setting must meet at least one of the following criteria: Clinical evaluation Therapeutic treatment Diagnostic procedures Extended length of hospital stay Increased nursing care and/or monitoring

Documentation & Coding Issues at Advocate Two separate languages Physician Document in CLINICAL terms Documentation for coding, profiling & compliance requires specificity in DIAGNOSIS terms This gap will be increased with ICD-10 Documentation Improvement can help bridge the gap

Clinical Diagnostic Unable to Code Able to Code Multi-system organ failure Severe respiratory distress Hemodynamically unstable Will rehydrate Rhythm stable today “Urosepsis” ↓ K = 2.0, will give KCL Chest X infiltrate ↓ Platelets ↓ Wbc ↓Hct ↓ HgB 5.2, Transfuse Altered Mental Status Emaciated, Total Protein/Albumin Low Liver failure, renal failure, resp failure Respiratory failure : acute, acute on chronic Hypotension, shock-cardiogenic/septic Dehydration, hypovolemia Ventricular tachycardia Simple UTI Hypokalemia Pneumonia Left Lower Lobe Pancytopenia secondary to Chemotherapy Acute/Chronic Blood Loss Anemia Coma, Encephalopathy Protein Calorie Malnutrition On the left, is an example of documented statements that leave a coder unable to code the diagnosis. The diagnoses on the right would contribute significantly to the final assignment of severity and/or risk of mortality.

(Documentation needs clarification) (Accurate code may be assigned) Emergency Medicine Clinical Terms (Documentation needs clarification) Diagnostic Statement (Accurate code may be assigned) Cardiac enzymes elevated, elevated troponin, EKG positive Acute myocardial infarction (specify type such as STEMI or NSTEMI; specific artery involved such as LAD, left circumflex; exact date of any recent AMI) Acute coronary syndrome (ACS) Document intended diagnosis such as intermediate/insufficiency syndrome, unstable angina, coronary slow flow syndrome, myocardial infarction Chest pain will treat with IV nitro and evaluate by cath Specify cardiac cause such as CAD (known or suspected), stable angina, unstable angina, AMI, aortic stenosis, hypertension, CHF Chest pain, noncardiac, treated with NSAID and H2-blockers Specify diagnosis being treated even if considered probable or suspected such as chest wall pain, GERD, costochondritis Rales & rhonchi lung bases, lungs sound wet, RR = 30, Ejection fraction 24%, JVD History of CHF, will continue furosemide, ACE inhibitors Heart failure (specify type such as systolic, diastolic, combined systolic and diastolic; specify acuity such as acute, chronic, acute on chronic) ↓BP, hemodynamically unstable, IV fluid bolus started, dopamine ordered Shock, hypotension (specify type and etiology such as chronic, drug-induced, iatrogenic, idiopathic, intra-dialytic, orthostatic, intraoperative or postoperative) Unresponsive to painful stimuli, obtunded, GCS=8 Coma/comatose (document specific cause, if known or suspected) A code may not be assigned based on abnormal laboratory results or diagnostic report findings alone. The physician must document the corresponding diagnosis in the body of the medical record.

General and Internal Medicine Clinical Terms (Documentation needs clarification) Diagnostic Statement (Accurate code may be assigned) Continue home medications such as furosemide, HCTZ, ACE inhibitor Document specific diagnosis such as chronic systolic/diastolic heart failure, CAD, atrial fibrillation, angina, HTN History of CHF, will continue home meds Specify acuity (chronic, acute, acute on chronic); specify type (systolic, diastolic, combined systolic and diastolic) Cardiac enzymes elevated, elevated troponin, EKG positive Acute myocardial infarction (specify type such as STEMI or NSTEMI; document specific artery involved such as LAD, left circumflex; exact date of any recent AMI) Acute coronary syndrome (ACS) Document intended diagnosis such as intermediate/insufficiency syndrome, unstable angina, coronary slow flow syndrome, myocardial infarction Cardiac history Document specific diagnoses such as CAD, angina, old MI (document date when MI occurred) Atrial fibrillation Specify type (e.g., paroxysmal, permanent, persistent, chronic) Atrial flutter Specify type such as typical (type I) or atypical (type II) BP 70/40, ordered norepinephrine or dopamine for support Shock (specify type such as cardiogenic septic, hypovolemic) A code may not be assigned based on abnormal laboratory results or diagnostic report findings alone. The physician must document the corresponding diagnosis in the body of the medical record.

Signs Symptoms Expectation of 2 Midnight E&M DRG Assurance Physician Inpatient The Key Elements : Chief Complaint History Examination Medical Decision Making Chief Complaint: Symptom, problem, condition, diagnosis ( reason for the encounter) Code diagnoses to the highest level of specificity known (i.e. symptoms) Definitive diagnosis unknown, document conditions evaluated treated up: “Probable” “Possible” “Suspected” Coded as if condition exists until condition has been excluded Facility Principal Diagnosis: Condition established after careful study to be chiefly responsible for occasioning admission to the hospital Two Midnight Rule Signs Symptoms Expectation of 2 Midnight Risk of Adverse Event

Physician and Advanced Practitioners Role Focus remains on patient care Respond to query and document in the EMR Do not need to learn coding Minimal impact on day-to-day routine Clinical Documentation Specialists – a resource to the physician 3M 360 : Natural Language Processing (NLP) 17

Impact of Responding to Query Query: “The magnesium level is 1.6 and the patient is receiving magnesium sulfate” “Please provide a corresponding diagnosis ” Physician documents: “hypomagnesimia” Cranial Procedure Impact w/o Response to Query RW = 2.9797 GLOS = 8.98 SOI = 2 Moderate ROM = 2 Moderate Impact w/ Response to Query RW = 2.9797 GLOS = 8.98 SOI = 3 Major ROM = 2 Moderate

Provider Documentation Principal & Secondary Diagnoses Principal & Secondary Procedures ICD-9-CM Codes ICD-10-CM Codes ICD-10-PS Codes DRG Assignment Severity & Risk of Mortality Classification Profiling/Reimbursement (Providers/Hospitals) © 3M 2008. All rights reserved.

Subdivide into subclasses Y APR-DRG 3M™ Subdivide into subclasses Severity of Illness Subclasses Minor Moderate Major Extreme Risk of Mortality Subclasses Minor Moderate Major Extreme Why 3 M?3M created the APR DRGs ( and addition tools such as PPRs and PPCs) and they reflect the Quality of care provided at .We own these tools and know how best to engage our physician colleagues to use them .. The APRs are broken down into subclasses by severity and risk. We understand those cormorbid conditions when present and then documented can drive both severity of illness- as well as ROM and quality. In this slide we illustrate that if you are sick enough to die at Union or your CAC facility the physicians documentation should support a level 4---if your patients are dying at level 1,2 or 3 then this implies: either a quality issues, a coding problem ---or documentation. In our experience it is the physician documentation is the most common factor or reason!! Mortality at < 4 Quality Coding Documentation

Principal Diagnosis "XYZ" Impact of Secondary Diagnosis Among the most powerfull slides based on MD feedback after presenting ( the XYZ is changed for each specialty presentation) Invite and “engage” a member of audience to share an example of a current patient in the hospital

Underlying Principle of 3M™ APR DRGs High SOI and ROM are characterized by: (a) multiple (b) serious diseases and (c) the interaction among those diseases. Key concept

Severity Summary Analysis by Service Lines Advocate Good Shepherd Hospital

Risk-Adjusted Mortality Analysis Advocate Good Shepherd Hospital Data based on all cases using selection criteria. No inference is made or conclusion can be drawn about the significance of actual to expected mortality variance without further study.

3M APR DRG Classification System Risk-Adjusted Mortality Example APR-DRG 194, HEART FAILURE Data Source: 3M APR DRG Classification System utilizing MEDPAR 2013 Data based on all cases using selection criteria. No inference is made or conclusion can be drawn about the significance of actual to expected mortality variance without further study.

Heart Failure Acuity Acute, chronic, acute on chronic/exacerbation Common Impacts all specialties Core Measure Driver of SOI ROM Quality (PPR) Acuity Acute, chronic, acute on chronic/exacerbation Type Systolic and/or diastolic heart failure Etiology If known or suspected: Ischemia Anemia Kidney failure Hypertension Myocarditis Structural heart disease Supraventricular tachycardia Cardiomyopathy : Alcoholic congenital, congestive, constrictive, dilated, endomyocardial, idiopathic hypertrophic sub aortic stenosis ,nonobstructive hypertrophic, obstructive hypertrophic, restrictive Collaboration and clinically effective: Core measure ;Potential Preventable Readmission (PPR);continuum

Acute Kidney Failure Documentation Impact of Appropriate Documentation on SOI and ROM and Physician Scorecard Acute renal “insufficiency” SOI 1; ROM 1 Acute kidney injury (AKI) SOI 3; ROM 3 Acute kidney failure SOI 3; ROM 3 Versus Acute kidney failure “ due to” Acute tubular necrosis SOI 4; ROM 4 Cortical necrosis SOI 4; ROM 3 Medullary (papillary) necrosis SOI 4; ROM 3 You should avoid using the term ‘acute renal insufficiency’ when you mean ‘acute renal failure’ as insufficiency is assigned to a generic or non-specific code in ICD-10 which will not do justice in explaining your patient’s severity of illness and risk of mortality.

Chronic Kidney Disease Specify the stage of chronic kidney disease: Stages 1-5 ESRD Do not document CKD stage as a range. Alternatively note if there is a progression of the stage of CKD during the stay Document the etiology of the CKD, when known, for example: Diabetic CKD Hypertensive CKD Document dependence on chronic dialysis, if appropriate You must specify the stage of CKD – stages 1 -5, or end-stage renal disease. Additionally, you must also indicate the etiology such as Diabetic CKD or Hypertensive CKD.

Training objective: Heart Failure Respond to query Document the drivers of SOI Treat underlying cause: clinical effectiveness Heart Failure Sample Physician: SOI less than Peers Target for Training/guidance Lower SOI

Physician Performance following physician training by service line

Average length of stay by APR subclass: efficiency opportunities

Severity adjusted LOS Severity

Identify Specific Departmental Costs Heart Failure & Shock by Level of Severity

Probable, Possible, Suspected Diagnosis Uncertain Diagnosis Inpatient application only: These conditions may be coded as though they exist Applies to hospital setting only If condition is ruled out, it may not be coded Outpatient application: Must code signs/symptoms, not the suspected condition Supports appropriate E&M professional component 34

Possible/Probable Cause of Chest Pain Cardiac Cath MS-DRGs 286/287 RW = 1.9634 GERD Gastritis MS-DRGs 391/392 RW = 1.0958 Chest Pain MS-DRG 313 RW = 0.5404 Anterior CP Pleuritic CP Chest Wall Pain MS-DRG 204 RW = 0.6472 Costochondritis Tietze’s Disease MS-DRGs 205/206 RW = 1.2566 Pulmonary Embolism MS-DRGs 175/176 RW = 1.6121 Cardiac Arrhythmia MS-DRGs 308/309/310 RW = 1.2188 Angina MS-DRG 311 RW = 0.5128 CAD MS-DRGs 302/303 RW = 0.9999 Shingles MS-DRGs 595/596 RW = 1.7691 Psychogenic Chest Pain MS-DRG 882 RW = 0.6676 Pleurisy MS-DRGs 193/194/195 RW = 1.4378 Psychogenic Angina Pericarditis MS-DRGs 314/315/316 RW = 1.7589 Anxiety MS-DRG 880 RW = 0.6191 Biliary Colic MS-DRGs 444/445/446 RW = 1.5055 35

Documentation for Pulmonary Embolism Document acuity: Acute Chronic Healed/old Specify meaning of “history of PE” Chronic PE continuing to be treated, is being prophylactically treated or patient no longer has the condition “chronic pulmonary embolism” vs. “healed PE” or “old PE” Specify type: Saddle Septic Postprocedural or due to a vascular device Specify if related to any other condition such as: Atrial fibrillation DVT (specify site and laterality) Hypercoagulable state Malignancy/Orthopedic surgery/Sepsis/Trauma Not POA and after an operative episode is considered a patient safety indicator (PSI 12) A hospital acquired condition (HAC) when following certain orthopedic procedures Document presence of cor pulmonale (acute /chronic) “History of PE” can be interpreted to mean the patient has had the condition for a while, such as in “history of hypertension,” or interpreted to mean the patient no longer has the condition. Documentation of “chronic pulmonary embolism” versus “healed or old PE” makes a clear distinction and assures that the severity of illness of your patient is reported accurately. Severity of illness is increased when a patient has a chronic pulmonary embolism but there is no impact on severity of illness when the patient has a personal history of pulmonary embolism.

ICD-10 Myocardial Infarction ICD-10-CM documentation for myocardial infarction will need to include: Type of infarction (STEMI or NSTEMI) Specific site of myocardium involved ( anterior wall, inferior wall) Coronary artery involved (LAD, RCA, LMCA, LCx) New MI within 4 weeks of a previous MI Specify date of onset) ICD-10 April 5, 2006 37

Syncope Alternatives”: “possible” “probable” Arrhythmia MS-DRGs 308/309/310 RW = 1.2188 Syncope MS-DRG 312 RW = .7215 Stroke or CVA MS-DRGs 64/65/66 RW = 1.8258 Anemia MS-DRGs 811/812 RW = 1.2431 Dehydration MS-DRGs 640/641 RW = 1.0896 Heart Failure MS-DRGs 291/292/293 RW = 1.4609 Hypotension MS-DRGs 314/315/316 RW = 1.7589 Alcohol Abuse MS-DRGs 896/897 RW = 1.4155 Dig Poisoning MS-DRGs 917/918 RW = 1.4449 38

Transient Ischemic Attack “TIA” = unspecified code If known or suspected, document more specific diagnosis: Amaurosis fugax Carotid artery stenosis Carotid artery syndrome Precerebral artery syndrome Transient global amnesia Vertebro-basilar artery syndrome Other cerebral ischemic attacks and syndromes Documentation of “TIA” results in the reporting of an unspecified code… as it did in ICD-9. In ICD-10, that code is G45.9. If known or suspected, document the etiology of the patient’s symptoms, such as vertebro-basilar artery syndrome or carotid artery stenosis.

Cerebral Infarction Specify etiology or cause of the infarct: Thrombosis Embolism Occlusion or stenosis Document specific artery involved and laterality: Precerebral arteries which include: Carotid artery Basilar artery Vertebral artery Cerebral arteries which include: Anterior cerebral artery Cerebellar artery Middle cerebral artery Posterior cerebral artery

Cerebral Infarction Following Cardiac Surgery Document the link between the occluded vessel and the CVA, if appropriate Requires laterality distinction (left vs. right) Intraoperative or postprocedural cerebral infarction occurring during cardiac or other type of surgery Document etiology of cerebral infarction: Embolism Thrombosis Occlusion Stenosis Specify artery involved: Anterior cerebral artery Basilar artery Carotid artery Cerebellar artery Middle cerebral artery Posterior cerebral artery Vertebral artery Cerebral Infarction 1st bullet: What stays the same? The etiology of a cerebral infarction, or stroke, is still classified primarily by whether it is due to thrombosis or embolism. 2nd bullet: What’s new? ICD-10 has lots of new codes for cerebral infarction which identify the specific artery involved, and when applicable, whether right or left. (1st code box on screen) For example, you see here the codes for cerebral infarction due to thrombosis of the anterior cerebral artery. Keep in mind, coders can’t get the details of the etiology, site, or laterality from ancillary services reports, such as radiology, since coding must be based on what you document….so be sure to include these details your notes. Also new is that ICD-10 provide codes for cerebral infarction that occur intraoperatively or postoperatively during cardiac surgery or another type of surgery.

Respiratory Failure Acute/chronic/acute on chronic Cause or etiology (pneumonia, COPD,drug,trauma; if following surgery was it POA ( a PSI) or due to underlying pulmonary condition, failure to wean Signs :RR> 26, accessory muscles use, altered mental status Arterial blood gas and pH: pH of <7.30 or >7.50 pCO2 of >50 pO2 of <60 (impacted by hemoglobin level) Type I Hypoxemic: pO2 60 mm Hg normal or low pCO2 Type II Hypercapnic: pH < 7.30 and increased bicarbonate;pCO2 >50 Chronic : As above and low flow 02 at home; polycythemia; cor pulmonale; heart failure Document in Progress Notes and Discharge Summary: “improved”

Ventilator Support Document time of intubation, ventilator start/end times including weaning times Mechanical vent > than 96 hours and may impact the MS-DRG and APR-DRG risk of mortality (ROM) Mechanical ventilation support includes: Endotracheal respiratory assistance Intermittent mandatory ventilation (IMV) Positive end expiratory pressure (PEEP) Pressure support ventilation (PSV) Mechanical ventilation does not include non-ventilated respiratory treatments such as: CPAP, Bi-PAP or IPPB 43

3M APR DRG Classification System Risk-Adjusted Mortality Example APR-DRG 720, SEPTICEMIA & DISSEMINATED INFECTIONS Data Source: 3M APR DRG Classification System utilizing MEDPAR 2013 Data based on all cases using selection criteria. No inference is made or conclusion can be drawn about the significance of actual to expected mortality variance without further study.

Sepsis Urosepsis imprecise No IDD-10 a code for urosepsis Sepsis is classified by the bacteria causing the infection Streptococcal sepsis (group A, group B, Streptococcus pneumoniae, other streptococcal) or Other sepsis (e.g., MRSA, pseudomonas) Severe sepsis is associated with organ dysfunction/failure Document the specific associated organ dysfunction (not MOD) and Document presence of septic shock Sepsis is classified to one of two categories in ICD-10; either Streptococcal Sepsis or Other Sepsis. Streptococcal sepsis is further specified as being due to group A or group B streptococcus, Streptococcus pneumoniae, or other streptococcal infection. As mentioned earlier, the professional coding staff cannot simply read the laboratory results such as a blood culture to code an organism responsible for an infectious proces and it is therfore necessary for you to indicate a cause and effect relationship between the organism and the sepsis, if known, or suspected, in your notes. There are now combination codes for severe sepsis or SIRS due to an infectious process with acute/multi-organ dysfunction with or without septic shock. It is important to document shock as well as any associated organ dysfunction such as acute respiratory failure, acute renal failure, acute hepatic failure, disseminated intravascular coagulopathy, and so forth as they support the appropriate use of resources to provide good patient care and they are important indicators of severity of illness and risk of mortality in the critically ill patient. Sometimes we use the terms ‘sepsis’, ‘ bacteremia’, ‘septicemia’ and ‘severe sepsis’ interchangeably or indiscriminately in records. Make certain to clearly document the term that accurately describes your patient’s condition and update it should the patient progress along the sepsis continuum as the condition is treated or resolved. On another note, should you have a patient with SIRS due to a non-infectious process such as trauma, ICD-10 requires you to document if there is associated acute organ dysfunction.

Diabetes Document Type Type 1 Type 2 Drug or chemical induced Cause :Cushing's syndrome Cystic fibrosis malignant neoplasm malnutrition or Pancreatitis Other specified diabetes mellitus :Genetic defects of beta-cell function Genetic defects in insulin action or postpancreatectomy diabetes mellitus postprocedural diabetes mellitus Manifestations Cause and effect link between the diabetes and the condition “Chronic osteomyelitis of the left ankle due to type 2 diabetes” “Type 1 moderate nonproliferative diabetic retinopathy with macular edema” Control status: “Diabetes with hyperglycemia” “Diabetes out of control” Diabetes The look and feel for codes describing diabetes have changed but the level of detail describing the disease remains mostly the same. Therefore, your documentation doesn’t need to change as long as you are currently documenting the type of diabetes as type 1 or type 2, and any associated complications.

New Stays the Same Obesity New code for obesity documented as nutritional or due to excess calories Single combination code for morbid obesity with alveolar hypoventilation Stays the Same Due to drugs, also specify drug Other Endogenous, familial Endocrine, glandular Due to thyroid or pituitary disorder Obesity Bullet 1: Given the health risks of obesity and the number of obese patients, it is important for us to be able to continue to track the prevalence and cause of obesity among U.S. adults and children. Since overeating is the #1 cause of obesity, it should come as no surprise that ICD-10 has a new code for nutritional obesity or obesity due to excess calories. So consider incorporating “nutritional obesity” into your vocabulary, when applicable – it’s a few less words than obesity due to excess calories! If your patient has morbid obesity, also document if alveolar hypoventilation is present. ICD-10 has a single combination code for it. Bullet 2: As in ICD-9, ICD-10 continues to classify obesity due to other causes, such as due to drugs or endocrine disorders.

No changes BMI value: Body Mass Index Predict likelihood of joint replacement Predict how well patient will do after surgery Body Mass Index Bullet 1: There are no changes here; Bullet 2: There are no changes here; however, I mention BMI because it is used in studies to predict the likelihood of successful and effective joint replacement surgery and how well the patient may tolerated the procedure and recover after surgery. Bullet 3: When you consider BMI an important patient characteristic, including this information in your notes will increase accurate and consistent reporting.

Nutritional Anemias ICD-10 :more specificity Specific codes for the different types: Iron deficiency “secondary to blood loss, sideropenic, inadequate dietary iron intake Vitamin B12 “due to intrinsic factor deficiency, vitamin B12 malabsorption” Folate “dietary, drug induced “ Other nutritional “protein deficiency” Nutritional Anemias Bullet 1: New in ICD-10 is the ability to identify specific types of nutritional deficiency anemias; in ICD-9, different types of anemia were grouped under a generic code such as folate deficiency anemias.   Bullet 2: As you can see on screen, there are specific codes for the different types of iron, vitamin B 12, folate, and other nutritional deficiency anemias such as vitamin B12 deficiency anemia due to selective vitamin B12 malabsorption with proteinuria, or drug-induced folate deficiency anemia. Therefore, it’s important to detail the specific type of deficiency anemia in your notes. Remember that the coding professional cannot simply use and/or interpret laboratory results – let’s say, an iron level or transferrin results – to assign a code for iron deficiency anemia. They are reliant on your documentation of the results and your diagnosis in order to assign a code.

What’s New If chronic, specify: Bronchitis Combination codes for acute bronchitis due to specific organisms If chronic, specify: Simple Mucopurulent Mixed (both simple and mucopurulent) Bronchitis (Bullet 1 and code box on screen) ICD-10 provides combination codes to capture acute bronchitis due to 8 different organisms. Document the specific organism causing the acute bronchitis when known or suspected by using “due to” or “secondary to,” to indicate cause and effect. (grey arrow on screen) Note that you must document the word “acute” when your intended diagnosis is in fact acute bronchitis. (2nd blue box on screen) Otherwise, a diagnosis of “bronchitis” is assigned to a code describing “bronchitis, not specified as acute or chronic.” Chronic bronchitis has it’s own classification. If you can further specify the type of chronic bronchitis, such as simple, mucopurulent, or both, a unique code describing the specific type will be reported.

Document type Document acuity Asthma Mild intermittent Mild, moderate, or severe persistent Document acuity With acute exacerbation With status asthmaticus Asthma The classification of asthma is an example of the use of updated terminology in ICD-10. Bullet 1: Asthma is now classified as mild intermittent or mild, moderate, or severe persistent. Bullet 2: Documentation of acuity remains unchanged from ICD-9. You should continue to document the presence of an acute exacerbation or status asthmaticus. (box to come on screen as the following is read) For example, a diagnosis of severe persistent asthma with acute exacerbation is classified to J45.51.

Depression “Depression” is classified in ICD-10 as: F32.9 Major depression disorder, single episode, unspecified Additional specificity, if known or suspected, will change the code reported, for example: Adjustment disorders with depression and/or anxiety (grief reaction) Anxiety depressive disorders Bipolar disorder with depression Depressive neurosis, neurotic depression, or dysthymic disorder Major depression, single or recurrent episode Mild Moderate, Severe Severe with/without psychotic features Or in partial/full remission Depression Bullet 1:What’s new here is that a diagnosis of depression without further qualification is coded to F32.9 in ICD-10 which is the code for major depressive disorder, single episode, unspecified. In ICD-9, a diagnosis of unqualified depression was assigned a code that simply said depression. Bullet 2: If your intended diagnosis is something other than major depression such as a depressive neurosis, anxiety depressive disorder, bipolar disorder with depression, or an adjustment disorder with depression document this in order to avoid misrepresenting a less severe form of depression as a major depressive disorder. Bullet 3: If the patient does have a major depressive disorder, consider adding additional details to your documentation about the condition. For example, major depression can be further specified as being a single versus recurrent episode as well as being in partial or full remission. In addition, it can be categorized as a mild, moderate, or severe episode, and if severe, with or without psychotic features. According to published Medicare inpatient hospital data, the code for unspecified depression appears on one-fifth of hospital records covered by Medicare. According to published Medicare inpatient hospital data, the code for unspecified depression appears on one-fifth of hospital records covered by Medicare. We can do a better job of describing what we are treating which will result in more accurate data to explain treatment, use of resources, medications prescribed and length of stay.

Tobacco Dependence and Abuse/Use Separate codes for: Tobacco abuse/use Tobacco dependence Type of tobacco product Cigarettes Chewing tobacco Other, such as cigars Ability to differentiate Personal history of tobacco use versus current use For dependence: Currently in remission With withdrawal With nicotine-induced disorder Exposure to second hand smoke Tobacco Dependence and Use Bullet 1-left: ICD-9 provided a single code for tobacco abuse and dependence without differentiation and without further specificity for the type of tobacco product. ICD-10 provides separate codes for these. If your intended diagnosis is dependence, dependence is what you should document rather than abuse. According to the Centers for Disease Control and Prevention, most smokers are dependent and nicotine dependence is the most common form of dependence in the U.S. Bullet 2-left: Additionally, further specificity is provided in ICD-10 for the type of tobacco product dependence as cigarettes, chewing tobacco, or other, for example, cigars….so this should be documented as well. Bullet 1 – right: Your documentation should differentiate between current abuse or dependence versus a person who no longer uses tobacco. Starting in 2002, the number of former smokers has exceeded the number of current smokers. For tobacco dependence, ICD-10 provides the ability to report remission and withdrawal. Examples of nicotine withdrawal symptoms include irritability, anxiety, difficulty concentrating, and increased appetite. ICD-10 also provides the ability to show a cause and effect relationship between tobacco dependence and nicotine-induced disorders, when documented. Bullet 2 – right: Finally, your notes for a patient’s exposure to second hand smoke can be converted to an ICD-10 code that says exactly that.

Document intentional versus unintentional or accidental Drug Underdosing Identifies intentionally or unintentionally taking less of a medication than prescribed Document intentional versus unintentional or accidental Intentional For example, due to financial hardship Unintentional or accidental For example, due to age related disability Age-related dementia Rheumatoid arthritis of hands Drug Underdosing As physicians are increasingly held accountable for patient outcomes, a huge concern is how to classify the patient who fails to follow a recommended regimen of care and gets sicker as a result. Under ICD-9, there is only one generic code for such a patient that says “noncompliance” with no additional detail as to why the patient didn’t follow your instructions. But in ICD-10 there are several codes to describe why a patient is noncompliant in taking drugs prescribed by you. Bullet 1: This new clinical terminology is drug underdosing. Bullet 2: Underdosing identifies situations in which your patient has taken less of a medication than prescribed by you, either unintentionally or intentionally. Bullet 3: Document in your notes why the patient isn’t taking the correct amount of their medication and the associated condition. For example, “Patient was admitted due to acute exacerbation of systolic heart failure. Patient has age related dementia and forgot to take her Digoxin as prescribed” or “Patient cut her dose in half this month because of financial issues.”

Coma Glasgow Coma Scale (GCS) Based on 3 categories of responsiveness: eye opening, best motor response, and best verbal response. Lower the GCS, the deeper the level of unconsciousness. 90% with a score < or equal to 8 are in a coma 50% with score < than or equal to 8 at six hours die Head injury classification: Severe – GCS 8 or less Moderate – GCS 9 to 12 Mild – GCS 13 to 15

Documentation of Pancreatitis History: 66 year old male admitted with nausea, vomiting, and abdominal pain; history of elevated triglycerides and daily alcohol use. Lab: Elevated lipase and amylase Treatment: IVF, NPO, pain control, electrolyte correction. Current Documentation Improved Documentation Final Diagnosis: Pancreatitis, alcohol abuse Final Diagnosis: Acute pancreatitis due to alcohol dependence We see in this example of medical record documentation a final diagnosis of pancreatitis and alcohol abuse. There is no statement of acute versus chronic and there is no linkage between the pancreatitis and alcohol abuse. The final diagnosis on the right tells a better story. It clearly states the pancreatitis is acute and shows cause and effect by stating “due to alcohol dependence” which results in the reporting of “alcohol induced acute pancreatitis.” The coder is not permitted to assume the alcohol caused the pancreatitis. Only you are able to document and use words such as “caused by,” “due to,” or “secondary to.” Additionally, consider the statement in the history: “daily alcohol use.” If your intended diagnosis is alcohol dependence, state dependence rather than abuse or use. Dependence and use or abuse are two different codes.

Document anatomical site: Ulcerative Colitis Document anatomical site: Pancolitis Proctitis Rectosigmoiditis Document any associated complications such as: Abscess Fistula Intestinal obstruction Rectal bleeding Avoid documenting “inflammatory bowel disease” when the intended diagnosis is ulcerative colitis Inflammatory bowel disease is classified as noninfective gastroenteritis As was the case for Crohn’s disease, ICD-10 identifies ulcerative colitis with any associated complication. Again, be clear in your notes concerning associated complications so that you tell the story of the patient’s severity of illness. ICD-10 classifies anatomical site for ulcerative colitis as pancolitis, proctitis, and rectosigmoidisits. A diagnosis of ulcerative ileocolitis is coded as ulcerative pancolitis. Just be as specific as you can about the anatomical site and the coder will take care of the rest. Don’t use the term inflammatory bowel disease when your intended diagnosis is ulcerative colitis. A diagnosis of inflammatory bowel disease results in the reporting of a code that simply says “unspecified noninfectious gastroenteritis and colitis.” Once again, this may under state the severity of illness and risk of mortality.

For hepatitis B, document any findings of delta agent Specify acuity Viral Hepatitis Document type A, B, C, E, Non-A or Non-B For hepatitis B, document any findings of delta agent Specify acuity Acute, chronic Document presence of hepatic coma, encephalopathy or hepatic failure Codes are available to distinguish between acute and chronic hepatitis B and C. If you don’t specify the chronicity of hepatitis B and C, a code for unspecified viral hepatitis may be assigned. Hepatitis A and E are only classified as acute in ICD-10. The type of hepatitis needs to be documented as well as hepatic coma if present. In addition, the findings of delta agent in the hepatitis B patient should be documented as there are codes that indicate its presence with hepatitis B. This helps to better portray how sick your patient is.

Neoplasms Document specific site and laterality for example:“Malignant neoplasm of central portion of left female breast” or “Benign neoplasm of right ovary sites” Document primary and all secondary neoplasms Specify if the primary site is still present Document the reason or multiple reasons for admission: Chemotherapy/immunotherapy/radiotherapy Treatment of symptoms associated with the malignancy (e.g., headache, weakness, Intractable pain requiring pain control/management Staging to determine the extent of the malignancy Treatment of conditions associated with malignancy (e.g., anemia [specify type], ascites, dehydration, malnutrition) Treatment directly towards primary or secondary malignancy 59

Anemia in Chronic Disease Document the link between the chronic disease and the anemia Chronic kidney disease Neoplastic disease Examples Anemia due to CKD stage 3 Anemia associated with lung cancer Distinguish if the anemia is due to the malignancy or the chemotherapy

Link anemia to the blood loss, when appropriate Blood Loss Anemia Blood loss anemia may be due to trauma, gastrointestinal conditions, obstetrical delivery or surgery or other causes Document: Anemia due to acute blood loss Anemia due to chronic blood loss Postoperative anemia due to blood loss Link anemia to the blood loss, when appropriate Anemia following surgery with an expected amount of blood loss may be documented as acute blood loss anemia. It is imperative that you document the acuity of the blood loss anemia (acute, chronic, postoperative). When acute blood loss anemia is due to blood loss resulting from surgery, a diagnosis of “postoperative anemia” is not enough. Document instead “postoperative anemia due to acute blood loss,” if appropriate.

Adult Malnutrition Classification of adult malnutrition is based on the documented known or suspected etiology: Starvation-related Chronic disease-related Acute disease or injury-related Two or more of the following six characteristics required:* Insufficient energy intake Weight loss Loss of muscle mass Loss of subcutaneous fat Localized or generalized fluid accumulation that may mask weight loss Diminished functional status as measured by hand grip strength *May 2012, the Academy of Nutrition and Dietetics (Academy) and the American Society for Parenteral and Enteral Nutrition (ASPEN)

“Postoperative” Diagnosis: Two Definitions Clinical Definition “A condition occurring in the postoperative period”. Coder Definition “A diagnosis related to the surgical procedure” Complication-900 code “Coder cannot make the determination if it is a complication or an expected outcome” (Coding Clinic 4/27/2011)

Examples Complication Non-Complication Postop ileus (997.4 + 560.1) Ileus secondary to surgery (997.4 + 560.1) Post op atelectasis (997.39 + 518.0) Post op anemia (998.11 + 285.1) Non-Complication Ileus Prolonged ileus Expected ileus Incidental atelectasis Atelectasis Acute blood loss anemia 6464

Complications of Surgery ICD-10-CM codes provide specificity to report Timeframe of when complication occurred Intraoperative or postoperative Body system of organ related to complication Body system on which the procedure was performed Example of infection following a procedure Notice in this example, it does not matter what body system on which the procedure was performed Complications of Surgery In ICD-9, codes for complications did not identify when the complication occurred, the body system affected, or type of surgery performed. ICD-10 codes do. In order to code some complications, the coder must know whether the complication occurred intraoperatively or postoperatively, so include these details in your notes when it is not readily apparent. Additional elements needed for code assignment, which the coder should be able to determine from the record, are: body system of organ affected and body system on which the procedure was performed.

3M APR DRG Classification System Risk-Adjusted Mortality Example APR-DRG 308, HIP & FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT Data Source: 3M APR DRG Classification System utilizing MEDPAR 2013 Data based on all cases using selection criteria. No inference is made or conclusion can be drawn about the significance of actual to expected mortality variance without further study.

Documentation Requirements for Fractures Physician documentation requirements Encounter: initial, subsequent, sequale Open Closed (Gustilo Open Fracture Classification ) Salter-Harris Classification for growth plate fractures Displaced or nondisplaced Name of bone and specific part of the bone that is fractured Laterality – right or left Orientation of fractures of the shaft of the bone such as: Comminuted/Oblique/Segmental/Spiral/Torus/Transverse

ICD-10 General Awareness Session – ICD-10 Overview 4/27/2017 ICD-10 Diagnosis Code Code Example Fracture Femur S 7 2 4 K Fracture of the femur Head & Neck Base of Neck Displaced fracture left Subsequent encounter for closed fx with nonunion To show the complexity of the new structure of ICD-10, let’s build an ICD-10 code. Press ENTER. The first three characters indicate that this is a fracture of the femur. Press ENTER. The next character indicates the anatomical section of the head and neck. Press ENTER. The next character gives further specificity of the base of neck. Press ENTER. The next character adds a new component in ICD-10 which is that the fracture is displaced in addition to the laterality. Press ENTER. The final character tells us whether it was the initial encounter or subsequent encounter. If it was a subsequent encounter we need to identify whether it was for routine healing, non-healing, nonunion, malunion or for sequela. All of this is new information and will need to be documented in the medical record in order for the chart to be coded.

Documentation Examples ICD-10 General Awareness Session – ICD-10 Overview 4/27/2017 Documentation Examples Documentation example today: Patient seen for follow up of hip fracture 820.8 Fracture of hip, unspecified part of neck of femur, closed V54.13 Aftercare for healing, traumatic fracture of hip Documentation needed for ICD-10: Subsequent encounter for nonunion displaced fracture base of the femur neck left hip S72.042K Displaced fracture of base of neck left femur, subsequent encounter, closed fracture, non-union Here is an example of coding and documentation of what we see today compared to what we need in the future with ICD-10. Typical documentation, today, might be: Patient comes in for follow up of hip fracture. You can see the 2 diagnoses that will be coded according to the documentation. For ICD-10, we would know it was a subsequent encounter, but we wouldn’t know the exact location of the fracture, (base of femur neck), type of fracture (displaced), status of fracture (non-union) and laterality. Press ENTER. Here is an example of documentation needed to code this fracture: Subsequent encounter for nonunion displaced fracture base of femur neck left hip and the description of the diagnosis code chosen as a result of the documentation.

Fracture Treatment Reduction: open vs. closed Fixation: internal vs. external vs. no fixation device Reduction = “reposition” in ICD-10-PCS Example “Closed reduction with percutaneous internal fixation of right femoral neck fracture” ICD-10 coding of fracture treatment doesn’t necessarily require additional documentation from you since you would typically document all elements needed to determine the ICD-10 code, These elements are: bone involved, laterality, approach, and type of fixation device, if any. If an external fixation device is applied, additional elements of documentation would be monoplanar, ring, or hybrid. Here is the table the coder will use to construct a code for fracture reduction of some of the lower bones. Note that ICD-10 uses the terminology of “reposition” instead of “reduction” to describe the procedure You won’t have to change your vocabulary; the coder will know that ICD-10 reposition operations include fracture reduction. For example, the code for closed reduction with percutaneous internal fixation of a right femoral neck fracture is 0-Q-S-6-3-4-Z.

ICD-10 Documentation Requirements for Procedures Laterality of site Left Right Bilateral Specificity of approach Open Percutaneous Percutaneous endoscopic Via natural or artificial opening Via natural or artificial opening- endoscopic Open with percutaneous endoscopic assistance External

Documentation of Root Operation The root operation depends on the intent of the procedure If the intent of the procedure is vague or unknown, the physician may need to be queried for clarification Example: Revision of hip replacement Operative report needs to be descriptive as to how the hip joint was revised so that the appropriate root operation can be identified (e.g., revision, replacement, removal, supplement)

Documentation of Root Operation The physician is not expected to document in “ICD-10-PCS terms” It is the coder’s responsibility to determine what the documentation in the medical record equates to in the ICD-10-PCS definitions Example: Arthroscopy It is understood that the root operation for a arthroscopy is inspection – even without physician documentation of “inspection” Physician documentation needs to be complete enough to describe the entire procedure performed

Total Joint Replacement Specify joint and laterality Document device inserted: Autologous tissue substitute Nonautologous tissue substitute Synthetic substitute If synthetic substitute, specify: Metal Metal on polyethylene Ceramic Ceramic on polyethylene Also specify the following for synthetic substitute: Cemented Uncemented

Documentation of a procedure: Example stent ICD-10-PCS Section Body System Root Operation Body Part Approach Device Qualifier 0 2 7 B 3 4 Z Med/Surg Dilatation Percutaneous None We have med/surg which is the majority of the PCS procedure codes …………by far the majority are med/surg…….. Then an example body system would be respiratory system, excision would be the operation, body part would be the upper lung lobe, and so forth. ….. So each one has a meaning……….. “Z” just in general for your information ………means that there is nothing or doesn’t apply. So “Z”, in this case, is showing you that there was no device…… Heart & Great Vessels Coronary Artery Transluminal Device, Drug Eluting

Coronary Angioplasty Root operation: Dilation (expanding an orifice or the lumen of a tubular body part) Body part: Coronary artery [specify number of coronary artery sites receiving treatment] Approach: Open, percutaneous or percutaneous endoscopic Device: Drug-eluting intraluminal device, intraluminal device, radioactive intraluminal device, no device Qualifier: Bifurcation or no qualifier Document body part, approach, device and qualifier [if any]

ICD-10-PCS code assigned 02HV33Z Insertion of PICC Line In this example, you see the table used to code the insertion of a PICC line. The root operation definition for this procedure in ICD-10-PCS is ‘insertion’ which is defined as ‘putting in a nonbiological appliance that monitors, assists, performs, or prevents a physiological function but does not physically take the place of a body part.’ Pay particular attention to the column labeled, ‘approach’. The coding professional should be able to determine from your notes if the PICC line insertion was done via a cut-down (open) approach or a percutaneous approach in order to construct an accurate code. Even though it is more likely that most PICC lines are inserted via a percutaneous approach, the professional coding staff cannot make this assumption and must rely on documentation of the approach in your procedure note. Also take note of the column labeled ‘body part.’ The anatomic site or body part the PICC line resides in, such as the vena cava, will be used to create the code. ICD-10-PCS code assigned 02HV33Z

Lumbar Puncture Root operation: Drainage (taking or letting out fluids and/or gases from a body part) Body part: Spinal canal Approach: Percutaneous Document if procedure was therapeutic or diagnostic v Lumbar Puncture 009U3ZX

Impact of Documentation MS-DRG 330 2.4981 Bowel Procedure with CC PDx: Colon cancer SDx: Dehydration Post-op ileus (codes to 997.4 + 560.1) “Ulcer/Wound” noted by RN PPx: Left hemicolectomy MS-DRG 329 5.1396 Bowel Procedure with MCC PDx: Colon cancer SDx: Acute Renal Failure – ATN Expected ileus (560.1) Pressure Ulcer, site unspecific PPx: Left hemicolectomy MS-DRG 329 5.1396 Bowel Procedure with MCC PDx: Colon cancer SDx: Acute Renal Failure – ATN Expected ileus (560.1) Pressure Ulcer Stage IV on Sacrum PPx: Left hemicolectomy Highest MS-DRG payment APR DRG: 221 SOI Level: 2 APR Weight: 1.7681 ROM Level: 1 Peer Group 0.0% APR DRG: 221 SOI Level: 3 APR Weight: 2.9531 ROM Level: 3 Peer Group 2.5% APR DRG: 221 SOI Level: 4 APR Weight: 6.3732 ROM Level: 4 Peer Group 24.2%

Clinical Informatics/Clinical Documentation Improvement (CDI)/Coding How can we help you? January 29th & 30th, 2015

Clinical Informatics

Clinical Informatics Who we are: Informatics experts, leaders, and change agents utilizing innovation, evidence-based practice, quality, and collaboration, to create the safest environment resulting in the best health outcomes for our patients.

Clinical Informatics bridges…. Promotes understanding, integration, and application of technology in the healthcare setting Supports interdisciplinary approach across the continuum of care Clinical Science Clinical Informatics Computer Science Information Science

Clinical Informatics role with ICD-10 Ensure EMR documentation supports new requirements – partnering with CDI New documentation changes in EMR need to reflect physician workflows and evidence based practice Educate and support physicians with new documentation practices. Enhance voice recognition capabilities to reflect ICD-10 changes and best practice

CDI-ICD-10 Physician Education

Kelly Tarpey RN, MSN, CPHQ Stephen Crouch, MD Medical Director, Care Management stephen.crouch@advocatehealth.com Kelly Tarpey RN, MSN, CPHQ System Director, Clinical Documentation Improvement kelly.tarpey@advocatehealth.com

Plan: Standardizing CDI Practice People Process Tools Accurate picture of the patients we care for

Case Mix Index IMPACT: Improvement from baseline at 8 of 10 facilities in November Medicare only Reported 15 days post month end close

Advocate Care Connection Query Process Do not type your reply here- See step 2 below

Sherman CDI Query Process

How You Can Help Promptly reply to CDI staff query Agreement is not required If you do not agree, please provide a brief rationale Spread the word among your colleagues Interact with CDI staff / ask questions Learning process for physicians and CDI staff Will be able to track frequent questions and help CDI staff direct physician education More robust physician clinical documentation will smooth the transition to ICD-10

Documentation for Coding Lou Ann Schraffenberger, Downers Grove Support Center Dawn Monegato, Advocate Lutheran General Hospital

Principal Diagnosis Definition The reason for admission after study that is chiefly responsible for occasioning the admission of the patient for care After all is said and done… Why did the patient have to be in the hospital? Why couldn’t the patient been taken care of at home or in an outpatient status?

Patient’s Medical Record Medical Record is the “Storybook” Describes the patient’s illness and care What’s the patient’s story? Diagnoses are carried throughout the record Not just a diagnosis listed on a Problem List Not something only mentioned once Diagnoses: What’s been ruled-out? Diagnosis written by a consultant that the attending physician never mentions Timeliness and completeness of discharge summary

Diagnoses and Procedures All of these determine the MS-DRG Determines payment Determines severity of illness and risk of mortality Principal diagnosis Principal procedure Secondary diagnoses Condition evaluated, treated, had a diagnostic procedure, affected the length of stay or the amount of nursing care

Top 10 List of Questions to Doctors The top 10 diagnoses that coders contact a physician for diagnosis clarification Heart failure Debridement procedures Malnutrition Sepsis, SIRS, bacteremia Acute vs chronic blood loss anemia Catheter associated urinary tract infection Altered mental status vs. encephalopathy AKI, ARF Respiratory failure, insufficiency, distress Pathology diagnoses not included in attending physician’s documentation

#1 Heart Failure Systolic heart failure Diastolic heart failure Combined systolic and diastolic Acute Chronic Acute on chronic Congestive heart failure is considered less specific

#2 Debridement Excisional Non-Excisional Must be stated Coder cannot assume everything doctor does is surgical Coded to deepest depth Skin or subcutaneous Fascia Muscle Bone “Sharp” is not enough Non-Excisional Default code if excisional is not stated Not considered a surgical procedure Ultrasonic Versajet Pulsed lavage Dermabrader Wet-to-dry dressings

#3 Malnutrition Type and severity First-second-third degree Mild, Moderate, Severe Protein “calorie” “Protein” malnutrition codes to Kwashiorkor Rare severe protein deficiency Not seen in the USA

#4 Sepsis Sepsis, a systemic infection Is SIRS present? Bacterial organism, if known Is it viral instead of bacterial Is SIRS present? Is septic shock present? Is there an underlying infection? such as pneumonia, urinary tract infection, infected decubitus ulcer, peritonitis? Is it Bacteremia instead?

#5 Blood Loss Anemia Acute Chronic Anemia due to acute blood loss Cause? Intraoperative, postoperative, or posthemorrhagic Chronic Anemia due to chronic blood loss Normocytic anemia due to blood loss?

#6 CAUTI Catheter associated urinary tract infection Patient had a Foley catheter and a urinary tract infection Is the UTI due to the urinary catheter? Was it present on admission? Was it hospital acquired?

#7 AMS/Encephalopathy Altered mental status Encephalopathy-type? Cause? It will be coded to a “symptom” which means doctor could not identify the cause If the patient has AMS due to known condition, important to document Is it the same as encephalopathy? Encephalopathy-type? - Alcoholic - Arteriosclerotic - Hepatic - Hypertensive - Hypoglycemic - Metabolic - Posttraumatic - Septic - Toxic

#8 Acute Kidney…… AKI – acute kidney injury Do you mean the same as acute renal failure? It doesn’t mean acute kidney “insufficiency” – right? Anymore descriptions available? Tubular necrosis Acute cortical necrosis Medullary necrosis

#9 Respiratory Failure Find the mixing of the phrases in record Acute respiratory failure Respiratory insufficiency Respiratory distress Chronic respiratory failure-insufficiency-distress Underlying cause? Postoperative status?

#10 Pathology Findings Pathology diagnoses not documented by the attending physician or surgeon Coder cannot code from the pathologist’s report without the attending physician or surgeon documenting as a diagnosis Acceptable to be written after discharge if the pathologist report was not available when the patient went home

Sorry, there are more! CVA versus TIA Which is it? Pneumonia What type is it? BMI is calculated “obesity,” “overweight,” or “underweight,” must be written Syncope Was a cause established? Fall and Motor Vehicle Accident are not “diagnoses” Fracture Traumatic versus pathologic with its cause

Appreciate Your Attention…. Coder’s questions Clinical documentation specialist’s questions Your “responses” have to be written in the record in a progress note or discharge summary More insurance company audits occurring Not just Medicare and Medicaid Coding is being challenged every week Coding is telling the patient’s story… we want it to be accurate

Thank You! Questions? Comments? Requests? Remarks? Contact your hospital’s HIM Department Director or Coding Leader if we can help Diane.cronin@advocatehealth.com (ACMC) Susan.bittner@advocatehealth.com (COND) Kathryn.anthony@advocatehealth.com (GSAM) Kim.ferris@advocatehealth.com (GSHP) Latarsha.atkins@advocatehealth.com (IMMC) Dawn.monegato@advocatehealth.com (LGH) Julie.mueller@advocatehealth.com (SHERM) Felicia.evans@advocatehealth.com (SSUB) Patricia.warren@advocatehealth.com (TRIN) Heather.segerstrom@advocatehealth.com (BROMENN) Lynnette.haller@advocatehealth.com (EUREKA) Louann.schraffenberger@advocatehealth.com

Break 15 Minutes

Using CareConnection to Improve Documentation Anupam Goel (anupam.goel@advocatehealth.com)

Why document in the electronic medical record? Identify issues that need additional attention before moving the patient out of the hospital Let other team members know what you are doing Protect yourself in a lawsuit Justify payment

Why document in the electronic medical record? Identify issues that need additional attention before moving the patient out of the hospital Let other team members know what you are doing Protect yourself in a lawsuit Justify payment Determine Illness severity and risk of mortality Health of a population for value-based purchasing (to be done annually) Public physician quality scorecards

Documenting for multiple purposes Enter all relevant diagnoses Prefer discrete data entry, but free-text is acceptable Be as specific as possible about the patient’s condition or diagnosis IMO search field can help suggest specific diagnoses Use the free-text section after each diagnosis to Include all of the relevant information that you use to make a clinical decision justifying the diagnosis or treatment step you chose Update documentation as new information becomes available

Nuances to Advocate’s CareConnection system Currently, inpatient billing is performed in an outside system No ICD-10 code selected in CareConnection directly goes onto a patient’s bill CDI and coding teams need enough information to support specific diagnoses in your documentation for the relevant ICD-10 codes to be selected in the billing system Outside of ICD-10 or physician documentation, there are efforts to get patients information about their condition Encounter diagnoses (this hospitalization) Problem list (ongoing issues)

On admission Diagnoses: use symptoms rather than “rule out” “Chest pain,” not “rule out MI” Free-text section: consider adding these descriptors Where (site and laterality) Specificity Timing (acute or chronic) Manifestations Stage Status (new, unchanged, improving, resolving)

Daily progress notes Update diagnoses after reviewing test results and seeing the patient Use the “..dx” term to pull in all diagnoses with “_” to enter free-text information Copy-and-paste is strongly discouraged If you must, be sure to update every diagnosis based on new patient information

On discharge Include All diagnoses addressed over the course of the hospitalization Conditions that have been evaluated, but a definitive diagnosis is not yet known (chest pain, non-cardiac) Describe next steps for each ongoing condition in the discharge summary Update the patient’s problem list based on the hospital events

Case Examples Discussion

3M DRG Assurance Program

Physician Presentation The 3M DRG ASSURANCE™ Program Case Studies Advocate Physician Presentation Thomas C Kravis MD January 29 2015

Case Study Sepsis Patient admitted with dysuria, fever, altered mental status. “Urosepsis” documented in progress notes. Lab reports showed serum creatinine and BUN levels of 4.5 & 50, respectively. Low urinary output Physician ordered 1L of IV NS wide open with maintenance IV fluids of 150 cc/hr to follow. Serial creatinine and BUN levels declined over the next 3 days to 1.2 & 24, respectively.

Query for corresponding diagnosis Advocate Case Sepsis Before After MS-DRG: 690 (without MCC) Relative weight: 0.7693 MS-DRG: 871 (with MCC) Relative weight: 1.8527 PDx: Urinary tract infection SDx: AML Coronary artery dz Hypertension Hyperlipidemia Procedures: PDx: Sepsis SDx: Add: Acute renal failure with acute tubular necrosis Query for corresponding diagnosis Procedures: APR DRG: SOI Level: APR Weight: ROM Level: Exp. Mort Rate: 463 2 0.5233 0.3% APR DRG: SOI Level: APR Weight: ROM Level: Exp. Mort Rate: 720 4 2.8127 3 6.3% This report includes data produced by 3M’s proprietary APR-DRG Software.  All copyrights in and to APR-DRG Classification System and all APR-DRG Code Assignments are owned by 3M.  All rights reserved.

Altered Mental Status Alternatives Coma MS-DRGs 080/081 RW = 1.2252 Encephalopathy and Metabolic Encephalopathy MS-DRGs 070/071/072 RW = 1.6593 Seizures MS-DRGs 100/101 RW = 1.5185 Hepatic Encephalopathy MS-DRGs 441/442/443 RW = 1.8534 Hypertensive Encephalopathy MS-DRGs 077/078/079 RW = 1.6290 TIA MS-DRG 069 RW = 0.6948 CVA MS-DRGs 064/065/066 RW = 1.7417 Acute Confusional State MS-DRGs 880 RW = 0.6388 Diabetic Ketoacidosis MS-DRGs 637/638/639 RW = 1.3888 Drug-Induced and Alcoholic Delirium and Dementia MS-DRGs 896/897 RW = 1.5146 UTI MS-DRGs 689/690 RW = 1.1300 Altered Mental Status MS-DRGs 947/948 RW = 1.1324 Alzheimer’s Disease Parkinson’s Disease MS-DRGs 056/557 RW = 1.7368 Dementia and Vascular Dementia MS-DRG 884 RW = 1.0060 Toxic and Anoxic Encephalopathy MS-DRGs 091/092/093 RW = 1.5851 126

CMS Definitions Bacteremia – nonspecific laboratory finding of bacteria in the blood with no signs of illness. Septicemia – “systemic disease associated with the presence of pathogenic microorganisms in the blood.” (positive blood culture and fever) Sepsis – “SIRS due to an infection.” An infection-induced syndrome in the presence of two or more manifestations of SIRS without organ dysfunction. Septicemia that has advanced to involve two or more manifestations of SIRS. Severe sepsis – Sepsis with associated acute organ dysfunction. Septic shock – severe sepsis in which the cardiovascular system begins to fail, blood pressure drops, and vital organs are deprived of adequate blood supply Do we need bandemia rule on slide or as a concept 7/1/09 cmmm 127

Continuum of Illness Due to Infection Bacteremia Septicemia Sepsis Severe Sepsis Septic Shock Document the clinical “theme” in the medical record through to the discharge summary.

Documentation of Acute Tubular Necrosis (ATN) Document signs, symptoms, findings and treatments for ATN Acute tubular necrosis (ATN) Document hypoperfusion to the renal cell caused by surgery, hypovolemia, hypotension or infection Document causative medications such as antibiotics, ACE inhibitors, ARBs, chemotherapy agents , IV contrast Document other conditions such as rhabdomyolysis and sepsis Signs and Symptoms ↓decrease urine output, fluid retention Increase in serum creatinine Electrolyte abnormalities (hyperkalemia, hyponatremia, metabolic acidosis, altered mental status, nausea and vomiting) Diagnostic testing UA for renal tubular casts, renal ultrasound, biopsy Treatment Treating underlying cause, optimization of CV function and intravascular volume, diuretics or dialysis

Specificity of Secondary Diagnosis: Impact on SOI and ROM Severity of Illness Impact Risk of Mortality Impact Extreme High Medium Low Severe malnutrition X Malnutrition of moderate degree Malnutrition of mild degree Malnutrition, unspecified Cachexia (wasting disease) Anemia, unspecified Acute blood loss anemia Chronic blood loss anemia Dehydration Hyponatremia Hypernatremia Impact is based on SOI/ROM level at individual code level © 3M 2015. All Rights Reserved.

Case Study Neuro/Trauma Patient admitted with traumatic subdural hemorrhage. H&P s “significant amount of midline shift over 1 cm…largely symptomatic from her right sided subdural hematoma.” SEPS drain was placed in ICU without successful drainage. CT of head “left-to-right midline shift of 11mm…there may be early herniation as well.” Patient expired.

Sample Case Neuro PDx: Traumatic subdural hemorrhage, no LOC Before After MS-DRG: 087 (without CC/MCC) CMI: 0.7345 LOS: 2.2 MS-DRG: 085 (with MCC) CMI: 1.9733 LOS: 4.9 PDx: Traumatic subdural hemorrhage, no LOC SDx: Alzheimer’s dementia Unspecified fall Palliative care PDx: Same SDx: Add: Herniation of brain APR DRG: SOI Level: APR Weight: ROM Level: Exp. Mort Rate: 055 1 0.6365 2 2.9% APR DRG: SOI Level: APR Weight: ROM Level: Exp. Mort Rate: 055 3 1.3717 7.5% This report includes data produced by 3M’s proprietary APR-DRG Software.  All copyrights in and to APR-DRG Classification System and all APR-DRG Code Assignments are owned by 3M.  All rights reserved.

Head Injury Nonspecific: Document the specific type of injury: Closed head injury (CHI) Traumatic brain injury (TBI) - diffuse or focal Intracranial injury Document the specific type of injury: Brain herniation Cerebral edema Compression of brain Concussion Contusion of brain Hemorrhage of brain Laceration of brain Specify if any loss of consciousness and the time duration Encounter

Traumatic Brain Hemorrhage Specify site Left or right cerebrum Cerebellum Brainstem Epidural Subdural Subarachnoid Specify if with LOC and for how long in order to accurately report time. Unique ICD-10 codes are reported for traumatic brain hemorrhage of left cerebrum withloss of con < 30 Minutes of the sites you see here when you include this information in your notes. Additionally, you have the capability to report any associated loss of consciousness and how long it lasted. For example, 1 code is reported for loss of consciousness up to 30 minutes; a different code is reported for up to 59 minutes, etc…so include this information in the patient record.

Subarachnoid, Intracerebral and Intracranial Hemorrhage Clarify if subarachnoid, intracranial and intracerebral hemorrhages are traumatic or non-traumatic Subarachnoid hemorrhage: document the specific artery where hemorrhage occurred and the laterality : Carotid siphon and bifurcation Middle cerebral artery Anterior communicating artery Posterior communicating artery Basilar artery Intracerebral hemorrhage: document the specific location: Subcortical hemisphere Cortical hemisphere Brain stem Cerebellum Intraventricular Intracranial hemorrhage: document as extradural/epidural hemorrhage or subdural hemorrhage Subdural or extradural hemorrhage: document as acute, subacute or chronic

Cardiac Arrest Document the underlying cause or etiology if known or suspected Indicate a linkage to the known or suspected etiology by selecting words such as “due to” or “secondary to”

End of Life/Palliative Care Documentation When further treatment is deemed futile or in which patient/family has declined further treatment, the patient’s chart may have typical documentation that includes: “Comfort measures” “Supportive care” “Condition grave” Even though no aggressive treatment will be rendered, it is critical that documentation of the patient’s status and subsequent conditions are documented to accurately reflect patient’s extreme severity of illness and risk of mortality. Examples include: Coma Agonal respirations Respiratory failure Renal failure Also remember to fully document the underlying terminal diagnosis (cancer, end-stage heart failure or renal failure)

MacNews Tuesday October 11, 2011 “Steve Jobs Dies of Respiratory Failure . Steve Jobs' death certificate lists respiratory failure caused by the spread of a metastatic pancreas neuroendocrine tumor.”

Case Study Pulmonary Patient admitted through ED with obtundation, labored breathing, and fever. Diagnosed with pneumonia. Temp 102.9, BP 97/57; O2 sat 84% on R/A. WBCs 20,000 with left shift. BUN/Creatinine = 49/2.1. ABGs: pH 7.33; pCO2 60; pO2 55. Changed to 100% NRB mask. BP started to drop: 85/57, 97/46, 90/60. Placed on Levophed infusion @ 90cc/hr. BP cont’d to drop. Dopamine.added. Received IV Rocephin and IV Flagyl. Patient became unresponsive to tactile and verbal stimuli. Cardiac arrest occurred. Patient was subsequently intubated and expired.

Query for corresponding diagnoses and for principal diagnosis Sample Case: Pulmonary Medicine Before After MS-DRG: 194 (with CC) Relative weight: 0.9771 MS-DRG: 871 (with MCC) Relative weight: 1.8527 PDx: Pneumonia SDx: Atrial fibrillation Left heart failure Atelectasis Hypotension Cystic kidney disease Edema Renal insufficiency History of colon CA Procedures: Mech vent & intub PDx: Sepsis SDx: Add: Septic shock Acute renal failure Acute respiratory failure Coma Query for corresponding diagnoses and for principal diagnosis Procedures: Mech vent & intubation APR DRG: SOI Level: APR Weight: ROM Level: Exp. Mort Rate: 139 3 1.0089 4.5% APR DRG: SOI Level: APR Weight: ROM Level: Exp. Mort Rate: 720 4 3.0499 29.8% This report includes data produced by 3M’s proprietary APR-DRG Software.  All copyrights in and to APR-DRG Classification System and all APR-DRG Code Assignments are owned by 3M.  All rights reserved.

Case Study Orthopedics 80 y/o female admitted with fractured ankle after a fall at home. To surgery for repair. Admission orders indicated “continue home meds” including Lisinopril 20 mg daily Nurses’ notes indicate heart failure and the presence of a dual chamber permanent cardiac pacemaker.

Query for corresponding diagnoses Case study Orthopedics Before After . MS-DRG: 494 (without CC/MCC) Relative weight: 1.5073 MS-DRG: 493 (with CC) Relative weight: 1.9971 PDx: Fracture of ankle SDx: None Procedures: ORIF of ankle PDx: Same SDx: Add: Left heart failure S/P cardiac pacemaker Query for corresponding diagnoses Procedures: Same APR DRG: SOI Level: APR Weight: ROM Level: Exp. Mort Rate: 313 1 1.0420 0.0% APR DRG: SOI Level: APR Weight: ROM Level: Exp. Mort Rate: 313 2 1.5059 0.1% This report includes data produced by 3M’s proprietary APR-DRG Software.  All copyrights in and to APR-DRG Classification System and all APR-DRG Code Assignments are owned by 3M.  All rights reserved.

Documentation Requirements for Fractures Gustilo Open Fracture Classification The following is required for open fractures of the forearm, femur, lower leg or ankle: Type I: clean wound less than 1 cm with minimal soft tissue injury. Bone fracture is simple with minimal comminution. Type II: moderately contaminated wound greater than 1 cm with moderate soft tissue injury. Fracture contains moderate comminution. Type III: extensive skin damage involving muscle or nerves. Type III is further subdivided as follows: Type III A: extensive laceration of soft tissues with bone fragments from severe comminution or segmental fractures Type III B: extensive lesion of soft tissues with periosteal stripping and contamination which usually requires a flap to cover the exposed bone Type III C: exposed fracture with major vascular injury requiring repair for limb salvage

Documentation of Root Operation The physician is not expected to document in “ICD-10-PCS terms” It is the coder’s responsibility to determine what the documentation in the medical record equates to in the ICD-10-PCS definitions Example: Arthroscopy It is understood that the root operation for a arthroscopy is inspection – even without physician documentation of “inspection” However, the physician documentation needs to be complete enough to describe the entire procedure performed

ICD-10 Documentation Requirements for Procedures Laterality of site Left Right Bilateral Specificity of approach Open Percutaneous Percutaneous endoscopic Via natural or artificial opening Via natural or artificial opening- endoscopic Open with percutaneous endoscopic assistance External

Fracture Treatment Reduction: open vs. closed Fixation: internal vs. external vs. no fixation device Reduction = “reposition” in ICD-10-PCS Example “Closed reduction with percutaneous internal fixation of right femoral neck fracture” ICD-10 coding of fracture treatment doesn’t necessarily require additional documentation from you since you would typically document all elements needed to determine the ICD-10 code, These elements are: bone involved, laterality, approach, and type of fixation device, if any. If an external fixation device is applied, additional elements of documentation would be monoplanar, ring, or hybrid. Here is the table the coder will use to construct a code for fracture reduction of some of the lower bones. Note that ICD-10 uses the terminology of “reposition” instead of “reduction” to describe the procedure You won’t have to change your vocabulary; the coder will know that ICD-10 reposition operations include fracture reduction. For example, the code for closed reduction with percutaneous internal fixation of a right femoral neck fracture is 0-Q-S-6-3-4-Z.

ICD-9 vs. ICD-10 Structural Changes ICD-10 General Awareness Session – ICD-10 Overview 4/27/2017 ICD-9 vs. ICD-10 Structural Changes ICD-9 (Diagnoses) # Category etiology, site, manifestation 3-5 characters ICD-10 (Diagnoses) Here we will show the comparison of ICD-9 to ICD-10. In ICD-9 most of the characters are numeric, (exceptions are the V-codes and the E-codes). The decimal point is after the 3rd digit. Press ENTER. In comparison, in ICD-10, the first digit is always alpha, the second character is always numeric, characters 3 – 7 can be either alpha or numeric. The decimal point is also after the 3rd character, as in ICD9. You will notice in ICD-10 there’s an additional character to allow for additional specificity of the codes in the etiology, site and manifestation. (Point to this on the slide) Finally, there is the addition of the 7th character. This is new to ICD-10 which is called an extension character. This character is used in certain conditions to identify the type of encounter and status of the condition. The importance of complete, specific documentation in the medical record cannot be overemphasized. Without complete documentation, the coder will be unable to assign a code upon initial review of the chart and a query may have to be created in an effort to clarify documentation for coding purposes. You may receive query’s from both professional coders as well as from the Clinical Documentation Specialists. 3-7 characters a # a/# Category etiology, site, manifestation extension

Case Study Advocate Surgery Patient presented with active GI bleeding secondary to diverticular disease and AVM. Admission H&H = 12.7/36.5. Progress note on 2nd hospital day states “Hct 35 down to 33%. Continues to have slow bleed.” GI note on 4th hospital day states “actively bleeding AVM.” Lowest serial H&H is 11.3/32.7. Transfused with PRBCs. On the 5th hospital day, patient is given 250cc bolus of IV fluids and placed on strict I&Os with continued IV fluids. Cardiology consult note also indicates “pulmonary hypertension.”

Advocate Sample Case: Surgery This report includes data produced by 3M’s proprietary APR-DRG Software. All copyrights in and to APR-DRG Classification System and all APR-DRG Code Assignments are owned by 3M. All rights reserved

Drivers of Severity and ROM ( partial list) Common Severity/Mortality Drivers Acute blood loss anemia Acute renal failure (indicate underlying cause) Electrolyte imbalances (hypo/hypernatremia, hypo/hyperkalemia, hypo/hypermagnesemia, hypo/hypercalcemia) Encephalopathy (specify type, acuity and cause) End stage renal disease (specify underlying cause) Gastrointestinal hemorrhage (document acuity and link to site of bleed) Heart failure (specify acuity and type) Hemiparesis (specify cause and laterality) Hypotension (specify cause) Ileus Malnutrition (specify severity) Metastases to bone, brain, liver, lung, lymph nodes Sepsis Urinary tract infection (specify site of infection such as bladder, kidney, or urethra)

Gastrointestinal Hemorrhage Document underlying cause: Angiodysplasia Diverticulitis Diverticulosis Duodenitis Gastritis Ulcer (duodenal, esophageal, gastric, gastrojejunal, peptic) Document etiology and show cause and effect Example: Acute GI bleed due to bleeding esophageal varices If no active bleeding during endoscopic exam, clarify if a condition (e.g., ulcer) is the likely cause of the bleed If multiple causes of GI hemorrhage, document all causes Important for physician to document the underlying cause of the GI hemorrhage. If a patient is admitted with GI hemorrhage and a condition is diagnosed (such as diverticulosis), the coder cannot assume the GI hemorrhage is due to the diverticulosis. The physician has to document the linkage between the two conditions.

Gastrointestinal Ulcer Document all sites Duodenal Esophageal Gastric Gastrojejunal Peptic Document associated complications, if appropriate: Hemorrhage Perforation Document acuity Acute Chronic

Barrett’s Esophagus & Barrett’s Ulcer Barrett’s esophagus, disease, syndrome Document presence of dysplasia High grade dysplasia Low grade dysplasia Barrett’s ulcer Document presence of bleeding ICD-10 K22.10 Barrett’s ulcer without bleeding K22.11 Barrett’s ulcer with bleeding K22.70 Barrett’s esophagus without dysplasia K22.710 Barrett’s esophagus with low grade dysplasia K22.711 Barrett’s esophagus with high grade dysplasia K22.719 Barrett’s esophagus with dysplasia, unspecified ICD-10 now classifies Barrett’s esophagus separately from ulcer of the esophagus and provides increased specificity and the requirement to identify with and without dysplasia. If you know the patient has associated dysplasia, and whether it is low- or high grade, document this in your notes. The coder is not permitted to assign the code based only on a path report – codes are based on what you document.

Hemorrhoids Document the degree/grade/stage of hemorrhoids: First degree Hemorrhoids (bleeding) without prolapse outside of anal canal Second degree Hemorrhoids (bleeding) that prolapse with straining, but retract spontaneously Third degree Hemorrhoids (bleeding) that prolapse with straining and require manual replacement back inside anal canal Fourth degree Hemorrhoids (bleeding) with prolapsed tissue that cannot be manually replaced Document presence of any associated complications: Prolapsed Strangulated Thrombosed Ulcerated Current medical literature classifies hemorrhoids into four stages or degrees. The distinction among these stages is clear and affects the therapy given. Consequently, ICD-10 has included this new terminology in new codes. Note that bleeding, when present, is included in the code for each grade or stage of hemorrhoid. However, the source of the bleeding should be clearly documented in your notes as due to hemorrhoids or due to some other problem.

Open Resection of Ascending Colon Removal of Intestine Root operation: Excision (cutting out or off, without replacement, a portion of a body part) Resection (cutting out or off, without replacement, all of a body part) Body part: The anatomic site or body part removed (see next slide) Approach: Open, percutaneous endoscopic, via natural or artificial opening, via natural or artificial opening endoscopic Document body part, approach and if all the body part was removed The root operation is based on the intent/objective of the procedure. Documentation needs to support if all of the body part was removed. Open Resection of Ascending Colon 0DTK0ZZ

Document specific gastrointestinal body parts Esophagus, upper Esophagus, middle Esophagus, lower Esophagogastric junction Esophagus Stomach Stomach, pylorus Small intestine Duodenum Jejunum Ileum Ileocecal valve Large intestine Large intestine, right Large intestine, left Cecum Appendix Ascending colon Transverse colon Descending colon Sigmoid colon Rectum Anus Anal sphincter Greater omentum Lesser omentum Physician does not need to document precisely “excision” or “resection,” but the physician must clearly state if all or only a portion of the body part was removed.

Case Study Pediatrics Newborn H&P: Premature infant born at 36 weeks 2 days at 2550 grams. Fever to 101;Possible sepsis. Receiving IV Gent & Ampicillin. Discharge summary: “At risk for sepsis”

Query for clarification Sample Case: Newborn Before After :. MS-DRG: 790 Relative weight: 5.0315 MS-DRG: 790 Relative weight: 5.0315 PDx: Single liveborn SDx: Prematurity RDS 35-36 Gestation NB feeding problem Procedure: PDx: Single liveborn SDx: Add: Sepsis of newborn Query for clarification Procedure: APR DRG: SOI Level: APR Weight: ROM Level: Exp. Mort Rate: 634 1 0.5761 0.3% APR DRG: SOI Level: APR Weight: ROM Level: Exp. Mort Rate: 634 2 1.1003 3.2% This report includes data produced by 3M’s proprietary APR-DRG Software.  All copyrights in and to APR-DRG Classification System and all APR-DRG Code Assignments are owned by 3M.  All rights reserved.

Fever Alternatives FUO Bacterial Meningitis APR-DRG 049 0.9364 Organism Specific/Complex Pneumonia APR-DRG 137 0.6469 UTI APR-DRG 463 0.4007 Acute Leukemia APR-DRG 690 1.0480 Viral Meningitis APR-DRG 051 0.4921 Bronchiolitis APR-DRG 138 0.2932 Viral Diseases Including Mumps, Measles, & Viral Syndrome APR-DRG 723 0.3319 Infections of Upper Respiratory Tract Including Croup, Otitis Media, Flu & Tonsillitis APR-DRG 113 0.2723 Neutropenic Fever APR-DRG 660 SOI = 0.6548 Lupus APR-DRG 346 0.5823 Chronic Leukemia APR-DRG 691 0.9245 FUO APR-DRG 722 SOI = 0.3342 Pneumonia APR-DRG 139 0.3886 Febrile Seizure APR-DRG 053 0.4741 Benign Lymphoreticulosis, Cat Scratch Fever & Lyme Disease APR-DRG 724 0.5823 Gastroenteritis APR-DRG 249 0.3386 159

Newborn Documentation Issues “R/O Sepsis” Document if sepsis is either Confirmed Ruled out Treated and resolved Organism if known /suspected and link to sepsis 160

Newborn Documentation Issues 28 APR DRGs Related to Newborns The following factors impact APR DRG assignment: Birthweight Congenital or perinatal infection Major cardiovascular procedure <500 grams Major anomaly Major procedure 500-749 grams Respiratory distress syndrome 750-999 grams Discharge Disposition: 1000-1249 gram Other major respiratory condition 1250-1499 grams Transfer to another acute care facility 1500-1999 grams Other significant condition 2000-2499 grams >2499 grams Procedures: Diagnoses: ECMO 161

Diagnoses that Impact Newborn APR DRGs Major Respiratory Condition Examples: Aspiration of amniotic fluid, blood or stomach contents with respiratory symptoms Congenital pneumonia Meconium aspiration with respiratory symptoms Persistent fetal circulation Pulmonary hypertension Respiratory distress syndrome Combination of certain respiratory conditions with a different respiratory condition or mechanical ventilation or CPAP Major Anomaly Examples: Congenital neutropenia Cystic fibrosis Diabetes insipidus DiGeorge syndrome Down’s syndrome Hemangioma Lung anomaly Macroglobulinemia Neurofibromatosis Panhypopituitarism Polycystic kidney disease Sickle cell Spina bifida Thrombocytopenia Valve disorders Wiskott-Aldrich syndrome 162

Diagnoses that DO NOT Impact Newborn APR DRGs The presence or absence of the following diagnoses will not impact the base APR DRG: ABO/Rh incompatibilities Atrial septal defect Breast engorgement in newborn Conjunctivitis and dacryocystitis Facial nerve injury Fetal alcohol syndrome Fetal distress Fractured clavicle Hydrocele Hyperthermia Hypothermia Petechiae Phrenic nerve paralysis Polycythemia Positive blood screen for drugs without signs of withdrawal Respiratory distress in newborn Skull fracture Thrush Transient tachypnea of newborn (TTN) (Type II RDS) Ventricular septal defect 163

Common Severity Drivers in Newborns Newborn Conditions Apnea of newborn Atrial septal defect Congenital aortic stenosis Cyanosis of newborn Hyperbilirubinemia due to ABO incompatibility Hypoglycemia Hypoxemia of newborn Jaundice in preterm infant Meconium staining Neonatal bradycardia Neonatal dehydration Patent foramen ovale Patent ductus arteriosus Respiratory distress in newborn Respiratory distress syndrome Transitory tachypnea of newborn Ventricular septal defect Other Conditions Occurring in Newborns Hypoperfusion Heart failure Acute vs. chronic vs. unspecified Diastolic vs. systolic vs. combined vs. unspecified Cardiomyopathy Dilated cardiomyopathy Hypertrophic cardiomyopathy, IHSS Restrictive cardiomyopathy

Parting Thoughts Thank you for your time Future opportunities Additional educational sessions Updating feedback loops for physicians Please email Anupam or Michelle with comments, critiques or suggestions