ICD-10 for physicians: its about good patient care and clinical documentation

ICD-‐10
For
Clinical
Staﬀ

Clinicians

Health
Data
Consul�ng

ICD-‐10

Source:
Health
Data
Consul�ng
and
h�p://
www.noworldborders.com

A
Cornerstone
of
Healthcare
Informa�on

Pa�ent
Provider

Condi�on

ICD-‐10-‐CM

Service

ICD-‐10-‐PCS

Source:

Health
Data
Consul�ng

For
a
complete
copy
of
this
presenta�on

contact
us:

ICD-‐10@noworldborders.com

ICD10
Quick
Facts

Source:
Health
Data
Consul�ng
and
h�p://

  ICD-‐10
interna�onal
version

–  Adopted
by
WHO
in
1990

–  Most
countries
other
than
the
US
currently
use
ICD-‐10

–  ICD-‐10
(Interna�onal
version)
~
12,500
diagnos�c

codes

–  ICD-‐10
used
for
mortality
repor�ng
in
the
US
-‐
1999

  ICD-‐10-‐CM
(US
version)

–  ~
69,000
diagnos�c
codes

–  Final
rule
published
–
2009

–  Compliance
date
–
Oct
1,
2014

  ICD-‐10-‐PCS

–  ~72,000
codes

–  Not
part
of
an
interna�onal
standard

–  Inpa�ent
procedures
only

–  Compliance
date
–
Oct
1,
2014

Source:

Health
Data
Consul�ng

For
a
complete
copy
of
this
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us:


Nature
of
the
Changes

Volume

Source:
Health
Data
Consul�ng
and
h�p://

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

ICD-‐9-‐CM
ICD-‐10-‐CM
ICD-‐10
(WHO)
ICD-‐9-‐CM
ICD-‐10-‐PCS
ICD-‐10
(WHO)

Diagnosis

Procedure

Diagnosis
Procedure

Source:

Health
Data
Consul�ng

Source:

Health
Data
Consul�ng

For
a
complete
copy
of
this
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us:


Same
Condi�on
–
Diﬀerent
Codes

September
2014

Source:
Health
Data
Consul�ng
and
h�p://

What’s
the
Diﬀerence?

October
2014

ICD-‐9

ICD-‐10

82111:

Open
fracture
of
Sha�
of
Femur

S72351C:

Displaced
comminuted
fracture
of
sha�

of
right
femur,
ini�al
encounter
for

open
fracture
type
IIIA,
IIIB,
or
IIIC

All
codes
for
femur
fractures
=
16

All
codes
for
femur
fractures
=
1530

Source:

Health
Data
Consul�ng

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a
complete
copy
of
this
presenta�on
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us:


ICD9
Comparison
to
ICD10-‐CM

Source:
Health
Data
Consul�ng
and
h�p://

Diagnosis
Codes
–
Clinical
Example

A
pa�ent
is
admi�ed
as
the
result
of
[rupture
of
the
cardiac
wall
without
bleeding

into
the
pericardium].

The
pa�ent
is
[within
4
weeks]
of
a
[myocardial
infarc�on].

ICD9 Code Description
42979
Certain
sequelae
of
myocardial
infarc�on,
not
elsewhere
classiﬁed,

other
I233
Rupture
of
cardiac
wall
without
hemopericardium
as
current

complica�on
following
acute
myocardial
infarc�on
Source:

Health
Data
Consul�ng

For
a
complete
copy
of
this
presenta�on
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us:


ICD9
Comparison
to
ICD10-‐CM

Source:
Health
Data
Consul�ng
and
h�p://

Diagnosis
Codes
–
Clinical
Example

A
pa�ent
is
admi�ed
as
the
result
of
[rupture
of
the
cardiac
wall
without
bleeding

into
the
pericardium].

The
pa�ent
is
[within
4
weeks]
of
a
[myocardial
infarc�on].

42979

Certain
sequelae
of
myocardial
infarc�on,
not
elsewhere
classiﬁed,

other
I233
Rupture
of
cardiac
wall
without
hemopericardium
as
current

complica�on
following
acute
myocardial
infarc�on
Source:

Health
Data
Consul�ng

For
a
complete
copy
of
this
presenta�on

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us:


Current
Distribu�on
of
ICD-‐9
diagnosis
codes

Source:
Health
Data
Consul�ng
and
h�p://

All
claims
data
sample
containing
565
million
codes
(1
year
of
data)

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%

Total
Charges
by
Diagnosis
Code
(ICD-‐9)

3years
-‐
$10
Bill

Charge
%

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a
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ICD-‐10
PCS
Factoids

  ICD-‐10
PCS
is
a
system
of
coding
for
ins�tu�onal
procedures.

  These
procedure
codes
do
not
apply
to
coding
for
services
or

procedures
delivered
in
a
non-‐ins�tu�onal
environment

  ICD-‐9CM
chapter
3
is
the
equivalent
of
ICD-‐10PCS

  The
WHO
(World
Health
Organiza�on)
is
not
involved
in
the

standardiza�on
of
ins�tu�onal
procedure
codes

  CMS
is
responsible
for
maintenance
of
ICD-‐10PCS
codes

  Contract
with
3-‐M
to
develop
the
codes
in
1993;
ﬁrst
dra�
in

1993.

  1998
ini�al
release
of
ICD-‐10
PCS
with
annual
updates
every

year

Source:
Health
Data
Consul�ng
and
h�p://

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a
complete
copy
of
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us:


ICD9
Comparison
to
ICD10

Source:
Health
Data
Consul�ng
and
h�p://

Ins�tu�onal
Procedure
Codes
–
Clinical
Example

While
hospitalized,
a
pa�ent
has
a
procedure
done
through
an
[endoscope]

inserted
[through
the
skin]
to
[bypass]
the
blood
ﬂow
from
the
[abdominal
aorta]

to
the
[right]
[renal
artery]
using
a
[synthe�c
material]

3924 Aorta-‐renal
Bypass
04104J3
Bypass
Abdominal
Aorta
to
Right
Renal
Artery
with
Synthe�c

Subs�tute,
Percutaneous
Endoscopic
Approach
Source:

Health
Data
Consul�ng

For
a
complete
copy
of
this
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us:


ICD9
Comparison
to
ICD10

Source:
Health
Data
Consul�ng
and
h�p://

Ins�tu�onal
Procedure
Codes
–
Clinical
Example

While
hospitalized,
a
pa�ent
has
a
procedure
done
through
an
[endoscope]

inserted
[through
the
skin]
to
[bypass]
the
blood
ﬂow
from
the
[abdominal
aorta]

to
the
[right]
[renal
artery]
using
a
[synthe�c
material]

3924 Aorta-‐renal
Bypass
04104J3
Bypass
Abdominal
Aorta
to
Right
Renal
Artery
with
Synthe�c

Subs�tute,
Percutaneous
Endoscopic
Approach
[Note]
For
all
codes
related
to
Aorta-‐renal
Bypass:

• ICD-‐9
codes
=
2

• ICD-‐10
codes
=
30

Source:

Health
Data
Consul�ng

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a
complete
copy
of
this
presenta�on

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us:


Deﬁni�on
and
Terminology
Changes

Source:
Health
Data
Consul�ng
and
h�p://

ICD-9 Procedure Term ICD-10 Procedure Term
Amputation Detachment
Amniocentesis Drainage
Arthroscopy, Cystoscopy… Inspection… Endoscopic Approach
Closed Reduction Reposition
Debridement Excision, Extraction, Irrigation, Extirpation
Radical Mastectomy Resection (right, left or bilateral)
Subtotal Mastectomy Excision
Tracheostomy, Bypass
Cesarean section Extraction of Products of Conception
Incision No ICD-10 term
Source:

Health
Data
Consul�ng

Source:

Health
Data
Consul�ng

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a
complete
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“There
are
too
many
Codes”

  There
are
lots
of
words
in
the
dic�onary,
but
that
doesn’t

seem
to
trouble
authors…

  34,250
(50%)
of
all
ICD-‐10CM
codes
are
related
to
the

musculoskeletal
system

  17,045
(25%)
of
all
ICD-‐10CM
codes
are
related
to
fractures

  10,582
(62%)
of
fracture
codes
to
dis�nguish
‘right’
vs.
‘le�’

  There
are
over
1800
codes
for
fractures
of
the
radius

(forearm)
but
only
~
50
concepts
used
repeatedly
in
diﬀerent

pa�erns

  Only
a
very
small
percentage
of
the
codes
will
be
used
most

providers

Source:
Health
Data
Consul�ng
and
h�p://

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a
complete
copy
of
this
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“ICD-‐10
is
much
too
complicated”

  Physicians
have
as
much
educa�on
as
rocket

scien�sts…
this
isn’t
rocket
science.

  ICD-‐10
is
actually
more
consistent
and
pa�erns
are

reasonably
understandable

  There
are
great
evolving
tools
that
will
help
clinicians

iden�fy
the
right
codes
(assuming
they
accurately

document
the
facts)

Source:
Health
Data
Consul�ng
and
h�p://

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a
complete
copy
of
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us:


“We
should
wait
for
ICD-‐11”

  ICD-‐9
(WHO)
Published
in
1978

  ICD-‐10
(WHO)
–
Endorsed
in
1990

  ICD-‐10-‐CM
dra�
released
in
1995

  Proposed
rule
for
ICD-‐10
adop�on
in
2008

  ICD-‐10
used
for
Mortality
in
the
US
since
1999

  ICD-‐11(WHO)
not
slated
for
release
un�l
2015

  Based
on
historical
implementa�ons
by
the
�me
we
get

to
ICD-‐11-‐CM
and
from
there
to
implementa�on,
it
will

be
2039.

  The
gap
between
ICD-‐9
and
ICD-‐10
is

not
nearly
as

drama�c
as
the
gap
between
ICD-‐9
and
ICD-‐11

Source:
Health
Data
Consul�ng
and
h�p://

For
a
complete
copy
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this
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us:


“Documenta�on
for
ICD-‐10
is
an
unnecessary
burden.”

  The
number
and
type
of
new
concepts
required
for

ICD-‐10
are
not
foreign
to
clinicians

  The
focus
of
documenta�on
is
good
pa�ent
care

  Pa�ents
deserve
to
have
accurate
and
complete

documenta�on
of
their
condi�ons

  If
other
industries
understand
the
value
of
accurate

and
complete
documenta�on
of
data
about

encounters;
shouldn’t
we?

Source:
Health
Data
Consul�ng
and
h�p://

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a
complete
copy
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“We
should
just
go
to
SNOMED.”

  If
you
like
lot’s
of
codes,
you’ll
love
SNOMED
(over

300,000
codes)

  Most
stakeholders
in
the
industry
have
no
familiarity

with
SNOMED

  Most
physicians
cannot
describe
the
nature
of

SNOMED

  Coding
in
SNOMED
is
more
complex
than
ICD-‐10

  SNOMED
is
not
an
adopted
interna�onal
standard

Source:
Health
Data
Consul�ng
and
h�p://

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a
complete
copy
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“ICD-‐10
won’t
help
me
take
care
of
my
pa�ents.”

  Diﬃcult
to
make
the
case
about
how
ICD-‐10
will
help

Dr.
Smith
with
his
encounter
with
Mary
Jones

  Healthcare
crosses
the
boundary
of
�me
and

providers

  Improving
healthcare
requires
a
broad

understanding
of
what
works
and
what
doesn't
work

  Clinicians
should
be
leaders
in
the
healthcare

industry
by
providing
accurate
data,
accurate

analysis
of
the
data
and
change
in
healthcare
to

con�nuously
improve
the
value
their
pa�ents
receive

Source:
Health
Data
Consul�ng
and
h�p://

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a
complete
copy
of
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“ICD
diagnosis
codes
are
irrelevant
to
my
business.”

  ICD-‐9
codes
factor
into:

ü  Payer
processing
rules

ü  The
determina�on
of
appropriateness

ü  Measures
of
quality
(pay
for
performance)

ü  Compliance
(meaningful
use)

ü  Contrac�ng
decisions

ü  Risk
adjustments

ü  Fraud
waste
and
abuse

ü  Audits

ü  Authoriza�ons

Source:
Health
Data
Consul�ng
and
h�p://

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a
complete
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“ICD
diagnosis
codes
are
irrelevant
to
my
business.”

Source:
Health
Data
Consul�ng
and
h�p://

  ICD-‐10
codes
are
likely
to
factor
into:

ü  Changes
in
reimbursement
based
on
both
“what”
was

done
and
“why”

ü  Managing
ﬁnancial
risks
for
contracted
popula�ons

ü  Changes
in
reimbursement
based
on
more
robust

models
of
payment
adjusted
for
risk
and
severity

ü  More
sophis�cated
weigh�ng
of
payments
based
on

DRGs,
episodes
or
other
groupers
of
care.

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“It’s
unreasonable
for
administra�ve
bureaucrats
to

interfere
with
how
I
take
care
of
pa�ents.”

  The
success
or
failure
of
healthcare

goes
well
beyond
Dr.

Smith
and
his
visit
with
Mary
Jones.

  Purchasers
of
healthcare,
including
government
and

private
en��es
have
a
responsibility
to
assure
that
the

popula�on
they
are
responsible
for
gets
the
best
value

for
services
delivered.

  Providers
are
receiving
payment
for
services,
it
is

reasonable
to
believe
that
they
should
be
just
as

accountable
for
what
they
do
as
other
organiza�ons
that

provide
services
and
goods.

  Healthcare
has
clearly
moved
into
a
marketed
industry

and
“professionalism”
alone
cannot
assure
quality
and

limit
abuse.

Source:
Health
Data
Consul�ng
and
h�p://

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a
complete
copy
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us:


“There
are
a
bunch
of
dumb
codes
that
make
no
sense.”

  Clinician
organiza�ons
have
used
codes
like;
“Hit
by
a

spacecra�”
or
“Suicide
by
paintball
gun”
as
examples

of
the
“stupidity”
of
the
ICD-‐10
codes.

  Interes�ng
to
note
however
is
that
the
codes
noted

above
are
ICD-‐9
codes
and
have
been
around
for
a

long
�me.

  The
bo�om
line;
don’t
use
the
codes
that
don’t
make

sense
or
don’t
accurately
represent
your
pa�ent’s

condi�on.

They
may
mean
something
to
someone,

but
shouldn’t
bother
you.

Source:
Health
Data
Consul�ng
and
h�p://

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a
complete
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“More
�me
is
needed
to
implement.”

Source:
Health
Data
Consul�ng
and
h�p://

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a
complete
copy
of
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us:


“There
are
too
many
new
ini�a�ves
and
mandates.”

  Now
there’s
a
statement
we
can
all
relate
to…

  Without
accurate
standardized
data
about
the

pa�ents
health
condi�on:

ü  Meaningful
use
isn’t
very
meaningful

ü  Accountable
care
can’t
be
accountable

ü  It
will
be
difficult
to
reach
the
goal
of
affordable
care

ü  Health
informa�on
exchanges
may
not
be
interoperable

ü  Quality
measures
will
lack
quality
data

ü  Outcomes
can’t
be
independently
verified

ü  Pa�ent
Safety
can’t
be
assured

Source:
Health
Data
Consul�ng
and
h�p://

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a
complete
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ICD-‐10?

“Top
Ten
Reasons”

1.  The
value
of
good
data
for
be�er
care

2.  Audits
-‐
Fraud,
waste
and
abuse,
RAC,

and
other
annoyances…

3.  Impact
on
denials
and
payment
delays

4.  Impact
on
quality
measurement

5.  Improving
pa�ent
safety

6.  Improving
healthcare
for
all
pa�ents

7.  Impact
on
pa�ents
directly

8.  Be�er
popula�on
based
research

9.  The
goal
of
interoperability

10.  Changing
models
of
reimbursement

Source:
Health
Data
Consul�ng
and
h�p://

Why
should
I
care?

Source:

Health
Data
Consul�ng

For
a
complete
copy
of
this
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us:


Source:
Health
Data
Consul�ng
and
h�p://

Why
is
good
documenta�on
important?

For
a
complete
copy
of
this
presenta�on

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us:


Documenta�on

1889

Source:
Health
Data
Consul�ng
and
h�p://

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a
complete
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of
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us:


Documenta�on

Source:
Health
Data
Consul�ng
and
h�p://

1889

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a
complete
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us:


Documenta�on

Source:
Health
Data
Consul�ng
and
h�p://

2013

Progress?

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Documenta�on

  Supports
proper
payment
reduced
denials

  Assures
accurate
measures
of
quality
and
eﬃciency

  Assures
accountability
and
transparency

  Captures
the
level
of
risk
and
severity

  Provides
be�er
business
intelligence

  Supports
clinical
research

  Enhances
communica�on
with
hospital
and
other

providers

  It’s
just
good
care!

Source:
Health
Data
Consul�ng
and
h�p://

Why
is
it
important?

For
a
complete
copy
of
this
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us:


Documenta�on
Quality

  Poor
quality
documenta�on
is
bad
for
Providers,

Payers
and
Pa�ents

ü  Billing
accuracy

ü  Quality
measures

ü  Popula�on
management

ü  Risk
management

ü  Healthcare
analy�cs

ü  Pa�ent
history

Source:
Health
Data
Consul�ng
and
h�p://

Everyone
loses…

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a
complete
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Coding
–
The
Pa�ent
Interface

Source:
Health
Data
Consul�ng
and
h�p://

Where
it
all
begins

History

Physical
Exam

Internal
Record
Review

External
Record
Review

Assessment/Diagnosis

Studies

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a
complete
copy
of
this
presenta�on

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us:


Ge�ng
to
the
Code

Source:
Health
Data
Consul�ng
and
h�p://

A
Necessary
Evil?

Back-‐oﬃce
Coding

The
“Super
Bill”
Back
to
the
Doctor?

For
a
complete
copy
of
this
presenta�on

contact
us:


The
Super
Bill

Source:
Health
Data
Consul�ng
and
h�p://

Not
That
Super
Really…

[Note]
For
all
codes
related
to
fractures
of
the
radius:

• ICD-‐9
codes
=
33

• ICD-‐10
codes
=
1818

For
a
complete
copy
of
this
presenta�on

contact
us:


Medical
Concepts

Source:
Health
Data
Consul�ng
and
h�p://

Medical
Scenario:

A
[27
year
old]
[male]
pa�ent
is
seen
in
[follow-‐up]
for
a
[Smith’s

fracture]
on
the
[right]
that
was
exposed
through
an
[open

wound]
with
[minimal
opening
and
minimal
�ssue
damage].

The

fracture
has
[not
healed
a�er
6
months].

Though
not
explicitly
stated
in
this
scenario
certain
expressions

imply
other
concepts:

“Smith’s
fracture”
>>
[fracture],
[radius],
[distal],
[dorsal
angula�on],
[extra-‐
ar�cular],
[displaced]

“minimal
opening
and
minimal
�ssue
damage”
>>
[Gus�lo
classiﬁca�on
I]

“not
healed
a�er
6
months”
>>
[nonunion]

Expressing
the
pa�ent
condi�on
in
codes.

For
a
complete
copy
of
this
presenta�on

contact
us:


Source:
Health
Data
Consul�ng
and
h�p://

For
a
complete
copy
of
this
presenta�on

contact
us:


New
Concepts

Source:
Health
Data
Consul�ng
and
h�p://

Parameters
of
Severity
and
risk

  Co-‐morbidi�es

  Manifesta�ons

  E�ology/causa�on

  Complica�ons

  Detailed
anatomical
loca�on

  Sequelae

  Degree
of
func�onal
impairment

  Biologic
and
chemical
agents

  Phase/stage

  Lymph
node
involvement

  Lateraliza�on
and
localiza�on

  Procedure
or
implant
related

For
a
complete
copy
of
this
presenta�on

contact
us:


New
Concepts

Source:
Health
Data
Consul�ng
and
h�p://

  Open
Fracture
Classifica�on

ü  Gus�llo
Classifica�on

I,II,IIIa,IIIb,IIIc

  Growth
Plate
Injury
Classifica�ons

ü  Sal�er
Harris
I
–IV

  Fracture
Displacement

ü  Displaced,
non-‐displaced

  Joint
Involvement

ü  Intraar�cular,
extrar�cular

  Healing
Level

ü  Rou�ne
healing,
delayed
healing,
nonunion,
malunion

  Fracture
type

ü  Segmental,
oblique,
pathologic,
stress,
stability,
avulsion,
torus

Severity
(Fracture
Example)

For
a
complete
copy
of
this
presenta�on

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us:


Documenta�on
Requirements

Source:
Health
Data
Consul�ng
and
h�p://

Recurring
Concepts

Concept
Number
of
Codes

Right
12,704

Le�
12,393

Unilateral
127

Bilateral
821

Laterality

Concept
Number
of
Codes

Rou�ne
Healing
2,913

Delayed
Healing
2,913

Nonunion
2,895

Malunion
2,595

Healing

Concept
Number
of
Codes

Ini�al
Encounter
13,932

Subsequent
Encounter
21,389

Sequela
11,974

Encounter

For
a
complete
copy
of
this
presenta�on

contact
us:


Documenta�on
Requirements

Source:
Health
Data
Consul�ng
and
h�p://

Recurring
Concepts

Concept
Number
of
Codes

Transverse
690

Oblique
522

Spiral
522

Torus
198

Greens�ck
54

Displaced
5,298

Nondisplaced
5,253

Comminuted
660

Simple
42

2-‐part
42

3-‐part
or
4-‐part
21

Segmental
522

Open

Fracture
Pa�erns

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a
complete
copy
of
this
presenta�on

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us:


Coding
ICD-‐10
CM

Source:
Health
Data
Consul�ng
and
h�p://

Diabetes
Concepts

Diabetes
=
276
ICD-‐10
Codes
/
83
ICD-‐9
Codes

Unique
concepts
within
in
ICD-‐10
codes
=
62

Diabetes
Type
Pregnancy
Neurologic
complica�ons

Type
1
diabetes
First
trimester
Neurological
complica�on

Type
2
diabetes
Second
trimester
Neuropathy

Underlying
condi�on
Third
trimester
Mononeuropathy

Drug
or
chemical
induced
Childbirth
Polyneuropathy

Pre-‐exis�ng
Puerperium
Autonomic
(poly)neuropathy

Gesta�onal
Antepartum
Amyotrophy

Poisoning
by
insulin
and
oral
hypoglycemic
Postpartum
Coma

Adverse
eﬀect
of
insulin
and
oral
hypoglycemic

Underdosing
of
insulin
and
oral
hypoglycemic

Neonatal

Secondary

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a
complete
copy
of
this
presenta�on

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us:


Coding
ICD-‐10
CM

Source:
Health
Data
Consul�ng
and
h�p://

Diabetes
Concepts

Lab
Findings
Renal
complica�ons
Ophthalmologic
Complica�ons

Ketoacidosis
Nephropathy
Re�nopathy

Hyperosmolarity
Chronic
kidney
disease
Macular
edema

Hypoglycemia
Kidney
complica�on
Cataract

Hyperglycemia
Ophthalmic
complica�on

Mild
nonprolifera�ve
re�nopathy

Moderate
nonprolifera�ve
re�nopathy

Severe
nonprolifera�ve
re�nopathy

Prolifera�ve
re�nopathy

Background

re�nopathy

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a
complete
copy
of
this
presenta�on

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us:


Coding
ICD-‐10
CM

Source:
Health
Data
Consul�ng
and
h�p://

Diabetes
Concepts

Vascular
Complica�ons
Skin
Complica�ons
Joint
Complica�ons

Circulatory
complica�ons
Derma��s
Neuropathic
arthropathy

Peripheral
angiopathy
Foot
Ulcer
Arthropathy

Gangrene
Skin
complica�ons

Skin
ulcer

For
a
complete
copy
of
this
presenta�on

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us:


Coding
ICD-‐10
CM

Source:
Health
Data
Consul�ng
and
h�p://

Diabetes
Concepts

Oral
Complica�ons
Diabe�c
Control
Encounter
Other
Concepts

Oral
complica�ons
Diet-‐controlled
Ini�al
encounter
Complica�ons

Periodontal
disease
Insulin
controlled
Subsequent
encounter
Right

Uncontrolled
Sequela
Le�

Controlled
Accidental

Inten�onal
self-‐harm

Assault

Family
history

Personal
history

Screening

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a
complete
copy
of
this
presenta�on

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us:


Good
pa�ent
data

1.  Complete
observa�on
of
all
objec�ve
and

subjec�ve
facts
relevant
to
the
pa�ent

condi�on

2. Documenta�on
of
all
of
the
key
medical

concepts
relevant
to
pa�ent
care
currently

and
in
the
future

3. Coding
that
includes
all
of
the
key
medical

concepts
supported
by
the
coding
standard

and
guidelines

Source:
Health
Data
Consul�ng
and
h�p://

It’s
all
about
good
pa�ent
care…

For
a
complete
copy
of
this
presenta�on

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us:


Ge�ng
Speciﬁc

When
is
unspeciﬁed
OK?

Source:
Health
Data
Consul�ng
and
h�p://

For
a
complete
copy
of
this
presenta�on

contact
us:


Coding
specificity

  What
makes
a
code
unspecified?

  Is
“not
elsewhere
classified”
unspecified?

  Does
the
use
of
codes
with
3-‐4
characters
mean
that

they
are
less
specified
than
codes
with
7
characters?

  Does
the
use
of
the
term
“unspecified”
mean
that

the
code
is
not
specific
to
the
nature
of
the
condi�on

as
observed?

Source:
Health
Data
Consul�ng
and
h�p://

What’s
an
unspecified
code?

For
a
complete
copy
of
this
presenta�on

contact
us:


Coding
specificity

  Does
specificity
require
more
than
one
code?

  When
is
unspecified
the
right
choice?

  When
should
unspecified
change
to
specified?

Source:
Health
Data
Consul�ng
and
h�p://

What’s
an
unspecified
code?

For
a
complete
copy
of
this
presenta�on

contact
us:


Poorly
Specified
Coding

“Coding
that
does
not
fully
define
important

parameters
of
the
pa�ent
condi�on
that
could

otherwise
be
defined
given
informa�on
available
to
the

observer
(clinician)
and
the
coder.”

Source:
Health
Data
Consul�ng
and
h�p://

A
proposed
defini�on

For
a
complete
copy
of
this
presenta�on

contact
us:


Coding
specificity

  NOS
(Not

Otherwise
Specified)
means
that
the
code

selected
does
not
specify
some
level
of
detail
that

may
be
available
for
similar
condi�ons.

ü  In
ICD-‐10
NOS
is
referred
to
as
“Unspecified”

  NEC
(Not

Elsewhere
Classified)
means
that
the
code

selected
does
is
not
defined
in
any
ICD
classifica�on.

ü  In
ICD-‐10
NEC
is
referred
to
as
“Other”
or
“Other

Specified”

  While
in
theory
there
is
a
difference
between
the

two,
from
data
perspec�ve
either
code
is
not

specific.

Source:
Health
Data
Consul�ng
and
h�p://

NEC
or
NOS?

For
a
complete
copy
of
this
presenta�on
contact

us:


Coding
specificity

  3
characters
,but
specific:

Source:
Health
Data
Consul�ng
and
h�p://

More
characters
–
be�er?

J60
-‐
Coalworker's
pneumoconiosis

  7
characters
,but
less
specific:

S069X9A
-‐
Unspecified
intracranial
injury
with
loss
of

consciousness
of
unspecified
dura�on,
ini�al
encounter

For
a
complete
copy
of
this
presenta�on

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us:


Coding
specificity

  The
use
of
the
term
“unspecified”
may
simply
refer

to
one
concept
of
several
concepts
about
a

condi�on.
For
example:

Source:
Health
Data
Consul�ng
and
h�p://

Does
the
term
“unspecified”
mean
less
specific.

S82202J
–
Unspecified
[fracture]
of
[sha�]
of
[le�
�bia
],

[subsequent
encounter
]
for
[open
fracture
]
[type
IIIA,

IIIB,
or
IIIC
]
with
[delayed
healing
]

  In
this
case,
mul�ple
details
in
[red]
about
this
fracture

are
specified
and
the
only
thing
not
specified
is
the
type

of
fracture
(displaced,
non-‐displaced,
spiral,
oblique
…)

For
a
complete
copy
of
this
presenta�on

contact
us:


Coding
specificity

  The
fact
that
the
descrip�on
does
not
use
the
term

unspecified,
does
not
mean
the
code
is
specific.

Source:
Health
Data
Consul�ng
and
h�p://

No
term
“Unspecified”?

C7641
-‐
Malignant
neoplasm
of
right
upper
limb

M4837-‐
Trauma�c
spondylopathy,
lumbar
region

R6889
-‐
Other
general
symptoms
and
signs

R45.2
-‐
Unhappines

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a
complete
copy
of
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presenta�on

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us:


Coding
speciﬁcity

  Beyond
the
primary
code,
accurate
representa�on
of
the

pa�ent’s
health
condi�on
may
require
other
codes
to

represent:

ü  Causa�on

ü  Infec�ous,
chemical,
physical
or
other
agents

ü  Loca�on
of
Injury

ü  External
causes
of
injury

ü  Manifesta�ons

ü  Comorbid
condi�on
or
contribu�ng
factors

ü  Sequela

ü  Findings

ü  Mul�ple
other
factors
associated
with
the
primary
condi�on

being
treated
or
evaluated

Source:
Health
Data
Consul�ng
and
h�p://

More
than
one
code.

For
a
complete
copy
of
this
presenta�on
contact

us:


Coding
specificity

  Some�mes
unspecified
makes
sense…

ü  The
pa�ent
may
be
early
in
the
course
of
evalua�on

ü  The
claim
may
be
coming
from
a
provider
who
is
not

directly
related
to
diagnosis
of
the
pa�ents
condi�on

ü  The
clinician
seeing
the
pa�ent
may
be
more
of
a

generalist
and
not
able
to
define
the
condi�on
at
a
level

of
detail
expected
by
a
specialist

Source:
Health
Data
Consul�ng
and
h�p://

A
place
for
“unspecified”
codes

For
a
complete
copy
of
this
presenta�on

contact
us:


Coding
specificity

  If
there
is
sufficient
informa�on
available
to
more
accurately

define
the
condi�on

  For
basic
concepts
such
as:

ü  Laterality
(Right,
Le�,
Bilateral,
Unilateral)

ü  Anatomical
loca�ons

ü  Trimester

ü  Type
of
diabetes

ü  Known
complica�ons
or
comorbidi�es

ü  Descrip�on
of
severity,
acute
or
chronic
or
other
known

parameters…

  Where
care
is
implemented
that
demands
a
more
specific

level
of
detail

  At
specialty
level
that
should
be
able
to
define
the
detail

required

Source:
Health
Data
Consul�ng
and
h�p://

No
place
for
“unspecified”
codes

For
a
complete
copy
of
this
presenta�on

contact
us:


Source:
Health
Data
Consul�ng
and
h�p://

Analy�cs

Issues
with
transi�on

Ge�ng
the
most
of
ICD-‐10

For
a
complete
copy
of
this
presenta�on

contact
us:


Source:
Health
Data
Consul�ng
and
h�p://

Repor�ng
and
Analy�cs

Historical
Data
During
the
Transi�on

ICD-‐9
ICD-‐10

ICD-‐9
ICD-‐10

ICD-‐9
ICD-‐10

Early 2015
Late 2015
Early 2014
For
a
complete
copy
of
this
presenta�on

contact
us:


Source:
Health
Data
Consul�ng
and
h�p://

Coding
Quality

Accurate
and
Consistent

Assuring
accuracy
and
consistency

in
repor�ng
and

decision
making.

Consistent
Accurate
Accurate
&
Consistent

For
a
complete
copy
of
this
presenta�on
contact

us:


Source:
Health
Data
Consul�ng
and
h�p://

Quality
Measures

Challenges
to
measuring
performance

For
a
complete
copy
of
this
presenta�on

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us:


Quality
Measures
Impacts

Source:
Health
Data
Consul�ng
and
h�p://

AMI
example

  Defini�on
of
acute
myocardial
infarc�on
(MI)
has

changed

ü  ICD-‐9
–
Eight
weeks
from
ini�al
onset

ü  ICD-‐10
–
Four
weeks
from
ini�al
onset

  Subsequent
vs.
Ini�al
episode
of
care

ü  ICD-‐9
–
Fi�h
character
defines
ini�al
vs.
subsequent
episode
of

care

ü  ICD-‐10
–
No
ability
to
dis�nguish
ini�al
vs.
subsequent
episode

of
care

  Subsequent
(MI)

ü  ICD-‐9
–
No
ability
to
relate
a
subsequent
MI
to
an
ini�al
MI

ü  ICD-‐10
–
Separate
category
to
define
a
subsequent
MI
occurring

within
4
weeks
of
an
ini�al
MI

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a
complete
copy
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this
presenta�on

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us:


Fraud
Waste
and
Abuse

If
you
can’t
stop
expenditures
upfront
…

Source:

$60,000,000,000/Year

Fraud,
Waste
and
Abuse

Enough
money
to
take
care
of
a

lot
of
need.

Source:
Health
Data
Consul�ng
and
h�p://

For
a
complete
copy
of
this
presenta�on

contact
us:


Fraud,
Waste
and
Abuse

Source:
Health
Data
Consul�ng
and
h�p://

Medicare
Deﬁni�on

Source:

CMS

For
a
complete
copy
of
this
presenta�on

contact
us:


Fraud,
Waste
and
Abuse

With
increasing
challenges
to
control
cost,
the
intensity

of
audits
related
to
fraud,
waste
and
abuse
is

increasing.

In

the
“Jus�fica�on
of
Es�mates
for

Appropria�ons
Commi�ees”
CMS
states:

“Although
the
ICD-‐10
code
set
will
not
eliminate
all

fraud,
waste,
and
abuse,
CMS
believes
that
its

increased
specificity
will
make
it
much
more
difficult

for
fraud,
waste
and
abuse
to
occur.”

Source:
Health
Data
Consul�ng
and
h�p://

Don’t
get
caught
in
the
trap…

Source:

CMS

For
a
complete
copy
of
this
presenta�on

contact
us:


Source:
Health
Data
Consul�ng
and
h�p://

4
Billion

Recovered

in
2010

Fraud,
Waste
and
Abuse

Don’t
get
caught
in
the
trap…

Source:

CMS

For
a
complete
copy
of
this
presenta�on
contact

us:


Healthcare
on
the
“RAC”

Source:
Health
Data
Consul�ng
and
h�p://

Ge�ng
�ghter…

FY
-‐2010
FY
-‐2011
FY
-‐2012
Fy-‐2013
(Q1)

(Q1)X4

Series1
$75

$797

$2,291

$745

$2,979

$-‐

$500

$1,000

$1,500

$2,000

$2,500

$3,000

$3,500

Correc�ons
in
Millions
Collected
Overpayments

Source:

CMS

For
a
complete
copy
of
this
presenta�on

contact
us:


Advantage
of
Moving
to
ICD-‐10

  More
consistent
with
the
rest
of
the
world

  ICD-‐9
is
30
years
old

  We
are
already
using
ICD-‐10
for
mortality
repor�ng

  Considerably
more
informa�on
per
code

  More
clinically
relevant

  Greater
expandability
in
and
ﬂexibility
of
coding

structure

Source:
Health
Data
Consul�ng
and
h�p://

For
a
complete
copy
of
this
presenta�on

contact
us:


Advantage
of
Moving
to
ICD-‐10

  Be�er
clarity
in
coding
guidelines

  More
logical
tabular
structure

  Be�er
defini�on
of
co-‐morbidi�es,
complica�ons

and
disease
manifesta�ons

  Improved
support
for
analysis
related
to:

ü  Predic�ve
modeling

ü  Quality
and
cost
efficiency
analysis

ü  Popula�on
based
research

ü  Stra�fica�on
of
illness

ü  Public
health
trending

Source:
Health
Data
Consul�ng
and
h�p://

For
a
complete
copy
of
this
presenta�on

contact
us:


Summary

  ICD-‐10
will
be
a
substan�al
change
in
the
standard
for

deﬁning
the
pa�ent’s
health
state
and
the
ins�tu�onal

procedures
performed
to
maintain
or
improve
that
health

state.

  There
are
signiﬁcant
impacts
to
both
the
clinical
and
business

side
of
the
prac�ce.

  There
are
poten�al
impacts
to
Quality
and
Cost
metrics.

  Documenta�on
is
a
cri�cal
requirement
for
proper
coding
and

billing

  There
is
value
in
be�er
informa�on
based
on
be�er
coding

based
on
be�er
documenta�on

Source:
Health
Data
Consul�ng
and
h�p://

Key
Points

For
a
complete
copy
of
this
presenta�on

contact
us:


Summary

  Focus
clinicians
on
the
need
for
good
documenta�on

  Champion
the
value
of
ICD-‐10
in
a
new
environment
and

demonstrate
the
pi�alls
of
inadequate
documenta�on

and
coding

  Provide
tools
and
templates
to
assist
in
documenta�on

and
coding

  Collaborate
with
coding
professionals

  Take
a
leadership
role
in
the
success
of
the
organiza�on

through
this
transi�on

  Iden�fy
opportuni�es
to
collect
and
use
be�er
data

  Get
started
now!!

Source:
Health
Data
Consul�ng
and
h�p://

Ac�on
Items

For
a
complete
copy
of
this
presenta�on

contact
us:


ICD-10 for physicians: its about good patient care and clinical documentation

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