The Impact of Physician and ICD-10

Terminology On ObamaCare Initiatives

August, 2015

James S. Kennedy, MD, CCS

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Disclaimer The materials utilized in this presentation are intended solely for use in

conjunction with today’s seminar. Although great efforts have been taken in the preparation of today’s

material, the speaker and his employer does not assume responsibility for errors or omissions or for damages resulting from the use of the information contained therein.

Advice is general, thus participants should consult professional counsel for specific legal, ethical, technical and clinical questions prior to claim submission.

This lecture was prepared with information that was publicly available on August 6, 2015

ICD-9-CM, ICD-10 and MS-DRGs are constantly evolving. Please consult official guidance prior to code preparation or submission.

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Speaker Information

• James S. Kennedy MD CCS President, CDIMD Engaged in Clinical Documentation and Coding Integrity (CDCI)

physician/CDS/coder education, training, and process development • Education and Certifications Medical School – UT Memphis, 1979 Board Certified – Internal Medicine, 1983 AHIMA CCS Certification – 2001 • Publications

– 2007 – AHIMA – Severity Adjusted DRGs, an MS-DRG Primer – 2009 – ACDIS – Physician Query Handbook – Ongoing – “Minute for the Medical Staff” in HcPRO’s Medical Records Briefings – Ongoing – “Coding Clinic Update” – HcPRO’s CDI Journal (ACDIS)

• Contact (615) 479-7021 – Cellular jkennedy@cdimd.com

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Objectives • Have a firm understanding of how CMS and the state of

California evaluate physician/hospital quality

• Know the differences between the CDC’s ICD-9-CM and ICD-10-CM/PCS terminology

• Master challenging definitions impacting severity and risk adjustment

• Devise a plan to assure the integrity of their ICD-10-CM/PCS data measuring patient outcomes

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Like the Phone Book Interesting Characters – Terrible Plot

Dictionary without

Definitions

ICD-10-CM/PCS Basics

• ICD-10-CM/PCS (and ICD-9-CM) are NOT clinical languages (like SNOMED) – ICD-9-CM and ICD-10-CM/PCS are useful for classifying

healthcare data for administrative purposes, including reimbursement claims, health statistics, and other uses where data aggregation is advantageous

• ICD-10-CM/PCS is based ONLY on provider documentation of clinical language, not on a patient’s clinical characteristics that are abstracted by a data analyst (e.g. like STS, NCDR, or ATS databases) – The provider must use the magic words that drive ICD-10-

CM/PCS code assignment based upon patient circumstances

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ICD-10 Implementation Date October 1, 2015

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Diagnoses Procedures

ICD-10-CM (Clinical Modification)

All entities - providers and facilities for diagnoses in all settings: – Hospital inpatients – Hospital outpatients – Physicians offices – Emergency department – Home health – Long-term care – Rehabilitation facilities

ICD-10-PCS (Procedure Coding System)

Used by inpatient facilities ONLY • Includes outpatient facility services

rendered within the prior 72 hours of writing the inpatient order

• Very different than ICD-9-CM or CPT

CPT • Physician and outpatient/observation

facility services still utilize CPT • CPT does not change!!

US Modifications – ICD-10-CM and PCS The Cooperating Parties

• CDC • Responsible for diagnoses

• CMS • Responsible for inpatient

procedures

• American Hospital Assn. • Responsible for interpreting

ICD-9 or ICD-10 (Coding Clinic)

• American HIM Assn. • Provides input from coding

community

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What’s Old? ICD-9-CM

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What’s New ICD-10-CM

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Overall Changes

• 34,250 (50%) are related to the musculoskeletal system

• 17,045 (25%) are related to fractures

• 10,582 (62%) of fracture codes to distinguish ‘right’ vs. ‘left’

• ~25,000 (36%) of all ICD-10 codes to distinguish ‘right’ vs. ‘left’

Clinical Changes Expansions and Deletions

• Marked expansion of codes – Trauma, overdoses, or complications

treatment phases – Office encounters – Asthma – Diabetes mellitus – Obstetrics (trimesters) – Non-pressure ulcer staging – Myocardial infarction timing and vessel

involvement – Open fractures staging – Cerebral hemorrhage location – Ischemic stroke vessel involvement – Coma (Glasgow Coma Scale) – Atrial flutter and fibrillation – Drug underdosing

• Deletion of MD language, such as: – Urosepsis

• Must say “sepsis due to UTI”

– SIRS due to infection • Must say “sepsis” or

“severe sepsis”

– Accelerated or malignant hypertension

• Must describe the organ dysfunction caused by hypertension to measure severity

MD progress notes and DC summaries must use ICD-10-CM’s language (Index or Table) as to defend the assigned code

Differences from ICD-9-CM to ICD-10-CM

ICD-9-CM

Diagnosis Codes ICD-10-CM

Diagnosis Codes

Laterality No Laterality

Laterality –

Right or Left account for 35-40% of codes

Code Construction

3-5 digits 7 digits

First digit is alpha (E or V) or numeric

Digit 1 is alpha; Digit 2 is numeric

Digits 2-5 are numeric Digits 3–7 are alpha or numeric

Decimal is placed after the third character

Decimal is placed after the third character

Placeholders No placeholder characters “X” placeholders

# of Codes 14,000 codes 69,000 codes

Severity Limited Severity Parameters Extensive Severity Parameters

Combination Limited Combination Codes Extensive Combination Codes

Excludes Notes

1 type of Excludes Notes 2 types of Excludes Notes

New Changes Excludes Notes

Excludes1 - A type 1 Excludes note is a pure excludes. – It means 'NOT CODED HERE!' – An Excludes1 note indicates that the code excluded should

never be used at the same time as the code above the Excludes1 note.

– An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.

Excludes2 - A type 2 excludes note represents 'Not included here'. – An excludes2 note indicates that the condition excluded is not

part of the condition it is excluded from but a patient may have both conditions at the same time.

– When an Excludes2 note appears under a code it is acceptable to use both the code and the excluded code together.

Excludes1 Example

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Excludes1 Example

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Requirement for Documentation on Each Record

• Each encounter’s codes must be based on the physician’s documentation (not the problem list) for that encounter

– Coders are prohibited from using previous documentation to support the specificity of a code from the current encounter

Put the MEAT in your Documentation At Least Once A Year

• Monitor—signs, symptoms, disease progression, disease regression – “Diabetes, well controlled w/diet”; “Alcohol dependence in

remission, got 20 year chip”; “Toe amputation status, no evidence of complications”

• Evaluate—test results, medication effectiveness, response to treatment – “Hypertension, well controlled w/Rx”

• Assess/Address—ordering tests, discussion, review records, counseling – “HIV Disease w/lymphadenopathy, check CD4 count”

• Treat—medications, therapies, other modalities – “Thrush, treat with oral nystatin”

Conditions Interdependencies (M.U.S.I.C.)

• Manifestation – Aphasia, right sided weakness, amarosis fugax

• Underlying cause or pathology – Ischemic cerebral infarction

• Severity or specificity – Weakness involves right dominant side – Stroke involves left middle cerebral infarction

• Instigating or precipitating cause – Cerebral embolus in the setting of persistent atrial fibrillation – Underdosing of the patient’s warfarin due to financial difficulty in

obtaining medication • Complications or consequences

– Vasogenic edema requiring expectant intensive care monitoring – Hemorrhage within stroke due to heparin – Midline shift due to edema resulting in subfalcine herniation

When given a diagnosis, place it one of these categories and then look for

the other four, linking them with terms such as “due to,” “resulting in,” and

the like

General Coding Rules for Physicians (Even Inpatient Physicians)

• ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit – List first the ICD-10-CM code for the diagnosis, condition, problem, or

other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided.

• In some cases the first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician

– List additional codes that describe any coexisting conditions..

• H. Uncertain diagnosis – Do not code diagnoses documented as “probable”, “suspected,”

“questionable,” “rule out,” or “working diagnosis” or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.

– Please note: This differs from the coding practices used by short-term, acute care, long-term care and psychiatric hospitals.

Coding Rules for Hospitals Only Uncertain Diagnoses

• If the diagnosis documented at the time of discharge is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out”, or other similar terms indicating uncertainty, code the condition as if it existed or was established. – The bases for these guidelines are the diagnostic workup,

arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.

• Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.

• Inpatient coders cannot code from EKG, Echocardiogram, laboratory, X-ray or pathology reports – Even if interpreted by a board-certified cardiologist

– Results must be documented as diagnoses in the PN

• Arrow up (h) or down (i) with labs cannot be interpreted as abnormal – Document: “hyponatremia”

• i Na of 120 meq/liter ≠ hyponatremia – Document: “anemia”

• i Hct ≠ Anemia

• Physicians must completely describe and document conditions as to be coded

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ICD-10 Coding Rules

Personal and Family History

History (of) • There are two types of history Z codes, personal and family.

– Personal history codes explain a patient’s past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require continued monitoring.

– Family history codes are for use when a patient has a family member(s) who has had a particular disease that causes the patient to be at higher risk of also contracting the disease.

• A history of an illness, even if no longer present, is important information that may alter the type of treatment ordered. – Consequently, important to document and code whenever

present

Send Your Own Questions to

Coding Clinic Advisor

Anyone can send in questions and do it online – They are now accepting ICD-10-CM/PCS questions

http://www.codingclinicadvisor.com It’s FREE, so physicians should ask questions!

• Inpatient coders cannot code from EKG, laboratory, X-ray or pathology reports, even if interpreted by a board-certified physician – Results must be documented as diagnoses in the

physician’s notes

• Arrow up (h) or down (i) with labs cannot be interpreted as abnormal i Na of 120 meq/liter ≠ hyponatremia i Hct ≠ Anemia

• Physicians must completely describe and document conditions as to be coded

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ICD-10 Coding Rules

Federal Government - PPACA

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CMS’s Vision for Population Payment

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http://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD-10-guidance.pdf

“Family of Codes”

• “Family of codes” is the same as the ICD-10 three-character category. – Codes within a category are clinically related and provide

differences in capturing specific information on the type of condition.

– For instance, category H25 (Age-related cataract) contains a number of specific codes that capture information on the type of cataract as well as information on the eye involved.

• Examples include: H25.031 (Anterior subcapsular polar age-related cataract, right eye), which has six characters; H25.22 (Age-related cataract, morgagnian type, left eye), which has five characters; and H25.9 (Unspecified age-related cataract), which has four characters.

• One must report a valid code and not a category number. In many instances, the code will require more than 3 characters in order to be valid.

Medi-Cal ICD-10 Medical Necessity - Crosswalk

• Medi-Cal implementation of ICD-10 – Medi-Cal will be using a crosswalk solution in the legacy

California Medicaid Management Information System (CA-MMIS).

• Medi-Cal has mapped all ICD-10 codes to corresponding ICD-9 codes by starting with the General Equivalence Mappings (GEMs) provided by the Centers for Medicare & Medicaid Services (CMS) and modifying the mappings to align with existing Medi-Cal policy.

• Claims will be run against the crosswalk to determine the ICD-9 value to process through the system.

• Will an ICD-10 to ICD-9 crosswalk be published? – Medi-Cal will not publish the crosswalk. – However, the provider manuals will be updated with the

ICD-10 codes as appropriate.

Mapping Tool Provided by SJHS to You

Note how ICD-10-CM combined benign, malignant, and unspecified HTN into one code, I10 - HTN http://www.stjhs.org/documents/ICD-10/2014-ICD-9-CM-to-ICD-10-CM-GEMS.pdf

Emergency Department Billing

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Code NPP (Severity) History Physical MDM

99281 Self-limited PF PF SF

99282 Low-moderate EPF EPF Low

99283 Moderate EPF EPF Moderate

99284 High-urgent Detailed Detailed Moderate

99285 Life-threatening Comp Comp High

99291 Over 30 minutes of dedicated care for a critical illness

99219 99235

Moderate Comp Comp Moderate

99220 99236

High Comp Comp High

99217 Discharge services on any day subsequent to placing the patient in observation services

Abbreviations: NPP – Nature of the Presenting Problem; MDM – Medical Decision Making PF – Problem focused; EPF – Expanded problem focused; Comp - Comprehensive

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Medical Decision Making Quantity & Quality

High Extensive Extensive High

Moderate Moderate Multiple Medium

Low

Limited Limited Low

Minimal Minimal Minimal

Straight

forward

Patient Risk Amount

of Data No. of

Diagnoses/

Management

Options

Type

Need 2 out of 3 of these to qualify

CMS’s Definition of Critical Care Billing

• Critical care is defined as a physician’s (or physicians’) direct delivery of medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.

• Critical care involves high complexity decision making to assess, manipulate, and support vital system functions to treat single, or multiple, vital organ system failure; and/or to prevent further life threatening deterioration of the patient’s condition. Examples of vital organ system failure include (but are not limited to): – Central nervous system failure; – Circulatory failure; – Shock; – Renal, hepatic, metabolic, and/or respiratory failure

• Although it typically requires interpretation of multiple physiologic parameters and/or application of advanced technology(s), critical care may be provided in life threatening situations when these elements are not present. 35

Case Example ED History

• Patient presents with: – Nasal Congestion

– Cold

– Poor Feeding

– Decreased Urine Output - only 2 wet diapers today

– Crying

• HPI Comments: Pt is a 2 week female presenting to ED with rhinorrhea and cough x 3 days. Mom states that she has been having fevers at home, however Tmax 99.7 axillary. While in ER temp rectal= temp was 100.8. She has been taking decreased PO for the past day or so as well. Decreased wet diapers and decreased BMs.

Case Example ED Physical

• Note the prolonged capillary refill, mottled appearance, and dusky color • 70 cc saline fluid bolus administered • Lactate level was not drawn due to patient’s age

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Case Example Impressions

• ED Resident

– 2 week female with cough, rhinnorhea and neonatal fever. RSV +

– S/p LP with clear fluid.

• ED Attending

– 2 week female with RSV bronchiolitis presents with fever, tachycardia, respiratory distress

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Definitions of Shock

http://tinyurl.com/2006ShockConsensus

Recommendation 1

• We recommend that shock be defined as a life-threatening, generalized maldistribution of blood flow resulting in failure to deliver and/or utilize adequate amounts of oxygen, leading to tissue dysoxia

– Inadequate oxygen delivery typically results from poor tissue perfusion but occasionally may also be caused by an increase in metabolic demand

– Signs of inadequate tissue perfusion on physical examination are required to define shock

Recommendation 2

• We recommend that hypotension [SBP < 90 mmHg, SBP decrease of 40 mmHg from baseline, or mean arterial pressure (MAP) < 65 mmHg], while commonly present, should not be required to define shock

– Signs of inadequate tissue perfusion on physical examination are required to define shock

Recommendations 3 and 4

• In the absence of hypotension, when shock is suggested by history and physical examination, we recommend that a marker of inadequate perfusion be measured (decreased ScvO2, SvO2, increased blood lactate, increased base deficit, perfusion related low pH) – Apart from lactate and base deficit, current

evidence does not support the routine use of bio-markers for diagnosis or staging of shock

• Eligibility criteria – a suspected or confirmed infection, two or more

criteria for a systemic inflammatory response, and – evidence of refractory hypotension OR hypoperfusion.

• Refractory hypotension was defined as a systolic blood pressure of < 90 mm Hg or a mean arterial pressure of < 65 mm Hg after an intravenous fluid challenge of 1000 ml or more administered within a 60-minute period.

• Hypoperfusion was defined as a blood lactate level of 4.0 mmol per liter or more.

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N Engl J Med 2014; 371:1496-1506 October 16, 2014

Hypoxemic Respiratory Failure

• Hypoxemic – Classical definition:

pO2 < 60 mm Hg

– Critical care definition: pO2 divided by FiO2

< 200–250

• Chronic – Requires chronic oxygen

to maintain oxygenation

• Acute – Requires intensive care

(even if transient), such

as BiPAP, high-flow O2

or mechanical

ventilation

pO2 < 60 corresponds to O2 sat < 88%–90%

Hypercapnic Respiratory Failure

• Classically defined as pCO2 > 45 to 50

• pH value dependent upon chronicity and renal effects – Acute - < 7.33 – Chronic - >7.33

CRF

ARF

pCO2

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Renal Disease Options

• Azotemia (not a CC) – A medical condition characterized

by abnormally high levels of nitrogen-containing compounds, such as urea (BUN), creatinine, various body waste compounds, and other nitrogen-rich compounds in the blood

• Acute kidney insufficiency (not a CC) – A reduction of renal function

characterized by a rise of creatinine or fall of urine output fails to meet the criteria for acute renal failure or acute renal injury

• Acute kidney injury (a CC)

Acute kidney failure (a CC) – A common clinical syndrome

defined as a sudden onset of reduced kidney function manifested by increased serum creatinine or a reduction in urine output

• It is NOT the underlying renal pathology

• Uremia (not a CC) – A term used to loosely describe

the illness accompanying kidney failure, in particular the nitrogenous waste products associated with the failure of this organ

Clinical Criteria of Acute Kidney Injury

http://www.kdigo.org/clinical_practice_guidelines/pdf/KDIGO%20AKI%20Guideline.pdf

Published 2012

http://circ.ahajournals.org/content/early/2012/08/23/CIR.0b013e31826e1058.citation

Published online on August 24, 2012

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Third Universal Definition of MI Types of MI

SEPAS - January 2013 50

Third Universal Definitions of MI Etiologies of Myocardial Necrosis (Injury)

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Clinical Example for “Denominator Management”

• A 65 year old white male with known NYHA Class 4 systolic heart failure due to ischemic cardiomyopathy is admitted for acutely worse orthopnea and edema. – Past Hx: HTN, multiple

myocardial infarctions – Baseline creatinine 1.0 mg/dl,

last troponin <0.04

• PE: – SBP 100/palp; Pulse 90 &

regular; RR 32; – Reduced capillary refill – JVD & rales; – 3+ edema

• Current labs: Creatinine 1.6 mg/dl, BUN 40, troponin 0.16. ECG with subtle but new ST-depression inferiorly. Lactate 5.0. CXR with pulmonary edema

• Admitting Dx: – Decompensated HF – Prerenal azotemia – Hypotension – Lactatemia – Troponin “leak”

• Rx: ICU admission, increased diuretics, inotropic agents, IV TNG

Risk of Mortality Determinants Secondary Diagnoses (APR-DRG ROM)

Decompensated heart failure With + troponins, EKG Δs, and Cr rise of >0.5 mg/dl from baseline

Lactate level elevated; Rx with inotropic support

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3

2

1

0

Acute renal failure Explains the creatinine rise

“Demand ischemia” Explains the troponin rise & ECG

Acute NSTEMI

Consistent with 3rd Universal Definition of Myocardial Infarction

Cardiogenic shock Supported by elevated lactate level and renal hypoperfusion

CMS’s Vision for Population Payment

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Alternative Payment Models Bundled Payment Care Initiative

• Hospitals and physicians paid out of the same payment for current admissions and all care within 30 days of discharge

• Places physicians at risk for efficient hospital resource utilization.

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Impact of BPCI on Readmission Rates

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Impact on Cost Orthopaedics

• Costs in BPCI group fell below comparison group with intervention period

http://innovation.cms.gov/Files/slides/Bundled-Payments-Episode-Definition-Slides-01-05-12.pdf

Bundled Payments – Appendicitis

MS-DRG

MS-DRG title Weights GM LOS

Bundled payment

338 APPENDECTOMY W COMPLICATED PDx w MCC 3.2008 8.3 $32,008

339 APPENDECTOMY W COMPLICATED PDx w CC 1.8675 5.4 $18,675

340 APPENDECTOMY W COMPLICATED PDx w/o CC/MCC 1.2024 3.0 $12,024

341 APPENDECTOMY W/O COMPLICATED PDx w MCC 2.3116 4.8 $23,116

342 APPENDECTOMY W/O COMPLICATED PDx w CC 1.3516 2.9 $13,516

343 APPENDECTOMY W/O COMPLICATED PDx w/o CC/MCC 0.9547 1.6 $9,547

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“caused by,” “due to,” “resulting in”

“Peritoneal signs” ≠ “localized peritonitis”

• Localized or generalized peritonitis with appendicitis counts as a

“complicated principal diagnosis.”

• K353 Acute appendicitis with localized peritonitis MCC, SOI 3,

ROM 1

These are the rules that have been prepared for us to use.

Sepsis due to appendicitis is weighted higher.

Appendicitis What’s new in ICD-10

• K35.2 Acute appendicitis with generalized peritonitis – Appendicitis (acute) with generalized (diffuse) peritonitis

following rupture or perforation of appendix – Perforated or ruptured appendix NOS

• K35.3 Acute appendicitis with localized peritonitis – Acute appendicitis with or without perforation or rupture

with localized peritonitis – Acute appendicitis with peritoneal abscess

• K35.8 Other and unspecified acute appendicitis – K35.80 Unspecified acute appendicitis

• Acute appendicitis NOS • Acute appendicitis without (localized) (generalized) peritonitis

MS-DRG Pneumonia Classifications Simple pneumonia and pleurisy

MS-DRG 193, 194, 195 (RW 1.0)

Respiratory infections and inflammations

MS-DRG 177, 178, 179 (RW 1.6)

• Viral pneumonia (adenovirus, RSV,

parainfluenza, SARS-associated

coronavirus, influenza)

• Pneumonia due to pneumococcus,

streptococcus, H. flu, mycoplasma,

and chlamydia

• CAP, HAP, lobar, or

bronchopneumonia for which an

etiologic organism in the complex

pneumonia category is not explicitly

documented

• Mycoplasma, chlamydia pneumonia

• Pleurisy: adhesions lung or pleura,

calcification pleura, acute, sterile,

diaphragmatic, fibrous, interlobar,

thickening of pleura

• Gram-negative pneumonia

• Salmonella, Proteus, Serratia, Klebsiella, E.

coli, Pseudomonas, or GNR nonspecified

• Legionella

• Staph aureus (MSSA or MRSA)

• Pulmonary tuberculosis

• Fungus (specified) and other odd organisms

• Histoplasmosis, blastomycosis, candidiasis,

coccidiomycosis, tularemia

• Aspiration PNA, lipoid PNA

• Empyema with/without fistula, infected bacterial

pleural effusions, pleurisy w/effusions

• Lung abscess, gangrenous or necrotic

pneumonia

• Mediastinitis

Pneumonia must be the PDx Source: ICD-10 MS-DRG Definitions Manual

Note that CAP, HCAP, HAP, or nosocomial pneumonia group to MS-DRG 193, 194, 195.

Expected costs Pneumonia

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Multiple relative weight by base rate (e.g., $15,000) to get reimbursement

MS-DRG

MDC MS-DRG Title Wgts Bundle

871 18 SEPTICEMIA OR SEVERE SEPSIS W/O MV 96+ HOURS

1.8527 $27,791

177 04 RESPIRATORY INFECTIONS & INFLAMMATIONS

W MCC 1.9934 $29,901

178 04 W CC 1.3955 $20,933

179 04 W/O CC/MCC 0.9741 $14,612

193 04 SIMPLE PNEUMONIA & PLEURISY

W MCC 1.4550 $21,825

194 04 W CC 0.9771 $14,657

195 04 W/O CC/MCC 0.6997 $10,496

HCAP groups to

Simple Pneumonia

DRG

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Infection with “some” criteria

with documentation that the patient is toxic,

sick or “septic” appearing

Intensive Care Med (2003) 29:530–538

MS-DRG Pneumonia Classifications Simple pneumonia and pleurisy

MS-DRG 193, 194, 195 (RW 1.0)

Respiratory infections and inflammations

MS-DRG 177, 178, 179 (RW 1.6)

• Viral pneumonia (adenovirus, RSV,

parainfluenza, SARS-associated

coronavirus, influenza)

• Pneumonia due to pneumococcus,

streptococcus, H. flu, mycoplasma,

and chlamydia

• CAP, HAP, lobar, or

bronchopneumonia for which an

etiologic organism in the complex

pneumonia category is not explicitly

documented

• Mycoplasma, chlamydia pneumonia

• Pleurisy: adhesions lung or pleura,

calcification pleura, acute, sterile,

diaphragmatic, fibrous, interlobar,

thickening of pleura

• Gram-negative pneumonia

• Salmonella, Proteus, Serratia, Klebsiella, E.

coli, Pseudomonas, or GNR nonspecified

• Legionella

• Staph aureus (MSSA or MRSA)

• Pulmonary tuberculosis

• Fungus (specified) and other odd organisms

• Histoplasmosis, blastomycosis, candidiasis,

coccidiomycosis, tularemia

• Aspiration PNA, lipoid PNA

• Empyema with/without fistula, infected bacterial

pleural effusions, pleurisy w/effusions

• Lung abscess, gangrenous or necrotic

pneumonia

• Mediastinitis

Pneumonia must be the PDx Source: ICD-10 MS-DRG Definitions Manual

Note that CAP, HCAP, HAP, or nosocomial pneumonia group to MS-DRG 193, 194, 195.

Expected costs “Complex” vs. “Simple” Pneumonia

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Multiple relative weight by base rate (e.g., $15,000) to get reimbursement

MS-DRG

MDC MS-DRG Title Wgts Bundle

871 18 SEPTICEMIA OR SEVERE SEPSIS W/O MV 96+ HOURS

1.8527 $27,791

177 04 RESPIRATORY INFECTIONS & INFLAMMATIONS

W MCC 1.9934 $29,901

178 04 W CC 1.3955 $20,933

179 04 W/O CC/MCC 0.9741 $14,612

193 04 SIMPLE PNEUMONIA & PLEURISY

W MCC 1.4550 $21,825

194 04 W CC 0.9771 $14,657

195 04 W/O CC/MCC 0.6997 $10,496

HCAP groups to

Simple Pneumonia

DRG

ICD-9-CM/ICD-10-CM Coding Rule for Inpatient Facility Admissions

• If the diagnosis documented at the time of discharge is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out” or other similar terms indicating uncertainty, code the condition as if it existed or was established. – The bases for these guidelines are:

• the diagnostic workup

• arrangements for further workup or observation, and

• initial therapeutic approach that correspond most closely with the established diagnosis.

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Source: ICD-10-CM Official Guidelines for Coding and Reporting - 2014

Pneumonia Antibiotic Utilization Rules of Thumb for >3 days use

• 193–195 Simple pneumonia “Community-acquired pneumonia”

– Levaquin – or other fluroquinolone – Claforan®/Rocephin® + Zithromax® combo – Oselatmivir – Influenza w/o bacterial infection

• 177–179 Respiratory infections & inflammations – Doxycycline – Legionnaire’s disease – Clindamycin = anaerobes or staph aureus – Ceftaroline (Teflaro®) – MRSA – Daptomycin – specified gram-positive organisms – Zosyn®/Unasyn® = Gram-negative rods, aspiration – Zyvox® = MRSA, other specified Gram-positives – Aminoglycosides – Gram-negative rods – Fortaz® or Maxipime® – Pseudomonas – Carbepenams – aspiration, pseudomonas, other GNRs – Vancomycin – MRSA or enterococcus (rare) – Amphotericin or fluconazole – Fungus – INH, Rifampin, Ethambutol – Possible TB

Just because a

physician chooses

these antibiotics does

not mean he or she

does not suspect a

more serious cause

Uncertain diagnoses may be coded if documented at the time of discharge

Usually administered

for more than three

days after admission

Empiric vs. definitive

treatment

Expected costs “Complex” vs. “Simple” Pneumonia

68

Multiple relative weight by base rate (e.g., $15,000) to get reimbursement

MS-DRG

MDC MS-DRG Title Wgts Bundle

871 18 SEPTICEMIA OR SEVERE SEPSIS W/O MV 96+ HOURS

1.8527 $27,791

177 04 RESPIRATORY INFECTIONS & INFLAMMATIONS

W MCC 1.9934 $29,901

178 04 W CC 1.3955 $20,933

179 04 W/O CC/MCC 0.9741 $14,612

193 04 SIMPLE PNEUMONIA & PLEURISY

W MCC 1.4550 $21,825

194 04 W CC 0.9771 $14,657

195 04 W/O CC/MCC 0.6997 $10,496

HCAP groups to

Simple Pneumonia

DRG

MS-DRG CC/MCC Table

Not a CC CC MCC

AMS or acute delirium

Unresponsive

Delirium due to a

“medical condition” or

postprocedural state

Toxic or metabolic

encephalopathy

Unconscious or coma

Oxygen dependency

Chronic

respiratory failure

Acute on chronic

respiratory failure

Cystitis

Urosepsis (no code)

UTI or acute cystitis

Bacteremia Sepsis due to UTI

CAD

Stable angina

Demand ischemia

AS of CABG graft

NSTEMI

STEMI

HFpEF

HFrEF

Systolic CHF

Diastolic CHF

Acute systolic CHF

Acute diastolic CHF

DSM-5 Diagnostic Criteria

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Alternatives to “Altered Mental Status”

DSM-5 Brief Acute Psychosis

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Alternatives to “Altered Mental Status”

Delirium Underlying Causes

http://www.tinyurl.com/TMEncephalopathy

Toxic/Metabolic Encephalopathies Definitions

• Toxic and metabolic encephalopathies are a group of neurological disorders characterized by an altered mental status – A delirium, defined as a disturbance of

consciousness characterized by a reduced ability to focus, sustain, or shift attention

that cannot be accounted for by preexisting or evolving dementia and that is caused by the direct physiological consequences of a general medical condition.

• Causes – Medications – Drug overdose – Uremia – Liver failure – Hypercalcemia – Pancreatitis – Hyponatremia – Sepsis – Hypercapnia

Encephalopathy can be the Underlying Cause of Delirium

Hypoxemic Respiratory Failure

• Hypoxemic – Classical definition:

pO2 < 60 mm Hg

– Critical care definition: pO2 divided by FiO2

< 200–250

• Chronic – Requires chronic oxygen

to maintain oxygenation

• Acute – Requires intensive care

(even if transient), such

as BiPAP, high-flow O2

or mechanical

ventilation

pO2 < 60 corresponds to O2 sat < 88%–90%

Hypercapnic Respiratory Failure

• Classically defined as pCO2 > 45 to 50

• pH value dependent upon chronicity and renal effects – Acute - < 7.33 – Chronic - >7.33

CRF

ARF

pCO2

50

Hypoxemia & Hypercapnia Respiratory Insufficiency/Failure

Always list the underlying cause, such as

status asthmaticus, drug overdose, CHF

Entity MS-DRG

Hypoxemia No CC

Hypercapnia No CC

Respiratory insufficiency or distress

No CC

Acute respiratory insufficiency or distress

Not a CC

Acute resp. failure MCC

Chronic resp. failure CC

Systolic and Diastolic Heart Failure

• As above, not codeable in ICD-9-CM as diastolic or systolic HF • Physician must state “diastolic” or “systolic” or both to get CC or

MCC

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Decompensated = Acute Systolic/Diastolic Heart Failure

To get the MS-DRG MCC, physicians must document acute or decompensated “systolic”, “diastolic”, or both “systolic/diastolic” heart failure

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MS-DRG CC/MCC Table

Not a CC CC MCC

Diabetes Mellitus

Uncontrolled -

Hyperosmolar state

DKA

Blood loss anemia

Acute blood loss

anemia

Toxic anemia

(x chemotherapy)

+ HIV AIDS or +HIV with

previous Hx of AIDS

Ranson’s criteria

(w/pancreatitis)

SIRS

(due to pancreatitis)

SIRS w/organ

dysfunction

Stool with

+ occult blood GI bleeding

GI bleeding from

defined site

(e.g., PUD)

Diabetes

• History of Diabetes – BS controlled and on no Rx

• Uncontrolled Diabetes – HgbA1C > 7 – Mulitple plasma glucoses over 250-300 mg/dl

80

Metric

DKA (plasma glucose >250 mg/dl) Hyperosmolar Hyperglycemic Syndrome

(plasma glucose >600 mg/dl) Mild Moderate Severe

Arterial pH 7.25–7.30 7.00 - 7.24 <7.00 >7.30 Serum bicarbonate (mEq/l) 15–18 10 to <15 <10 >18 Urine ketone* Positive Positive Positive Small Serum ketone* Positive Positive Positive Small Effective serum osmolality Variable Variable Variable >320 mOsm/kg Anion gap‡ >10 >12 >12 Variable Mental status Alert Alert/drowsy Stupor/coma Stupor/coma

If these are not diagnosed as

“present on admission”, they are

complications of care or not

considered as MCCs

Kitabchi, AE, et. al. Diabetes Care July 2009 vol. 32 no. 7 1335-1343

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Acute Blood Loss Anemia (not ↓ Hct)

• “Acute blood loss anemia” - CC • Major Bleeding Definition

– Clinically overt – Associated with a fall of the hemoglobin level of 2.0 g/dL (e.g. Hct

drop of 6) or required transfusion of at least 2 units of red cells, or involved a critical organ or was fatal

MS-DRG MS-DRG Title Weights Payment 377 G.I. HEMORRHAGE W MCC 1.7775 $14,220 378 G.I. HEMORRHAGE W CC (e.g. acute blood loss anemia) 1.0021 $8,017

379 G.I. HEMORRHAGE W/O CC/MCC 0.6776 $5,421

+HIV vs. HIV Disease (MCC)

• +HIV (no code)

– Includes HIV-infected individual who never had exhibited symptoms

– Based on documentation of +HIV only

• HIV-disease (MCC)

– Currently having acute HIV symptoms

– + HIV with previous HIV-related symptoms

– + HIV with current or previous HIV-related disease

– Current AIDS or previous history of AIDS

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Must Be Documented on Each Admission

MS-DRG CC/MCC Table

Not a CC CC MCC

Acute renal

insufficiency

Toxic nephropathy

Acute renal failure

Acute kidney injury

Acute tubular necrosis

Acute cortical necrosis

CRI or CKD CKD Stage 4 or 5 ESRD

Chronic/persistent

atrial fibrillation

Persistent

atrial fibrillation

Acute systolic/diastolic

HF due to rapid afib

Past Hx of multiple

DVT on warfarin

Hypercoagulable

state -

Peripheral neuropathy Autonomic peripheral

neuropathy -

Underweight with

anorexia

Cachexia

Malnutrition Severe malnutrition

MDC 5 – DVTs With Hypercoagulable State

MS-DRG MS-DRG title Weights

294 DEEP VEIN THROMBOPHLEBITIS W CC/MCC 1.0373

295 DEEP VEIN THROMBOPHLEBITIS W/O CC/MCC 0.6403

• Primary hypercoagulable states (CC) Initial Recurrent

– Factor V Leiden – 12%–20% / 40%–50%

– Protein C def – 2%–5% / 5%–10%

– Protein S def – 1%–3% / 5%–10%

– AT3 deficiency – 1%–2% / 2%– 5%

• Secondary hypercoagulable states (CC) – Active cancer, chemotherapy (L-asparaginase, thalidomide,

anti-angiogenesis therapy), myeloproliferative disorders, HIT, nephrotic syndrome, intravascular coagulation and fibrinolysis/DIC, TTP, sickle cell disease, oral contraceptives or estrogen, pregnancy/postpartum state, selective estrogen receptor modulator therapy (tamoxifen and raloxifene), antiphospholipid antibodies, PNH, Wegener granulomatosis

Thrombophilia now

has a code

“Still to be ruled out”

MS-DRG CC/MCC Table

Not a CC CC MCC

Anemia – neutropenia

Thrombocytopenia Pancytopenia

Pancytopenia due to

any pharmaceutical

Bedridden state “Functional

quadriplegia”

Seizure disorder

Poorly controlled

seizures

Poorly controlled

seizure disorder Status epilepticus

Syncope

Ventricular pause

Ventricular

tachycardia

Ventricular fibrillation

or asystole

TIA Stroke

Chemo Rx Drug-Induced Complications

• Bone marrow suppression – no code – Anemia, thrombocytopenia, and/or neutropenia

• MS-DRG 846 – Chemotherapy w/o acute leukemia w/o CC/MCC – 0.8635

– Pancytopenia • MS-DRG 845 – Chemotherapy w/o acute leukemia

w/CC/MCC – 1.1062

– Pancytopenia due to drug or chemotherapy • MS-DRG 844 – Chemotherapy w/o acute leukemia

w/MCC – 2.4344

Ventricular Pause vs. Ventricular Asystole

Stroke Differentiation from TIA

88

Stroke Consequences

• Hemiparesis or monoparesis (CC)

– Not weakness

• Aphasias (CC)

– Not just “altered mental status”

• SIADH as a cause of hyponatremia

• Mechanisms of death

– Significant cerebral edema

– Sulfalcine herniations

– Acute respiratory failure

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CDI’s Impact on Bundled Payments

Clinical scenario

requiring query

Query

response

MS-

DRG Title

Bundled

payment

70 yo male with

previous Hx of

AIDS undergoes

TJR for DJD. MD

only documents

“+HIV.”

AIDS or + HIV

with previous

Hx of AIDS

469

Major Joint Replacement or

Reattachment of Lower

Extremity W/ MCC

$51,627

+ HIV only or

“unable to

determine”

470

Major Joint Replacement or

Reattachment of Lower

Extremity W/O MCC

$31,299

65 yo male

undergoes

cardiac cath and

CABG.

Documented with

postoperative

acute renal

failure.

Acute renal

failure is “likely”

due to ATN due

to contrast

233 Coronary Bypass With

Cardiac Cath W/MCC $107,127

Cause of acute

renal failure is

“undetermined”

234 Coronary Bypass With

Cardiac Cath W/O MCC $72,471

Notes: MS-DRG version 30; base rate $15,000

Bottom Line

• ICD-9-CM (and ICD-10) codes are crucial – Definitions are critical – Documentation infrastructure must support the

higher specificity

• Physicians are be incentivized to document and code completely in their offices – Especially important if they form Accountable Care

Organizations or participate in other entities emphasizing cost efficiency and outcomes.

• This lecture will orient the healthcare provider of what is needed now and what we can expect in the future

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