Value Based Purchasing, Changes
for ICD-10 and the Future of
Radiation Oncology
Robert S. Gold, MD
Medicine Under the Microscope
•
•
•
•
•
•
•
•
Morbidity
Mortality
Cost per patient
Resource utilization
Length of stay
Complications
Outcomes
ARE YOU SAFE –
avoiding harm,
avoidable
readmissions?
Value-Based Purchasing Program
• Beginning in FY 2013 and continuing annually,
CMS will adjust hospital payments under the VBP
program based on how well hospitals perform or
improve their performance on a set of quality
measures. The initial set of 13 measures includes
three mortality measures, two AHRQ composite
measures, and eight hospital-acquired condition
(HAC) measures. The FY 2012 IPPS final rule
(available at http://tinyurl.com/6nccdoc) includes a
complete list of the 13 measures.
Goals of Implementation –
Prove You Are Value Based
• Excellence in severity adjusted data
• Reasonable occurrence of PSIs
• Lower than average Readmissions for
Pneumonia, Heart Failure, AMI
• Cooperation with quality initiatives
• Patient satisfaction
Where Does This Data
Come From?
• Documentation leads to identification of
diagnoses and procedures
• Recognition of diagnoses and procedures lead
to ICD codes – THE TRUE KEY
• ICD codes lead to APR-DRG assignment
• APR-DRG assignment massaged to “Severity
Adjustments
• Severity adjusted data leads to morbidity and
mortality rates
World Health Organization and ICD Codes
•
•
•
•
•
Semantics
Coding guidelines and conventions
Use of signs, symbols, arrows
Accuracy and specificity
Relationship between accuracy and
specificity of code assignment and
Complexity of Medical Decision
Making
Is There a Diagnosis?
82 yo WF altered mental status, shaking
chills, fevers, decr UO, T = 103, P =
124, R = 34, BP = 70/40 persistent
despite 1 L NS, on Dopamine, pO2 = 78
on non-rebreather, pH = 7.18, pCO2 =
105, WBC = 17,500, left shift, BUN =
78, Cr = 5.4, CXR – Right UL infiltrates,
start Cefipime, Clinda, Tx to ICU. May
have to intubate – full resusc.
Is There a Diagnosis?
Assessment/Plan
82 YO F patient presented to ER with:
1. Sepsis,
2. Septic Shock,
3. Acute Hypercapnic Respiratory Failure,
4. Acute Renal Failure due to #2, (don’t forget CKD
and stage, if present)
5. Aspiration Pneumonia,
6. Metabolic Encephalopathy
Will transfer to ICU, continue Dopamine and monitor
respiratory status for possible ARDS, renal status with
hydration and initiate Cefapime/clindamycin for
possible aspiration pneumonia
CC time 1hr 45 minutes
John Smith MD
So What’s the Difference?
Principal Diagnosis
Chills and Fever
Sepsis
Secondary Diagnoses
Altered Mental Status
Septic Shock
Acute Respiratory Failure
Aspiration Pneumonia
Acute Renal Failure (or AKI)
Respiratory Acidosis
Metabolic Encephalopathy
Medicare MS-DRG
864 Fever w/o CC/MCC
871 Septicemia or severe
Sepsis w/o MV 96+ hrs
w/ MCC
APR-DRG
722 Fever
720 Septicemia &
Disseminated infection
APR-DRG Severity Illness
1 – Minor
4 – Extreme
APR-DRG Risk of
Mortality
1 – Minor
4 - Extreme
Medicare MS-DRG Rel Wt
0.8153
1.8437
APR DRG Relative Weight 0.3556
2.9772
National Mortality Rate
(APR Adjusted)
62.02%
0.04%
What Is An Index?
What Is An Index?
•
•
•
•
Mortality index
Complication index
Length of stay index
Cost per patient index
Observed Rate of Some Thing
Severity Adjusted Expected Rate of That
Thing
=1
Profiles Come from Severity Adjusted
Statistics
<1; preferred
provider – 
significantly better
Observed mortality
Expected mortality
From severity adjusted DRGs
=1; as good as
the next
guy
>1; excessive
mortality; find
another provider
- 
Univ VA
2013
Respiratory Diseases
Pneumonia
Hosp plus 6 months
COPD
Hosp plus 6 months
Critical Care
Respiratory Failure
Hosp plus 6 months
Sepsis
Hosp plus 6 months
Cardiac Diseases
Heart Failure
Hosp plus 6 months
Acute MI
Hosp plus 6 months
Cardiac Surgery
CABG
Hosp plus 6 months
Interv Cardiology
Hosp plus 6 months
Heart Valve
Hosp plus 6 months
Surgery
ORIF Hip Maj Compl
GI Surgery
Hosp plus 6 months
THA Maj Compl
Cholecystectomy Maj C
VCU
2013
Retreat
Doctors
Augusta
Health
Culpeper
Regional
Rockingham
Memorial
Henrico
Doctors
Clinical Documentation Improvement
What is this all for?
Physicians accurately describe the
etiology/specificity of diseases
Coders follow rules & guidelines
translating explicitly documented
diagnoses and procedures
Improve patient care
Get the credit for the work we do
Improve CMI
• Core Measures
• Patient Safety Indicators
• Medical Necessity
• HealthGrades
Avoid fraud and abuse
Enhance YOUR PROFILES
Improve severity adjusted mortality
rates
Patient Safety
Death in procedures where mortality is usually very low
Pressure sores or bed sores acquired in the hospital
Death following a serious complication after surgery
Collapsed lung due to a procedure or surgery in or
around the chest
Catheter-related bloodstream infections acquired at the
hospital
Hip fracture following surgery
Excessive bruising or bleeding as a consequence of a
procedure or surgery
Electrolyte and fluid imbalance following surgery
Respiratory failure following surgery
Deep blood clots in the lungs or legs following surgery
Bloodstream infection following surgery
Breakdown of abdominal incision site
Accidental cut, puncture, perforation or hemorrhage
during medical care
Foreign objects left in body during a surgery or procedure
Worse
than
Average
Average
Better
than
Average
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●
●
●
●
0 Events
Examples
• Differentiate tracheoesophageal fistula
due to the cancer from TEF due to the
radiation
• Fluid losses from gastrointestinal
mucositis vs other causes of fluid losses
• Lymphedema from the radiation vs from
the superior vena cava syndrome
• Radiation pneumonitis vs aspiration
pneumonitis in esophageal cancer pt
Complication?
• Access site injury
– Pseudoaneurysm or significant hematoma?
– Incidental, insignificant ecchymosis?
• Hepatic artery injury
– Specific obstruction, perforation, dissection
• Infection
– Distinguish hepatic abscess from procedure or was it
already there, procedural blood stream infection vs
incidental bacteremia
• Nontarget embolization
• Pulmonary embolism/air embolism
• Iatrogenic pneumothorax – clinically significant or
just minimal apical cap?
Clinical Integration
• CMS proposes to pay separately for complex chronic
care management services starting in 2015.
• "Specifically, we proposed to pay for non-face-to-face
complex chronic care management services for
Medicare beneficiaries who have multiple, significant,
chronic conditions (two or more)." Rather than paying
based on face-to-face visits, CMS would use "Gcodes" to pay for revision of care plans,
communication with other treating professionals, and
medication management over 90-day periods.
• These code payments would require that beneficiaries
have an annual wellness visit, that a single practitioner
furnish these services, and that the beneficiary
consent to this arrangement over a one-year period.
Change in the Entire System
ICD-9
ICD-10
Notable Changes
• ICD-9 has maximum of 5 digits with rare
alphanumeric codes (V-, E-) limiting breakdown
for specificity or addition of categories; ICD-10
has three to seven alphanumeric places
• ICD-9: 14,000 codes; ICD-10: 73,000 codes
• ICD-9 has no specificity as to which side of the
body (e.g., percent burn on right or left arm or
leg, side of paralysis after stroke)
How Close Are We Now?
AAPC AUDIT RESULTS
Data compiled from results of 20,000 medical charts audited the First half of 2013
% Documentation Sufficient to Transition To ICD-10
CLIENT SERVICES
Anesthesiology
87%
Ophthalmology
69%
Cardiology
65%
Orthopedic
73%
Dermatology
86%
Otorhinolaryngology (ENT)
74%
Emergency Medicine
71%
Pathology
75%
Endocrinology
63%
Pediatrics
53%
Family Practice
68%
Plastic Surgery
98%
Gastroenterology
48%
PMR
65%
General Surgery
86%
Primary Care
63%
Hospital Medicine
73%
Psychiatry
61%
Infectious Disease
78%
Psychology
81%
Internal Medicine
58%
Pulmonary
56%
Nephrology
64%
Rheumatology
71%
Neurology
70%
Sleep Medicine
68%
Neurosurgery
75%
Urgent Care
56%
Obstetrics & Gynecology
84%
Urology
80%
Oncology
63%
Overall
63%
Example - Specificity
Category 1–3
S52: Fracture of forearm
S52.5: Fracture of lower end of radius
Etiology,
anatomic site,
severity, other
detail 4–6
Extension 7
S52.52: Torus fracture of lower end of
radius
S52.521: Torus fracture of lower end of
right radius
S52.521A: Torus fracture of lower end of
right radius, initial encounter for closed
fracture
Example - Integration
ICD-9 – Multiple codes
707.03 – Chronic skin ulcer, lower back
707.21 – Pressure ulcer, stage I
No code for which side
ICD-10 – Single code
L89.131 – Pressure ulcer right lower back,
stage I
(stages II, III, IV, unspecified have 6th digits 2, 3, 4, 9)
Example Specificity - Location
M67.4 Ganglion
– M67.41 shoulder
• M67.411, right
• M67.412, left
• M67.419, unspecified
– M67.42 elbow
– M67.43 wrist
– M67.44 hand
– M67.45 hip
– M67.46 knee
– M67.47 ankle and foot
Sixth digits
1 – right
2 – left
9 - unspecified
Principal Diagnosis – Describe It!
16 year old female with acute myelogenous leukemia
diagnosed in 2004 who underwent consolidation
chemotherapy and went into successful remission. She
was doing well until she was hospitalized with syncope
from severe anemia and bruising from thrombocytopenia
found to be due to relapse in November 2013 and is now
admitted for allogeneic bone marrow transplantation.
80 year old WF with episode of syncope in March led to
findings of iron deficiency anemia and positive stool
guaiac, probably due to chronic blood loss.
Colonoscopy late March revealed right colon exophytic
lesion with erosions. Biopsy adenoca colon. Abdominal CT
showed possible evidence of solitary lesion in left lobe of
liver. Right hemicolectomy performed two weeks ago
with benign postoperative course. Liver biopsy positive
for adenocarcinoma of colon. In now for percutaneous
embolization of metastatic colon cancer in left lobe of liver.
Consider Issues That Make it Tough
Do other conditions of the patient make the route,
positioning, choice of therapies more complex?
• Kyphoscoliosis?
• Chronic respiratory failure?
– Hypoxemic? Hypercapnic?
– What’s the cause? Pleural effusion? Ascites?
• Morbid obesity?
• Coagulopathies?
Primary and Metastatic Cancer
• Tell where the primary is (was)
and if it was previously
removed or treated and
treatment is over or currently
under treatment
• State where the metastatic
sites are and if they (any) are
symptomatic and if they are
currently under treatment
• State if new site is found and if
it led to the symptoms that
required admission – ALWAYS
LINK SYMPTOMS TO THE
CANCER, when you can
Lung Cancer I-9
162 Malignant neoplasm of trachea,
bronchus, and lung
162.0 Trachea
162.2 Main bronchus
162.3 Upper lobe, bronchus or lung
162.4 Middle lobe, bronchus or lung
162.5 Lower lobe, bronchus or lung
162.8 Other parts of bronchus or lung
162.9 Bronchus and lung, unspecified
Laterality of Lung Cancer I-10
C34.0 Malignant neoplasm of main bronchus
C34.00 Malignant neoplasm of unspec main bronchus
C34.01 Malignant neoplasm of right main bronchus
C34.02 Malignant neoplasm of left main bronchus
C34.1 Malignant neoplasm of upper lobe, bronchus or lung
C34.10 Malignant neoplasm of upper lobe, unspec bronchus or lung
C34.11 Malignant neoplasm of upper lobe, right bronchus or lung
C34.12 Malignant neoplasm of upper lobe, left bronchus or lung
C34.2 Malignant neoplasm of middle lobe, bronchus or lung
C34.3 Malignant neoplasm of lower lobe, bronchus or lung
C34.30 Malignant neoplasm of lower lobe, unspec bronchus or lung
C34.31 Malignant neoplasm of lower lobe, right bronchus or lung
C34.32 Malignant neoplasm of lower lobe, left bronchus or lung
C34.8 Malignant neoplasm of overlapping sites of bronchus and lung
C34.80 Malignant neoplasm of overlapping sites of unspec bronchus and lung
C34.81 Malignant neoplasm of overlapping sites of right bronchus and
lung
C34.82 Malignant neoplasm of overlapping sites of left bronchus and lung
Adrenal Gland Malignancy I-9
194.0 Adrenal gland
Adrenal cortex
Adrenal medulla
Suprarenal gland
All in one
Laterality/Specificity I-10
C74.0 Malignant neoplasm of cortex of adrenal gland
C74.00 Malignant neoplasm of cortex of unspecified
adrenal gland
C74.01 Malignant neoplasm of cortex of right
adrenal gland
C74.02 Malignant neoplasm of cortex of left
adrenal gland
C74.1 Malignant neoplasm of medulla of adrenal gland
C74.10 Malignant neoplasm of medulla of unspecified
adrenal gland
C74.11 Malignant neoplasm of medulla of right
adrenal gland
C74.12 Malignant neoplasm of medulla of left
adrenal gland
Colon Cancer I-9
153 Malignant neoplasm of colon
153.0 Hepatic flexure
153.1 Transverse colon
153.2 Descending colon
153.3 Sigmoid colon
153.4 Cecum
153.5 Appendix
153.6 Ascending colon
153.7 Splenic flexure
153.8 Other specified sites of large intestine
153.9 Colon, unspecified
154 Malignant neoplasm of rectum, rectosigmoid junction, and anus
154.0 Rectosigmoid junction
154.1 Rectum
154.2 Anal canal
Colon Cancer I-10
C18 Malignant neoplasm of colon
C18.0 Malignant neoplasm of cecum
C18.1 Malignant neoplasm of appendix
C18.2 Malignant neoplasm of ascending colon
C18.3 Malignant neoplasm of hepatic flexure
C18.4 Malignant neoplasm of transverse colon
C18.5 Malignant neoplasm of splenic flexure
C18.6 Malignant neoplasm of descending colon
C18.7 Malignant neoplasm of sigmoid colon
C18.8 Malignant neoplasm of overlapping sites of colon
C18.9 Malignant neoplasm of colon, unspecified
Malignant neoplasm of large intestine NOS
C19 Malignant neoplasm of rectosigmoid junction
Malignant neoplasm of colon with rectum
Malignant neoplasm of rectosigmoid (colon)
Mets to Bone
ICD-9
198.5 Bone and bone
marrow
ICD-10
C79.51 Bone
C79.52 Bone marrow
Pathologic Fracture
• Medical Textbook
A fracture involving
abnormal bone is a
pathologic fracture. The
abnormality may be due
to disuse, a surgical
defect, infection, a
metabolic disorder, a
primary benign tumor, a
primary malignant tumor
or metastatic carcinoma.
The fracture occurs
spontaneously or with
minimal trauma
• Coding Guidelines
A break in a diseased bone
due to weakness of the
bone structure by
pathologic process (such
as osteoporosis or bone
tumors) without
identifiable trauma or
following only minor
trauma. Only the
physician can make the
determination that the
fracture is out of
proportion to the degree
of trauma
Pathologic Fracture
• If a patient with severe osteoporosis or
myeloma falls from the second story of her
home and suffers a compression fracture of
the spine, that’s a traumatic fracture.
• If a patient gets the same fracture setting the
table – or raising a window - with the bone
weakened by SOME pathologic process, that’s
a pathologic fracture
• Pediatric orthopedic textbooks describe over
100 causes of pathologic fracture that are not
malignancies.
• Be sure pathologic fracture in a cancer patient
is not due to another cause.
Osteoporosis and Pathologic Fx I-9
733.0 Osteoporosis
Use additional code for history of pathologic (healed) fracture (V13.51)
733.00 Osteoporosis, unspecified
733.01 Senile osteoporosis
733.02 Idiopathic osteoporosis
733.03 Disuse osteoporosis
733.09 Other Drug-induced osteoporosis
733.1 Pathologic fracture
Excludes: stress fracture (733.93-733.95), traumatic fractures (800-829)
733.10 Pathologic fracture, unspecified site
733.11 Pathologic fracture of humerus
733.12 Pathologic fracture of distal radius and ulna
733.13 Pathologic fracture of vertebrae
733.14 Pathologic fracture of neck of femur
733.15 Pathologic fracture of other specified part of femur
733.16 Pathologic fracture of tibia and fibula
733.19 Pathologic fracture of other specified site
Osteoporosis ICD-10
M81 Osteoporosis without current pathological
fracture
personal history of (healed) osteoporosis fracture, if
applicable (Z87.310)
M81.0 Age-related osteoporosis without current
pathological fracture
M81.6 Localized osteoporosis [Lequesne]
Excludes1: Sudeck's atrophy (M89.0)
M81.8 Other osteoporosis without current
pathological fracture
Osteoporosis with Pathologic Fx I-10
M80 Osteoporosis with current pathological fracture
Excludes1: collapsed vertebra NOS (M48.5)
pathological fracture NOS (M84.4)
wedging of vertebra NOS (M48.5)
Excludes2: personal history of (healed) osteoporosis fracture (Z87.310)
M80.0 Age-related osteoporosis with current
pathological fracture
M80.8 Other osteoporosis with pathological fracture
drug induced, idiopathic, disuse,
Osteoporosis with Pathologic Fx ICD-10
1
2
3
4
5
6
7
8
Shoulder
Humerus
Forearm
Hand
Femur
Lower leg
Ankle/foot
Vertebra
Add 7th digit for episode
of care
Sixth digit
1 = right
2 = left
Traumatic Fracture vs Pathologic
• M84.3 Stress fracture
• M84.4 Pathologic fracture NEC
• M84.5 Pathologic fracture in neoplastic
disease
• M84.6 Pathologic fracture in other
specified disease – name the disease,
too (excludes, osteoporosis M80.x)
Neoplastic and Other Pathologic Fx ICD-10
1
2
3
4
5
6
7
8
Shoulder
Humerus
Ulna or Radius
Hand
Pelvis or Femur
Tibia or Fibula
Ankle or foot
Other site
Add 7th digit for episode
of care
And Then There Were Seven
(Digits) … for Injuries
A
Initial encounter for fracture
D
Subsequent encounter for fracture with routine
healing
G
Subsequent encounter for fracture with delayed
healing
K
Subsequent encounter for fracture with nonunion
P
Subsequent encounter for fracture with malunion
S
Sequela
Anemia Designations
D62
D50.0
D63.1
D63.0
D63.8
285.1 – anemia due to acute blood loss
FROM … name it
280.0 – anemia due to chronic blood loss
FROM … name it
285.21 – anemia due to chronic renal
failure and what caused the renal
failure?
285.22 – anemia due to malignant
disease – effect of the tumor!
285.29 – anemia due to a specific chronic
illness – and name that illness (chronic
hepatitis, lupus, osteomyelitis, etc.)
Anemia/Cytopenias in Malignancy
There is no code for “anemia of chronic disease”
280.0 D50.0 anemia due to chronic blood loss from
bleeding colon cancer
284.11 D61.810 pancytopenia from chemo
284.12 D61.811 pancytopenia from other drugs
284.2 D61.82 pancytopenia from cancer taking over bone
marrow (myelophthisis) – code the cancer causing it
284.89 D61.1 aplastic anemia due to chemo, other drugs
284.89 D61.2 radiation induced aplastic anemia
285.22 D63.0 anemia due to neoplastic disease – code
the cancer causing it
285.3 D64.81 antineoplastic chemotherapy induced
anemia
Lymphoma Subdivisions in ICD-9
•
• Hodgkins cell types
•
• Small Cell
•
• Mantle zone
•
• Large cell
•
lymphoma
•
• Lymphoblastic
•
• Burkitt
•
• Non-follicular
•
•
Unspecified site
Head, face, neck nodes
Intrathoracic nodes
Intraabdominal nodes
Nodes axilla, upper limb
Inguinal, lower limb
Pelvic nodes
Spleen
Multiple sites
Extranodal and solid
organ sites
Lymphoma ICD-10
C81 Hodgkin’s Lymphoma
C81.0 Nodular lymphocytic
C81.1 Nodular sclerosing
C81.2 Mixed cellularity
C81.3 Lymphocyte
depleted
C81.4 Follicular grade IIIB
C81.5 Diffuse follicular
center
C81.6 Cutaneous follicle
center
C81.8 Other specified
Fifth Digit
0 – unspecified site
1 – head, face neck nodes
2 – intrathoracic nodes
3 – intraabdominal nodes
4 – axilla, upper limb
5 – inguinal, lower limb
6 – pelvic nodes
7 – spleen
8 – multiple sites
9 – unspecified site
Fifth Digit
0 – unspecified site
1 – head, face neck nodes
C83.0 Small B cell
2 – intrathoracic nodes
C83.1 Mantle
3 – intraabdominal nodes
C83.3 Diffuse large B cell
4 – axilla, upper limb
C83.5 Lymphoblastic diffuse
5 – inguinal, lower limb
C83.7 Burkitt
6 – pelvic nodes
C83.8 Other nonfollicular
7 – spleen
C84.0 Mycosis fungoides
C84.1 Sezary disease
8 – multiple sites
C84.4 Peripheral T-cell
9 – unspecified site
C84.6 Anaplastic large cell (ALK pos)
C84.7 Anaplastic large cell (ALK neg)
C84A Cutaneous T-cell
C84.9 Mature T/NK cell
C85 B-cell lymphomas
Lymphoma ICD-10
Status of Leukemias
• All leukemia codes are divided into
subdivisions to demonstrate the patient’s
status NOW:
– Never having achieved remission
– In remission
– In relapse
If you don’t specify, it defaults to never
having achieved remission
Your success in treatment depends on
accuracy.
What is Your Definition of
Remission?
• Is it immediate reduction of blasts in
bone marrow with patient still to continue
ongoing chemo or radiation therapy?
• Or is it completion of therapeutic regimen
with evaluation demonstrating that
patient’s malignancy is evidently gone?
• Which does the statistics mean?
Side Effects/Complications
• “Mucositis” due to chemo
• Bleeding by severity – chronic? Acute
with hypovolemia, hemorrhagic shock?
• During neutropenic phase, specify:
– Probable bacterial infection in
immunocompromised host
– Sepsis in neutropenic patient when septic
– “Neutropenic fever” does not indicate
concern that there is an infection
Side Effects/Complications
• Veno-occlusive disease
– Identify when patient comes through the
door with it (POA)
– Identify what vein involved – sural veins,
deep femoral vein subclavian vein
• Organ failures from GVHD or from
another source
– Insufficiency isn’t failure
– Azotemia isn’t failure
– Transaminasemia isn’t disease
Side Effects/Complications
• Link and differentiate pulmonary disease
to the disease, the drug, the radiation or
the BMT
– Pneumonitis
– Recurrent pneumonia
– Obliterative bronchiolitis
– Cryptogenic organizing pneumonia
– Diffuse alveolar hemorrhage
– CMV or PCP pneumonia
Risks to Therapeutic Treatment of the
Cancer Patient
• Malnutrition
• Immunosuppression
• Decreased function of organs
– Respiratory dysfunction
– Cardiac dysfunction
– Renal dysfunction
– Hepatic dysfunction
• Lack of support – physical, emotional,
financial
Nutrition in the Cancer Patient
• Cachexia, inanition is an appearance
• When the patient needs nutritional support,
it may be because of one of three reasons:
– Chronic malnutrition due to malignancy
– Acute malnutrition due to surgery or
infection
– Prevention of malnutrition when patient who
is not malnourished now is at risk
• State if malnutrition DUE TO tumor, DUE
TO side effects of chemo, DUE TO …
what?
Malnutrition
• Be wary of BMI in patients with ascites,
pleural effusions, anasarca from
hypoproteinenia
• Work with dietary to use ASPEN eval of
pt to stratify malnutrition when it exists
• Malnutrition quick estimates
– Mild - < 10% body mass loss
– Moderate – 10 – 20% body mass loss
– Severe - > 20% body mass loss
Malnutrition
• One third of hospital patients are affected by
moderate or severe malnutrition
• Capability to tolerate tests, treatments,
surgeries significantly impaired with moderate
to severe malnutrition
• What we see:
– Cachexia
– 20 lb wt loss in past month
– Poor nutrition due to dysphagia
Infectious Disease
• Although sepsis and septicemia
determined to be two different entities
(local infection with systemic impact
through release of kinins from
macrophages vs infection of the blood
stream), both have same code now - A41
• Bacteremia R78.81, viremia B34.9,
fungemia B49 have specific codes, none
of which carry severity
Specific “Sepsis/Septicemia”
•
•
•
•
•
Anthrax sepsis A22.7
Septicemia of plague A20.9
Salmonella sepsis A02.1
Listeria sepsis A32.7
Meningococcemia
– Acute A39.2
– Chronic A39.3
• Streptococcal sepsis – specify group
• Toxic shock syndrome A48.3
• Sepsis not specified A41
The Future Must Be Started Now
ICD-9-CM
995.91 Sepsis (SIRS due
to infection without
organ dysfunction
995.92 Severe sepsis
(SIRS due to infection
with organ dysfunction
995.93 SIRS due to
noninfection without
organ dysfunction
995.94 SIRS due to
noninfection with organ
dysfunction
ICD-10-CM
*****
R65.20 Severe sepsis
without septic shock
R65.21 Severe sepsis with
septic shock
R65.10 SIRS due to
noninfection without
organ dysfunction
R65.11 SIRS due to
noninfection with organ
dysfunction
Conditions Related to …
Sepsis due to:
UTI
Pneumonia
Ascending cholangitis
Infected decubitus
Osteomyelitis
Infected vascular cath
Subphrenic abscess
All are infections!
SIRS due to:
Hemorrh pancreatitis
Burns (not infected)
Pulmonary embolism (clot,
fat, amniotic fluid)
Multiple trauma
Allergy
None are infections!
Severe Sepsis
Intent is to identify sepsis with distant
organ failure. Organs may include:
– Acute renal failure (due to sepsis)
– ARDS/acute respiratory failure
– Shock liver/ acute hepatic necrosis
– Demand NSTEMI
– Disseminated intravascular coagulopathy
– Encephalopathy (metabolic – due to
sepsis)
– Critical care myopathy
– Circulatory system failure – inability to
perfuse vital organs
Indwelling Device Infections
• Specific code sets apply when
infection or “septicemia” is related to
indwelling:
– Vascular access catheter for dialysis
– Urinary tract catheter or device
– Orthopedic appliance
– Artificial heart valve
– Prosthesis for vascular bypass or for
hernia support
MAKE THE LINK
Confusing Terminology
Must Differentiate After Study …
• Neutropenic fever - fever in a patient with low white
count but no infection found
– Fever of at least 38.3° C occurring on several occasions
in a patient whose neutrophil level is lower than 500/mm3
or is expected to fall below that level within 1 or 2 days,
the cause of which cannot be determined after 3 days of
investigation, including 2 days of incubation of cultures
– Or is there a specific infectious process identified
• Neutropenic sepsis
– Sepsis in a patient with low white count from cancer or
chemo
– Severe sepsis with bone marrow dysfunction due to
infection
• Fever because of destruction of white cells
Fever in an
Immunocompromised Host
Question: A patient undergoing chemotherapy presents with
acute onset of fever and chills. His WBC is 800. Chest xray and cultures do not reveal any etiology. The patient is
placed on antibiotic therapy and improves over the 72 next
hours. The physician states the principal diagnosis to be
fever in an immunocompromised host and documents in the
medical record that he suspects a culture-negative bacterial
infection. Is this coded as fever of undetermined origin?
Answer: No. This is an immunocompromised host who is very
susceptible to opportunistic bacterial infection as the
physician has delineated. The clinical situation, the
selection of the therapy, and the response to that treatment
support the physician's clinical suspicion. The appropriate
diagnosis code would be 041.9 (A49.9), Bacterial infection,
unspecified.
Cardiomyopathy
“CMP” – Vanilla
Is it hypertensive?
Is it ischemic?
Is it alcoholic, viral?
Is it toxicity due to chemotherapy?
Is it due to valvular disease?
Is it due to congenital disease?
Describe the pathogenesis! Name the
disease!
Chemotherapy Related Cardiac
Dysfunction
• CRCD can be classified into two types.
– Type I exemplified by anthracyline-induced
dysfunction
– Type II exemplified by trastuzumab-induced
dysfunction.
• Establish an early diagnosis and initiating early
treatment to prevent irreversible damage
• No guidelines developed specifically for the
treatment of chemotherapy induced
cardiomyopathy (CIC)
• Follow American College of Cardiology/
American Heart Association (ACC/AHA)
guidelines.
Criteria for CRCD
1) decrease in cardiac left ventricular ejection
fraction (LVEF), either global or more severe
in the septum;
2) symptoms of heart failure (HF) ;
3) associated signs of HF, including but not
limited to S3 gallop, tachycardia, or both; and
4) decline in LVEF of at least 5% to less than
55% with accompanying signs or symptoms
of HF, or a decline in LVEF of at least 10% to
below 55% without accompanying signs or
symptoms. The presence of any one of the
four criteria is sufficient to confirm a diagnosis
of CRCD
Premier Quality Demonstration
HEART FAILURE
• Left Ventricular function assessment
• ACEI or ARB for LVSD
– Angiotensin Converting Enzyme Inhibitor
– Angiotensin Receptor Blocker
– Change as of 1 January 2005
• Smoking cessation counseling
• Detailed DC instructions
Do You Use 428/L50 for Your Billing?
428.1 L50.1 Acute pulmonary edema from acute left heart failure
428.20 L50.20 Unspecified systolic heart failure
428.21 L50.21 Acute systolic heart failure
428.22 L50.22 Chronic systolic heart failure
428.23 L50.23 Acute on chronic systolic heart failure
428.30 L50.30 Unspecified diastolic heart failure
428.31 L50.31 Acute diastolic heart failure
428.32 L50.32 Chronic diastolic heart failure
428.33 L50.33 Acute on chronic diastolic heart failure
428.40 L50.40 Unspecified combined systolic and diastolic heart
failure
428.41 L50.41 Acute combined systolic and diastolic heart failure
428.42 L50.42 Chronic combined systolic and diastolic heart failure
428.43 L50.43 Acute on chronic combined systolic and diastolic heart
failure
Cardiomyopathy
The Causes
• Hypertensive
• Infectious
myocarditis
• Collagen vascular
diseases
• Transplant rejection
• Sarcoidosis
• Brugada’s disease
• Chemotherapeutic
agents
• Lead poisoning
• Cocaine or
amphetamine use
•
•
•
•
•
•
•
•
•
•
•
•
Ischemic
Alcoholic
Nutritional deficiencies
Thyroid disease
Diabetic CMP
Obesity
Amyloidosis
Hemochromatosis
Scleroderma
Radiation myocarditis
Septal hypertrophy
IHSS
49
“Chronic Renal Failure”
and Complexity of Medical Decision Making
Non Specific
formerly CRF or
CRI, now CKD
Specific
CKD DUE TO Hypertensive
nephrosclerosis
CKD DUE TO Diabetic
glomerulosclerosis
CKD DUE TO Intrinsic glomerular
disease
CKD DUE TO Tubulointerstitial
disease
CKD DUE TO Lupus
CKD DUE TO Polycystic disease
CKD DUE TO Multiple myeloma
KDIGO
Stage
GFR
1
90+
2
Kidney Disease Improving Global Outcomes
Description
Treatment stage
Normal kidney function but
urine or other
abnormalities point to
kidney disease
Observation, control of
blood pressure
60-89
Mildly reduced kidney function,
urine or other
abnormalities point to
kidney disease
Blood pressure control,
monitoring, find out
why.
3
30-59
Moderately reduced kidney
function
More of the above, and
probably diagnosis, if
not already made.
4
15-29
Severely reduced kidney
function
Planning for endstage
renal failure.
5
14 or
Very severe, or endstage
less
kidney failure (established
renal failure)
See treatment choices
for endstage renal
failure.
Stages of AKI
Stg
Serum creatinine criteria
Urine output
criteria
1
Increase in serum creatinine of more
than or equal to 0.3 mg/dl or increase
to more than or equal to 150% to
200% from baseline
Less than 0.5 ml/kg
per hour for more
than 6 hours
2
Increase in serum creatinine to more
than 200 – 300% from baseline
Less than 0.5 ml/kg
per hour for more
than 12 hours
3
Increase in serum creatinine to more Less than 0.3 ml/kg
than 300% from baseline or serum
per hour for 24 hours
creatinine of more than or equal to 4.0 or anuria for 12 hours
mg/dl with an acute increase of at
least 0l5 mg/dl
AKI Caveat
• It is imperative to NOT CALL changes
in creatinine AKI until the patient has
been volume repleted for at least six
hours. If creatinine bump persists
after fluid resuscitation, there was
likely AKI. If not, there was NOT AKI.
• “Acute kidney injury should be
both abrupt (within 1–7 days) and
sustained (more than 24 hours).”
Respiratory Failure in ICD-10
• Document acute or chronic or both
• Specify if hypoxemic or hypercapnic
respiratory failure for either acute or
chronic
• Without specificity,
defaults to unspecified,
with least severity
Acute Respiratory Failure
Definitions by chemistries agreed upon by
coding guidelines and by Medical textbooks:
• Hypoxemic – inability to maintain O2 sats of
90% on 6 liters
• pO2 10 - 15% lower than expected for that
patient
• Hypercapnic - pH < 7.30 and pCO2 > 55
regardless of pO2
• Clinical – patient tiring and need respiratory
support immediately, tubed or not
Chronic Respiratory Failure
• Adds to severity of any admission
• Adds to expected morbidity and
mortality of any admission
• Allows for immediate approval of home
oxygen and other medications
• Can be identified by pH=7.4 and pCO2
over 50 – 60 or pO2 under 50
• May consider CO2 over 35 on BMP in
absence of other acid-base issue
AMS is not Encephalopathy
When a patient is determined to have one of the
following as cause of AMS, specify as:
–
–
–
–
–
–
–
Alcoholic encephalopathy
Ischemic (anoxic) encephalopathy
Hepatic encephalopathy
Hypertensive encephalopathy
Metabolic (internal source) encephalopathy
Toxic (external source) encephalopathy
Traumatic (post-concussive) encephalopathy
Aspiration Pneumonitis, Aspiration
Bronchitis
• Microaspiration of gastric acid can lead to
acute aspiration bronchitis or aspiration
pneumonitis
• Pneumonia due to anaerobes or gram
negatives - likely outcome if
– Aspirated material large in volume
– Contains virulent components of the anaerobic
microbial flora if patient has teeth or
– Foreign bodies such as aspirated food or necrotic
tissue
DNR vs Palliative Care V66.7 Z51.5
DNR – patient desires some limitations in
case of perception of death (no code,
slow code, no vent, etc.)
Comfort measures only – patient and
family and physician and chaplain all
agree that treating measures will be
stopped or not instituted with exception
of pain management, fluids – comfort
Palliative care consult is NOT the same
Lab Result vs Disease?
Symbols and directions for abnormalities do
not translate into disease processes from a
severity standpoint.
• Troponin 
• Na+ = 124
• EtOH (+)
• Hb 
… do not translate into the economic language
of health care!
Handling the Problem List
It’s an Epic Task
Example Changes in Epic
to Support ICD-10
• Diagnosis Calculator
– For providers who directly enter diagnoses
(encounter diagnoses, charge capture,
order-association), guides users to more
specific code by prompting for laterality,
acuity, etc.
• Updating Documentation Tools
– To facilitate documentation of needed detail
for the coders
– Epic builders will work with you to update
SmartTexts, SmartPhrases, Note templates,
etc. Dr. Jason Lyman, ICD-10 Physician Champion, lyman@virginia.edu
Questions: Contact
Beware of cloned documentation
RACs and other auditors are on the
lookout for cloned
documentation, often a problem
in teaching hospitals and large
academic medical centers.
"Auditors look for instances when
the attending physician cuts and
pastes from the resident's note into
his own," says Nguyen.
CMS requires documentation of each
encounter so that the note stands on its
own and represents the actual services
provided by the attending physician for
each date of service or encounter. Data,
including vital signs, may not be copied
from one visit to the next. CMS states that
note cloning raises concerns about the
medical necessity of continued
hospitalization.
• The U.S. Department of Health & Human Services
and the Department of Justice have promised to
come down hard on providers who misuse electronic
health records to financially game the healthcare system.
• HHS Secretary Kathleen Sebelius and U.S. Attorney General Eric
Holder warned that law enforcement agencies are keeping an eye out
for fraud and "will take action where warranted," in a letter sent to the
American Hospital Association, Association of Academic Health
Centers, Association of American Medical Colleges and others
• Sebelius and Holder point to potential cloning of medical records as
one of several indications that fraud could be on the rise. Medicare
administrative contractor National Government Services earlier this
month issued a notice, stating that cloned documents from EHRs
mostly likely would result in payment denials.
Paint the picture of the patient
properly with WORDS
What you want…
may
not
be…
what you might
get.
So the coder can paint the same
picture with codes.
Questions
and Answers
Your Ideas and
Comments