1. 3M Health Information Systems, Inc. 3M provides these slides to better understand 3M's software and/or services. These slides contain 3M confidential information and are for customer’s internal review only. Innovating Health Language of the Innovating Health Language of the Advocate Condell Internal Medicine and selected subspecialties Family Practice Emergency Medicine Hospitalists Thomas C Kravis MD © 3M 2015 - 3M Confidential - For Customer's Internal Review Only.explaiFurther use or disclosure requiresexplain apr and inpatint prior approval from 3M.

2. 2 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Clinical Documentation Improvement Goals and Objectives 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

3. 3 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Value of Accurate and Complete Documentation MD and Hospital Quality Reports Care Coordination Team Medical Necessity Value Base Purchasing PSIs Core Measures Compliance Fraud Abuse RAC 2 MIDNIGHT RULE E&M Pro fees Denial related claims ICD-9-CM ICD-10 POA HACs Preventable Readmission Complications

4. 4 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. 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

5. 5 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Documentation & Coding Issues at Advocate Physician Document in CLINICAL terms Documentation for coding, profiling & compliance requires specificity in DIAGNOSIS terms This gap will be increased with ICD-10 Two separate languages Documentation Improvement can help bridge the gap

6. 6 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. 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 Able to CodeUnable 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 Clinical Diagnostic

7. 7 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. General and Internal Medicine (Pocket Card example) Clinical TermsDiagnostic Statement 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 medsSpecify 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 fibrillationSpecify type (e.g., paroxysmal, permanent, persistent, chronic) Atrial flutterSpecify 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.

8. 8 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. ICD-10 Hospitalist Documentation Tips  Use adjectives ―Acute, chronic, acute on chronic, mild, moderate, severe, persistent Example: Mild persistent asthma with exacerbation Example: Acute on chronic systolic heart failure  Indicate cause and effect ―Use “due to” or “secondary to” Example: Pneumonia due to Klebsiella; Pseudomonas pneumonia  Be specific about aspects of the disease ―Use current terminology Example: Atypical or type II atrial flutter or persistent atrial fibrillation  Be specific about anatomical site and laterality ― Example: Pressure ulcer of right heel, stage 3;AMI probable LAD  Use exact dates ―Example: “Myocardial infarction 10/10/2013” and not “MI last month”

9. 9 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M.  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  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) Physician Inpatient E&M DRG Assurance Two Midnight Rule Signs Symptoms Expectation of 2 Midnight Risk of Adverse Event

10. 10 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. ICD-10 Consists of 2 Components 1 2 ICD-10-PCS Procedure Classification System for Inpatient Hospital Use ICD-10-CM Diagnosis Classification System

11. 11 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. ICD-9 vs. ICD-10 Structural Changes  ICD-9 (Diagnoses) 3-7 characters a a # # a/# Category etiology, site, manifestation extension a/# ICD-10 (Diagnoses) # # # # # # # # # # Category etiology, site, manifestation 3-5 characters t

12. 12 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. ICD-10-CM requirements  Laterality  Neoplasm (example – malignant neoplasm of upper lobe of right lung)  Injuries (example – laceration of left subclavian vein)  Body Part - (example – DVT of left iliac vein)  Acuity:  Acute  Chronic  Acute on Chronic  Etiology or Cause  Encounter ( treatment status) Specificity:  Initial - patient receiving active treatment for a condition e.g. injuries,  Subsequent - patient has received active treatment and is receiving routine care during the recovery period Note: “visit” in CPT = patient type (new or established).

13. 13 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. ICD-10 Diagnosis Code Code Example Fracture Femur S S 7 7 2 2 0 0 4 4 2 2 K K Fracture of the femur Head & Neck Base of Neck Displaced fracture left Subsequent encounter for closed fx with nonunion

14. 14 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Physician and advanced practioners role  Focus remains on patient care  Real time 3M 360 :Natural Language Processing  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

15. 15 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Impact of Responding to Query Impact w/ Response to Query  RW = 2.9797  GLOS = 8.98  SOI = 3 Major  ROM = 2 Moderate Impact w/o Response to Query  RW = 2.9797  GLOS = 8.98  SOI = 2 Moderate  ROM = 2 Moderate Query: “ The magnesium level is 1.6 and the patient is receiving magnesium sulfate” “Please provide a corresponding diagnosis ” Physician documents: “hypomagnesemia” Cranial Procedure

16. 16 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Provider Documentation: Quality profile and reimbursement 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. Copy Right 3M 2014 All Rights Reserved

17. 17 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. All Patient Refined DRG APR-DRG 3M™ Severity of Illness Subclasses 1.Minor 2.Moderate 3.Major 4.Extreme Risk of Mortality Subclasses 1.Minor 2.Moderate 3.Major 4.Extreme Mortality at < 4  Quality  Coding  Documentation Subdivide into subclasses

18. 18 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Principal Diagnosis "XYZ" Impact of Secondary Diagnosis

19. 19 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. 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. © 3M 2015 - 3M Confidential - For Customer's Internal Review Only. Further use or disclosure requires prior approval from 3M.

20. 20 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Severity Summary Analysis by Service Lines

21. 21 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. 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. GS Hopital Risk-Adjusted Mortality Analysis: Actual vs Expected Advocate

22. 22 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. 3M  APR DRG Classification System Risk-Adjusted Mortality Example APR-DRG 194, HEART FAILURE 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. Data Source: 3M APR DRG Classification System utilizing MEDPAR 2013

23. 23 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M.  Acuity Acute, chronic, acute on chronic/exacerbation  Type Systolic and/or diastolic heart failure  Etiology If known or suspected: ―Ischemia ―Anemia ―Hypertension ―Myocarditis ― Kidney failure <<< How does Advocate train to improve performance ? ―Structural heart disease ―Supraventricular tachycardia ―Cardiomyopathy : Alcoholic congenital, congestive, constrictive, dilated, endomyocardial, idiopathic hypertrophic sub aortic stenosis,nonobstructive hypertrophic, obstructive hypertrophic, restrictive Heart Failure Videos Specialty Semiars Case Studies 1:1 Guidance

24. 24 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. 3M™ APR Physician Dashboard – Target & Train Physician Lower SOI 3 Peer Groups: Target physician Peers

25. 25 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Heart Failure  Sample Physician: SOI less than Peers  Target for Training/guidance Training objective:  Respond to query  Document the drivers of SOI  Treat underlying cause: clinical effectiveness  Lower SOI

26. 26 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. ―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 Acute Kidney Failure Documentation Impact of Appropriate Documentation on SOI and ROM and Physician Scorecard

27. 27 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Respiratory Failure  Acute/chronic/acute on chronic  Cause or etiology (pneumonia,COPD,drug,trauma;  If following surgery was it POA ( 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 7.50  pCO 2 of >50  pO 2 of <60 (impacted by hemoglobin level)  Type I Hypoxemic : pO 2 60 mm Hg normal or low pCO 2  Type II Hypercapnic: pH 50  Chroni c : As above and low flow 02 at home; polycythemia ;cor pulmonale; heart failure

28. 28 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. 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

29. 29 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Possible/Probable Cause of Chest Pain 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 Cardiac Cath MS-DRGs 286/287 RW = 1.9634

30. 30 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M.  Document acuity: ― Acute ― Chronic ― Healed/old  Specify meaning of “history of PE” ― Chronic PE being treated ― no longer has the condition ― “chronic pulmonary embolism” /“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) Documentation for Pulmonary Embolism ICD-10

31. 31 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. ICD-10 ICD-10-CM : 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) Myocardial Infarction

32. 32 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. 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 Dig Poisoning MS-DRGs 917/918 RW = 1.4449 Alcohol Abuse MS-DRGs 896/897 RW = 1.4155.

33. 33 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Transient Ischemic Attack  “TIA” = unspecified code ICD-10  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

34. 34 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. 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

35. 35 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M.  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  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 Cerebral Infarction Following Cardiac Surgery

36. 36 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. 3M  APR DRG Classification System Risk-Adjusted Mortality Example APR-DRG 720, SEPTICEMIA & DISSEMINATED INFECTIONS 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. Data Source: 3M APR DRG Classification System utilizing MEDPAR 2013

37. 37 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. 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

38. 38 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. 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 s tatus: »“Diabetes with hyperglycemia” »“Diabetes out of control”

39. 39 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. 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

40. 40 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M.  What’s New ―Combination codes for acute bronchitis due to specific organisms  If chronic, specify: ―Simple ―Mucopurulent ―Mixed (both simple and mucopurulent) Bronchitis

41. 41 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M.  Document type ―Mild intermittent ―Mild, moderate, or severe persistent Asthma  Document acuity ―With acute exacerbation ―With status asthmaticus

42. 42 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. 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 Coma

43. 43 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. 43 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

44. 44 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. 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.

45. 45 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. 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)

46. 46 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. “ 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).

47. 47 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. Examples 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

48. 48 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. 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

49. 49 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. 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

50. 50 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. 027B34Z 027B34Z Med/Surg Heart & Great Vessels Dilatation Coronary Artery Percutaneous Transluminal Device, Drug Eluting None Section Body System Body System Root Operation Root Operation Body Part Body Part Approach Device Qualifier Documentation of a procedure: Example stent ICD-10-PCS

51. 51 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M.  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” Fracture Treatment

52. 52 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. 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]

53. 53 3M Health Information Systems © 3M 2015. All Rights Reserved. 3M Confidential – for customer's internal review only. Further use or disclosure requires prior approval from 3M. 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 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% Highest MS- DRG payment 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 APR DRG:221 SOI Level:4 APR Weight:6.3732 ROM Level:4 Peer Group 24.2%