ICD-10 Preparation: Understanding your own data to create your ICD10

Strategy for SuccessData Analytics and Audit

Barbara Godbey-Miller, RHIA, CCS, CHC

Today’s Agenda• Step 1: Data Analytics:

– Aggregate information analysis

• Step 2: Audit Findings– Real results from clients

• Step 3: Education– What your team needs to know

But First A Word About Data Governance and Clinical Documentation Integrity

Data Variables

PhysicianClinical Documentation

Understanding the clinical documentation specificity of I-9, a system used for 30 years, required a CDI program to manage. What will the CDI error rate be?

CodingAccuracy

ICD-10 coder errors will increase with use of new system and increased requirement to interpret physician documentation requirements. What will the coding error rate be of coders and contract personnel?

Coding Quality Review

With increase demand for coding resources and cash flow demands, will organizations have an internal coding quality review process to identify increased coding errors?

Data Normalization

Not all DRGs are created equal or have the same probability for DRG assignments errors. Data normalization without manipulation. What is your DRG risk population for change and what is the revenue impact?

Regulatory Change

CMS givith and take it away. Regulatory factors should be included to determine revenue impact.•Documentation & Coding Adjustment Factor•Prospective Payment System Changes•ICD-10 Oncology Grouper Changes

Clinical DocumentationProgram

Managing the I-10 CDI process will require additional staff to cover increased workload. Will staffing be adequate to cover 100% of cases & what percentage of queries will go unasked or unanswered?

Clinical Documentation Integrity

The HIM professional’s role is to combine emerging technologies with innovative processes to meet the aims of this strategy ─ improve the quality of healthcare, improve the health of the US population, and reduce the cost of quality healthcare.

What is Data Governance?

Making strategic and effective decisions regarding the organization’s information assets.

Includes:– Defining roles and responsibilities for data– Establishing data quality policies– Creating metadata management practices– Arbitrating shared data questions– Release of Information

The HIM Professional’s Key to Successful Information Governance

• Data or Information governance is the high-level, corporate, or enterprise policies or strategies that define the purpose for collecting data, ownership of data, and intended use of data. Accountability and responsibility flow from governance.

• The Information Governance plan is the framework for the overall organizational approach to data governance.

Clinical Documentation Integrity

The HIM professional’s role is to combine emerging technologies with innovative processes to meet the aims of this strategy ─ improve the quality of healthcare, improve the health of the US population, and reduce the cost of quality healthcare.

ICD-10 Analytics ApproachKey activities and timing

Define assessment

scope

ICD-10 revenue impact analysis

Documentation audit

Focus on high-risk MS-DRGs

Recommended remediation or

mitigation of risk

Put plan into action

Init

iate

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Re

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Identify stakeholders

Educational mapping

ICD-10 Data Analytics

ICD-10 analytics are derived or analyzed using the GEMS file, which without audit is not a reliable tool to identify DRG shifts

ICD-10 analytics are derived or analyzed using the GEMS file, which without audit is not a reliable tool to identify DRG shifts

ICD-10 data analytics will return higher probability rates if they are fact based using a set of variables that will influence the outcomes analysis for DRG assignment predictability

ICD-10 data analytics will return higher probability rates if they are fact based using a set of variables that will influence the outcomes analysis for DRG assignment predictability

Data Analytics – How its Done

• 12 months of claims are processed through an analytics program for ICD-10 CM/PCS using GEMS and reimbursement maps

• Data Analysts review each mapping to identify legitimate risks– Two scenarios – financial risk, operational risk

• ICD-10 Auditors validate documentation on highest risk areas– Output – Physician and Coder education strategy

Data Analytic Analysis 2 Sites - Post Audit Results

Total Cases I-9 CMI I-10 CMI

98 1.84 1.56

CMI Increases I-9 CMI I-10 CMI

40 1.31 1.99

CMI Decreases I-9 CMI I-10 CMI

58 2.21 1.27

Post Audit FindingsReason for DRG Change Cases

PDX Change 19

Add CC 6

Add MCC 3

Minus CC 15

Minus MCC 5

Root PX 56

DRG Logic 5

Scenarios

Specific examples of MS-DRG changes discovered on I-10 re-code projects

MS-DRG SHIFT

Cardiology: Patient was readmitted for treatment of post infarction angina & CAD, 1 week status post acute myocardial infarction

ICD-10 Re-Code: What We Discovered

• MS-DRG changed due to timeframe established within ICD-10 to indicate an acute myocardial infarction – Even as a secondary diagnosis, the AMI will “drive” this MS-

DRG based on grouper logic with PDX from Circulatory MDC 5 and AMI

• Category I21 (AMI) is coded up to 4 weeks following the AMI regardless of reason for admission

• The terminology used in ICD-9 to capture “subsequent episode of care” for AMI does not exist in ICD-10– Subsequent AMI codes are used when a patient has a second

AMI within 4 weeks of the initial AMI– NOTE: “Subsequent” refers to the MI and NOT the episode of

care in ICD-10

Acute Myocardial InfarctionAcute Myocardial Infarction• ICD-10-CM has decreased the acute phase of an acute myocardial

infarction from 8 weeks or less to 4 weeks (28 days) or less.

• ICD-10-CM classifies acute myocardial infarction in two separate categories. STEMI and NSTEMI

• Clinical documentation will need to indicate laterality. Additional specificity is required to identify the anatomical site affected

I21.02 ST elevation (STEMI) myocardial infarction involving left main coronary artery

Laterality

Subsequent Myocardial InfarctionSubsequent Myocardial Infarction• ICD-10-CM has added a category for subsequent myocardial infarction.• Subsequent is identified as a myocardial infarction occurring within 4

weeks (28 days) of a previous myocardial infarction.• Clinical documentation must include the type of subsequent myocardial

infarctionExample:A patient is admitted with a subsequent STEMI of the anterior wall 7 days after being discharged for a STEMI of left main artery, anterior wall

I22.0 subsequent STEMI myocardial infarction of anterior wall

I21.01 STEMI myocardial infarction involving left main coronary artery of anterior wall

Code indicates this is the subsequent MI

Code indicates this was the first MI

Potential Readmission Flag

ICD-9 Acute Myocardial Infarction – 8 weeks

ICD-10 Acute Myocardial Infarction – 4 weeks

Readmission Risk if patient winds up back in the hospital in 30 days. Zero additional payment – potential gain may be lost in this instance

MS-DRG SHIFTCardiology: Patient was admitted with AMI and had coronary intervention with four drug-eluting stents.

ICD-10 Re-Code: What We Discovered

• MS-DRG changed due to the fact that even though patient had four drug-eluting stents inserted there were only three sites being treated

• In ICD-10- PCS, the code is assigned based on number of sites being treated rather than number of stents inserted

• Occasionally, this will result in lower-weighted DRG assignment in ICD-10

Documenting Procedures

• Clinical documentation for all procedures will require documentation identifying the following:

General physiological system or anatomical region involved

What type of procedure was performed root operation administration, dilation, drainage, biopsy, excision, resection, bypass, transplantation

The exact anatomical site of the procedure body part Right, left, bilateral

The technique used to reach the site surgical appro ach open, closed, laparoscopic, percutaneous, endoscopic, needle

If a dev ice was used, what site/area was the device placed (e.g. stent, graft, implant)

If the procedure was for diagnostic purposes

Body system

Root Operation

Body part

Laterality

Surgical approach

Device

Qualifier

Documenting ProceduresDocumenting Procedures• When a PTCA is performed, clinical documentation by the physician

must indicate how many sites were dilated and what device was utilized for “each” site.

Example:OR report indicates that patient had PTCA of both the left anterior descending artery and the right coronary artery. A drug-eluting stent was placed in the right coronary artery.

02703ZZ Dilation, Artery, Coronary, One Site

027034Z Dilation, Artery, Coronary, One Site

No stent inserted

Stent inserted

Two codes required to

identify procedure on each artery

MS-DRG SHIFT

Medicine: Patient was admitted for treatment of anemia secondary to ESRD. Patient also has hypertension.

ICD-10 Re-Code: What We Discovered

• MS-DRG changed due to change in principal diagnosis per sequencing instructions in ICD-10-CM Official Coding Guidelines

• Anemia in chronic kidney disease is a classified as a manifestation of chronic kidney disease– Manifestation codes cannot be assigned as

principal diagnosis• Notes instruct to code first the underlying

disease of ESRD• Under ESRD, there is another instructional to

code first any hypertensive chronic kidney disease

Chronic Kidney Disease

ICD-10-CM uses the following table to identify the stage of kidney disease

Hypertensive DiseasesHypertensive Diseases

• Clinical documentation for hypertension in ICD-10-CM should be described as accelerated, benign, essential, idiopathic, malignant, and systemic

I10Essential (primary) hypertension

Documentation by physician indicates Essential

Hypertensive DiseasesHypertensive Diseases• ICD-10-CM presumes a cause-and-effect relationship between

hypertension and chronic kidney disease. Clinical documentation will need to include the stage of chronic kidney disease.

I12 Hypertensive Kidney DiseaseN18.5 Chronic Kidney Disease, Stage 5

Clinical documentation indicates hypertension and chronic kidney disease

Clinical documentation requires the correct staging of the chronic kidney diseases

Hypertensive DiseasesHypertensive DiseasesExample:

A 68-year-old gentleman is admitted with hypertension, heart disease, acute on chronic CHF, and stage 4 renal disease. The physician documents that the heart disease is associated with the hypertension.

I13.10 Hypertensive heart and chronic kidney disease with heart failure,with stage I-IV CKD

N18.4 Chronic Kidney Disease, Stage 4, severeI50.33 Acute on chronic diastolic heart failure

Code shows hypertension, heart disease, CHF, and stage 4 renal disease all combined in one code

Additional codes show stage of CKD and specificity of heart failure

Chronic Kidney Disease with Hypertension

• ICD-10-CM presumes a relationship between chronic kidney disease and hypertension.

• Clinical documentation for hypertensive kidney disease will also require identification of the stage of kidney failure

I12 Hypertensive Kidney DiseaseN18.5 Chronic Kidney Disease, Stage 5

Disease

Stage of CKD

Hypertensive Heart and CKD Case Study

A 68-year-old gentleman is admitted with hypertension, heart disease, acute on chronic CHF, and stage 4 renal disease. The physician documents that the heart disease is associated with the hypertension.

I13.10 Hypertensive heart and chronic kidney disease with heart failure,with stage I-IV CKD

N18.4 Chronic Kidney Disease, Stage 4, severe

I50.33 Acute on chronic diastolic heart failure

Disease

Stage of CKD

Type of Heart Failure

MS-DRG SHIFT

Medicine: Patient was admitted for treatment of anemia secondary to lung cancer

ICD-10 Re-Code: What We Discovered

• MS-DRG changed due to change in principal diagnosis per sequencing instructions in ICD-10-CM Official Coding Guidelines

• When the admission is for management of an anemia associated with malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis followed by code D63.0, Anemia in neoplastic disease

Anemia in Chronic Diseases• ICD-10-CM classifies anemia in chronic diseases into

several categories. Clinical documentation will be required to identify the type of chronic anemia as well as the associated causeAnemia in neoplastic disease

Documentation will need be required to identify associated neoplasm

Anemia in chronic kidney diseaseDocumentation will be required to identify the stage of chronic

kidney disease

Anemia in other chronic disease

Acquired Aplastic Anemia• Clinical documentation for acquired

aplastic anemia should indicate the cause as follows:High-dose radiation or chemotherapyEnvironmental toxinsMedicationsViral infectionsAutoimmune diseaseParoxysmal nocturnal hemoglobinuria

MS-DRG SHIFTSurgery: Patient was admitted with rectal bleeding and peritoneal abscess. Treatment included partial resection of ileum and lysis of peritoneal adhesions.

ICD-10 Re-Code: What We Discovered

• MS-DRG changed due to the fact that a partial small bowel resection (ileum in this case) no longer groups to major small and large bowel procedures DRG in ICD-10

• Surgical hierarchy dictates the principal procedure selection– In this case, the lysis of adhesions overrides

any other procedure performed based on surgical hierarchy

MS-DRG SHIFTPulmonary: Patient was admitted with exacerbation of COPD. Patient also had accelerated hypertension which was treated.

ICD-10 Re-Code: What We Discovered

• MS-DRG changed due to the fact that a specific code for accelerated or malignant hypertension does not exist in ICD-10 thereby, eliminating the ability to capture CC

• There is only one code for hypertension in ICD-10 which encompasses all types and is NOT classified as a CC

Diseases of the Gastroenterology System

• Clinical terminology used to describe diseases of the digestive system and has been updated to reflect advances in diagnosis and procedures as well as greater specificity

Example:

ICD-9-CM

555.1 Regional enteritis large intestine

ICD10-CM

K50.10 Crohn’s disease of large intestine without complicationsK50.111 Crohn’s disease of large intestine with rectal bleedingK50.112 Crohn’s disease of large intestine with intestinal obstructionK50.113 Crohn’s disease of large intestine with fistulaK50.114 Crohn’s disease of large intestine with abscessK50.118 Crohn’s disease of large intestine with other complicationK50.119 Crohn’s disease of large intestine with unspecified complications

Diseases of the Digestive System• Terminology for many of the categories in gastroenterology have

been updated to reflect current terminology. • The gastroenterology category contains specific respiratory

diagnosis codes for infections, inflammations, causative organisms, and external agents

• The physician will be required to document details such as

Specific forms of the disease Site of the disease/disorder Laterality Causative organism External agents Associated conditions Acuity

Additional Documentation for Gastroenterology

• ICD-10-CM requires additional documentation to identify external factors attributing to diagnoses within this category. Clinical documentation will be required to show associated causes such as:

Alcohol abuse and dependence Exposure to environmental tobacco smoke Exposure to tobacco smoke in the perinatal period History of tobacco use Occupational exposure to environmental tobacco smoke Tobacco dependence Tobacco use

Regional Enteritis (Crohn’s Disease)

• ICD-10-CM categorizes regional enteritis (Crohn’s Disease) by site: Small intestine Large intestine Both small and large intestine

• Clinical documentation will also be required to identify any associated complications such as: Abscess Fistula Intestinal obstruction Rectal bleeding Other specified complication

K50.114 Crohn’s disease of large intestine with abscess

LocationDisease Complication

Ulcerative Colitis• Clinical documentation for ulcerative colitis in ICD-10-CM will require identification of the

site of ulcerative colitis or other condition within this category, such as:

Inflammatory polyps Left sided colitis Panocolitis (enterocolitis, ileocolitis, universal colitis) Proctitis Rectosigmoiditis (proctosigmoiditis) Other specified site

• Additional documentation will be required to identify any associated complication, such as:

Abscess Fistula Intestinal obstruction Rectal bleeding Other specified complication

Diverticulosis/Diverticulitis• Clinical documentation will be required to identify

between diverticulosis and diverticulitis• Specificity will be required to identify the location of

the disease as: Small intestine Large intestine Both small and large intestine

• Additional documentation will be required to identify any associated conditions such as: Perforation Abscess Bleeding

K57.32 Diverticulitis, large intestine, without perforation or abscess, without bleeding

Disease Location No associated conditions

Diagnosis Quick Tip

Barrett’s Esophagus With dysplasia-Low grade-High gradeWithout dysplasia

Gastritis Acute, alcoholic, chronic superficial, chronic atrophic, associated hemorrhage

Gastroenteritis Salmonella, viral, infectious, toxic, allergic, causative agents, causative organism

Alcoholic liver disease Alcoholic fatty liver, alcoholic hepatitis, alcoholic fibrosis and sclerosis of liver, alcoholic cirrhosis liver, alcoholic hepatic failure, associated ascites, associated coma

Acute Pancreatitis Alcohol-induced, biliary (gallstone), drug induced, idiopathic

Documenting Procedures

• Clinical documentation for all procedures will require documentation identifying the following:

General physiological system or anatomical region involved

What type of procedure was performed root operation administration, dilation, drainage, biopsy, excision, resection, bypass, transplantation

The exact anatomical site of the procedure body part Right, left, bilateral

The technique used to reach the site surgical a open, closed, laparoscopic, percutaneous, endoscopic, needle

If a d evicwas used, what site/area was the device placed (e.g. stent, graft, implant)

If the procedure was for diagnostic purposes

Body system

Root Operation

Body part

Laterality

Surgical approach

Device

Qualifier

Partial Large Bowel Resection

Operating Room Report indicates open right hemicolectomy with end-to-end anastomosis for treatment of large carcinoid tumor

ODT F 0 Z Z

Resection

Large Intestine, Right

Open Approach

No Device

No Device

Chronic Obstructive Pulmonary Disease• The following conditions are classified in this

category: Asthma with chronic obstructive pulmonary disease Chronic asthmatic (obstructive) bronchitis Chronic bronchitis with airways obstruction Chronic bronchitis with emphysema Chronic emphysematous bronchitis Chronic obstructive asthma Chronic obstructive tracheobronchitis

• Clinical documentation of chronic obstructive pulmonary disease should identify any associated acute exacerbation or lower respiratory infection

J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection

J20.2 Acute bronchitis due to streptococcus

Disease

Associated Condition/Organism

Emphysema• Clinical documentation for emphysema should include a full

description of the disease and document the specific types as:

Unilateral emphysema (MacLeod’s syndrome) Centrilobular emphysema Panlobular emphysema Other emphysema Unspecified emphysema

• Clinical documentation should also include any associated exposures such as:

Exposure to environmental tobacco smoke History of tobacco use Occupational exposure to environmental tobacco smoke Tobacco dependence Tobacco use

Asthma• Clinical documentation should identify additional

diagnoses that could affect the current treatment of asthma, such as:

Exposure to environmental tobacco smoke Exposure to tobacco smoke in the prenatal period History of tobacco use Occupational exposure to environmental tobacco smoke Tobacco dependence Tobacco use Allergen induced Exercise induced Stress induced Associated respiratory infections

• Additional documentation should identify the long term use of steroids associated with asthma:

Long term (current) use of inhaled steroids Long term (current) use of systemic steroids

Asthma• Clinical documentation will require specificity to

show whether the reported asthma is “uncomplicated”, “with acute exacerbation”, or “with status asthmaticus”

• Clinical documentation of asthma should always include the following: Acute exacerbation of asthma With status asthmaticus Type of asthma

Mild Intermittent Persistent

Moderate persistent Severe persistent Other specified type Unspecified type

Intrinsic (nonallergic) Extrinsic (allergic) Associated external agents

Asthma

• Clinical documentation should identify the severity of asthma

Asthma Case Study

40-year-old female presents with a diagnosis of acute asthma. She has a long history of moderate persistent asthma. She takes inhaled steroids daily. Final discharge diagnosis is documented as moderate persistent asthma with acute exacerbation.

J45.41 Moderate persistent asthma with (acute) exacerbation

Z79.51 Long term (current) use of inhaled steroids

Severity

Use of Steroids

Acuity

Diagnosis Quick Tip

Pneumonia Causative Organism, manifestation of other condition, lobar, multilobar

COPD Associated acute respiratory infection, acute exacerbation, Causative agents, long term use steroids

Influenza Type, causative organism, manifestations

Asthma Type, intermittent, persistent, mild, moderate, severe, causative irritant, exacerbation, associated conditions, status asthmaticus

Respiratory Failure Acute, chronic, with hypoxia, with hypercapnia, Associated conditions, causative irritants

Respiratory System Documentation

In Summary: Clinical Documentation Integrity

• Integrity of health information is an obligation of HIM

• HIM professionals must assume a leadership role in transforming these functions

• Now is the time to analyze and visualize documented and undocumented intra and interdepartmental HIM functions to understand the current and future state of the HIM department while ensuring HIM best practices and standards are consistently maintained

Action Items as you prepare for ICD10 Implementation– Identify risks and opportunities for your hospital– Use examples in this presentation to identify the same

issues in your facility• DRG Shifts

– Positive» Principal Diagnosis» Principal Procedure (root operation)» CC/MCC

– Negative» Principal Diagnosis» Principal Procedure (root operation)» CC/MCC

– Educate Physicians, CDI Team and Coding Professionals– Compare I-9 to I-10 DRG assignment if dual coding

Action Items post - Implementation– Prepare a DRG report by month for beginning the

go live date• List of cases by individual DRG

– Compare by month DRGs year to year• Identify total numbers for pre-I-10 and post I-10

by DRG for each month• Work the list of DRG shifts

– Print out I-9 DX and PX with descriptions– Compare to I-10 DX and PX with

descriptions– Identify PDX, PPX and CC/MCC changes