Value Based Purchasing, Changes
for ICD-10 and the Future of
Urology
Robert S. Gold, MD
Medicine Under the Microscope
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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.
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
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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?
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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
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
Surgery Bundling Test Model
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Disclosed May 16, 2008
ACE (Acute Care Episode) project
Combine Part B payments with Part A
“Value Based Centers” started with Texas,
Oklahoma, New Mexico and Colorado
Value based purchasing
28 cardiac and 9 orthopedic inpatient surgical
services
Gainsharing also permitted here
Based on severity adjusted financial outcomes
Florida Blue and Mayo Clinic Introduce
Knee Replacement Bundled Payment
Program
Friday, December 14, 2012
JACKSONVILLE, Fla. — Florida Blue and Mayo Clinic
jointly announce a new collaboration aimed at providing
the utmost in quality care for knee replacement patients
in Florida. The two Florida health care leaders are
teaming up to create a bundled payment agreement
specific to the treatment of knee replacement surgery.
Knee replacement surgery is the most common joint
replacement procedure. According to the Agency for
Healthcare Research and Quality, health care
professionals perform more than 600,000 knee
replacements annually in the United States.
Florida Blue and Holy Cross Create
Accountable Care Arrangement
Jacksonville and Fort Lauderdale, Fla. – Florida Blue,
Florida’s Blue Cross and Blue Shield Company, and
Holy Cross Physician Partners are pleased to announce
that effective January 1, 2013, Holy Cross Physician
Partners will participate in the Florida Blue Accountable
Care Program.
“Florida Blue is excited to expand our relationship with Holy
Cross surrounding this exciting new partnership,” said
Dr. Jonathan Gavras, chief medical officer and senior
vice president for Florida Blue. “In the age of reform,
both organizations realize the importance of moving
away from the fee-for-service model to one that focuses
on quality outcomes that will benefit our members in
South Florida.”
Aetna, Baptist Memorial Health Care
Announce Collaborative Care
Agreement
Thursday, April 25, 2013 4:11 pm EDT
MEMPHIS, Tenn.--(BUSINESS WIRE)--Aetna (NYSE: AET) and Baptist
Memorial Health Care today announced a collaborative care
agreement to bring a new health care model to Aetna members and
introduce Aetna Whole HealthSM, a commercial health care product.
This collaboration will give employers and their workers access to highly
coordinated care from physicians and facilities in the Baptist Select
Health Alliance. The Baptist Select Health Alliance is a clinically
integrated group of physicians focused on tracking outcomes,
sharing data and measuring clinical standards to improve quality and
efficiency.
In collaborative care models, a group of health care providers delivers
more coordinated care for patients to drive better quality and lower
overall costs. Through Baptist Memorial Health Care, Aetna
members will receive an enhanced level of coordinated care in
addition to the member benefits of their current Aetna plan.
Getting Studies Paid For
Laboratory/Radiographic
• Bundled payment modes rely on payment being
made for lab or x-ray studies
• Validation of reason for performing any
procedure or test depends on Medical Necessity
• Local Medical Review Policies (LMRPs), Local
or National Coverage Determinations (LCDs,
NCDs)
• Not giving a reason for a test you order
(symptom or diagnosis) could result in:
– Advance Beneficiary Notification (ABN) saying
patient may have to pay for the test
– Somebody bugging you for a reason for the test
Readmissions Initiative
• Identify hospitals with excess readmissions for
certain selected conditions beginning in FY 2013
for discharges on or after October 1, 2012.
– Acute myocardial infarction (i.e., heart attack)
– Heart failure
– Pneumonia
• Definition of readmission: “occurring when a
patient is discharged from the applicable hospital
and then is admitted to the same or another acute
care hospital within a specified time period from
the time of discharge from the index
hospitalization.” The specified time period would
be 30 days.
20
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.
Patient Safety Indicators
Hospital acquired preventable diagnoses
• Hospital falls that lead to patient damage (fractures, etc.)
• Mediastinitis post-CABG
• Catheter-associated UTIs – Foley, suprapubic
cystostomy, nephrostomy, ureteral stents
• Vascular catheter associated infections
• Pressure ulcers
• Iatrogenic pneumothorax following central line insertion
• Object accidentally left in patient
• Air embolism
• Reaction from blood incompatibility
What Does This Mean?
• Properly identify complication of care
when complication – specify when due to
a disease
• We don’t want to assign complication
codes when not complication
– If event due to disease, not a complication
– If even doesn’t exist, not a complication
• Don’t use the word “post-op” in the
post-op period!
Is an Adverse Event Always a
Complication?
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Not at all.
Stuff happens.
Diseases cause adverse effects
Anemia due to blood loss is usually due to the
disease and not to the surgery
State so: anemia of chronic blood loss due to
right renal cell carcinoma; anemia of acute blood
loss due to femur fracture
• Adverse effects are easily explained and
defended in a patient with more risk factors. If you
didn’t name these, you lose.
NOT Acute Respiratory Failure
• Patients being purposely maintained on the
ventilator after surgery because of weakness,
chronic lung disease, massive trauma are NOT in
acute respiratory failure – unless they are
• Patients being purposely maintained on the
ventilator after extensive surgery in the face of
morbid obesity or COPD are NOT in acute
respiratory failure – unless they are.
• Prevention of acute respiratory failure from
angioedema, stroke, trauma when patient does
NOT HAVE acute respiratory failure when
intubated for airway protection
Goals of Implementation –
Prove You Are Value Based
• Competitive severity adjusted mortality and
morbidity statistics
• Low incidence of HACs
• Reasonable occurrence of PSIs
• Lower than average Readmissions for
Pneumonia, Heart Failure, AMI
• Cooperation with quality initiatives
• Decent responses to a new questionnaire on
discharge
Documentation Needs:
What’s The Surgery For?
• Provide the diagnosis for which the
surgery is being performed
• Tell why it’s necessary for that diagnosis
• DON’T just say that the patient is being
admitted for the surgery (Admitted for
radical suprapubic prostatectomy)
• DON’T just provide signs and symptoms
• Tell the story of the workup that led to
the diagnosis
Documentation Needs:
Complexity of Patient
• Name other diseases patient has coming
through the door – chronic, stable
conditions
• Avoid “Resume home meds” unless you
identify each disease being treated
• Permit other physicians to follow serious
co-morbidities, but name each at least
ONCE, especially in discharge summary
ACS NSQIP Data Collection Overview
The ACS NSQIP collects data on 136 variables,
including preoperative risk factors, intraoperative
variables, and 30-day postoperative mortality and
morbidity outcomes for patients undergoing major
surgical procedures in both the inpatient and
outpatient setting.
Surgical Risk Stratification
• NSQIP databases depend on
identification of risk factors
Heart – failure? MI?
Lungs – chronic?
Nutrition – over? mal?
Diabetes – cont?
Renal status – chr, ac.
Malignancy?
Smoking, ETOH?
Stroke – residua?
Hepatic fxn – name it
Encephalopathy?
Immunocomp – how?
Sepsis? Org fail?
Use ster, insul, chemo
Periph vasc?
Risk Stratification for Pulmonary
Complications
Age
Obstructive sleep apnea
Chronic lung disease
Impaired sensorium
Cigarette use
Surgical site
Congestive heart failure
Elective vs emergency
ASA Class of comorbids
Prolonged surgery
Functional dependence
General anesthesia
Obesity
Transfusion > 4 units
Modified NSQIP Data Sheet
WEIGHT/HEIGHT:
.
WEIGHT (KG)
.
HEIGHT (Cm) BMI
.
NUTRITIONAL STATUS (Overnutrition risk)
Obese
Morbidly obese
Obes/hypovent synd
Sleep apnea
MALNUTRITION (% Body Weight Loss)
N
Mild (<10% loss)
Moderate (10 – 20%)
Severe (>20%)
HISTORY OF SMOKING: (any tobacco use)
N
Pack year history _________
Current (within 30 days) _____ PPD
FAMILY HX CORONARY ARTERY DISEASE <55:
N
Y ____________________________ (family members)
DIABETES:
N
Type 1
Type 2
on insulin
Other secondary diabetes ____________
DIABETES CONTROL
CONTROLLED
UNCONTROLLED
OTHER ORGAN INVOLVEMENT
Neuropathy
Nephropathy
Vascular disease
Ulcers
DYSLIPIDEMIA:
N
Hypercholesterolemia
Hypertriglyceridemia
KIDNEY DISEASE (STAGE) GFR _______:
CKD 1
2
3
4
5
ESRD
Acute renal failure
DIALYSIS PATIENT:
N
Y
Hemodialysis
Peritoneal dialysis
STROKE:
N
Hemorrhagic
Ischemic
Recent (<2 wks)
Remote (> 2 wks)
CEREBROVASCULAR DISEASE:
N
Prior carotid surgery
Coma
TIAs
CNS DEFICITS
N
Quad
Parapl Hemipl dom Nondom
Nerve damage ___________
FUNCTIONAL HEALTH STATUS
Independent ADLs
Partially Dependent
Totally Dependent
INFECTIOUS ENDOCARDITIS:
N
Mitral
Aortic
Tricuspid
Pulmonic
CHRONIC LUNG DISEASE:
N
COPD
Bronchiectasis
Emphysema
Chronic respiratory failure
IMMUNOSUPPRESSIVE THERAPY
N
Chronic steroids
Antiinflammatories Antineoplastics
The Mayo
Model of
PreOperative Medical Evaluation
• Initial medical evaluation for risk stratification
– fill out POME
• Lab and radiographic studies as indicated – fill
out POME
• Consultative visits and tests as needed – fill
out POME
• Visit to Anesthesiology with recommendations
and results – fill out preop anesthesia forms
• Visit to surgeon with all needed risk factors
complete – complete H&P
• Eliminate cancelled surgeries, delays
Was It Present on Admission?
Patient safety indicators may give us a black
eye if it’s not documented!
• Ileus from perforated bowel or from peritonitis – was it
present on admission?
• DVT in patient from nursing home – was it present on
admission?
• Decubitus ulcer – is it an ulcer - was it present on
admission?
• Atelectasis in a morbidly obese patient – was it
present on admission?
If we don’t document it, we get
charged with it!
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)
Don’t Wait Till Tomorrow
for ICD-10
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
How Close Are We?
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%
Specificity is NOT Always Possible
Sign/Symptom/Unspecified Codes
In both ICD-9-CM and ICD-10-CM, sign/symptom and “unspecified” codes have
acceptable, even necessary, uses. While specific diagnosis codes should be
reported when they are supported by the available medical record
documentation and clinical knowledge of the patient’s health condition, there
are instances when signs/symptoms or unspecified codes are the best
choices for accurately reflecting the healthcare encounter.
Each healthcare encounter should be coded to the level of certainty known for
that encounter.
If a definitive diagnosis has not been established by the end of the encounter, it
is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a
definitive diagnosis.
When sufficient clinical information isn’t known or available about a particular
health condition to assign a more specific code, it is acceptable to report the
appropriate “unspecified” code (e.g., a diagnosis of pneumonia has been
determined, but not the specific type).
In fact, unspecified codes should be reported when they are the codes that most
accurately reflects what is known about the patient’s condition at the time of
that particular encounter. It would be inappropriate to select a specific code
that is not supported by the medical record documentation or conduct
medically unnecessary diagnostic testing in order to determine a more
specific code.
Source: Cooperating Parties for ICD-10-CM/PCS and ICD-9-CM Coding, May 2013.
Renal Malignancies ICD-9
189.0 Kidney, except pelvis (Includes Wilms
tumor, renal cell carcinoma, urothelial cell ca)
189.1 Renal pelvis
189.2 Ureter
189.3 Urethra
189.4 Paraurethral glands
189.8 Other specified sites of urinary organs
Malignant neoplasm of contiguous or
overlapping sites of kidney and other urinary
organs whose point of origin cannot be
determined
189.9 Urinary organ, site unspecified
Renal Malignancies ICD-10
C64.1 Malignant neoplasm of right kidney, except renal
pelvis (includes all cell types)
C64.2 Malignant neoplasm of left kidney, except renal
pelvis (includes all cell types)
C64.9 Malignant neoplasm of unspecified kidney, except
renal pelvis (includes all cell types)
C65 Malignant neoplasm of renal pelvis
C65.1 Malignant neoplasm of right renal pelvis
C65.2 Malignant neoplasm of left renal pelvis
C65.9 Malignant neoplasm of unspecified renal pelvis
C66Malignant neoplasm of ureter
C66.1 Malignant neoplasm of right ureter
C66.2 Malignant neoplasm of left ureter
C66.9 Malignant neoplasm of unspecified
Similarities and Differences
• Now identify right or left kidney, pelvis,
ureter
• Same differentiation by part of renal
system
• No breakdown as to cell types
• Do we need this?
– Wilms tumor (nephroblastoma)
– Renal cell carcinoma
– Urothelial cell carcinoma
Mets to Bone
ICD-9
198.5 Bone and bone
marrow
ICD-10
C79.51 Bone
C79.52 Bone marrow
Stones in 9 and 10
592.0 Calculus of kidney
Nephrolithiasis NOS
Renal calculus or stone
Staghorn calculus
Stone in kidney
Excludes: uric acid
nephrolithiasis (274.11)
592.1 Calculus of ureter
Ureteric stone
Ureterolithiasis
592.9 Urinary calculus,
unspecified
N20.0 Calculus of kidney
Nephrolithiasis NOS
Renal calculus
Renal stone
Staghorn calculus
Stone in kidney
N20.1 Calculus of ureter
Ureteric stone
N20.2 Calculus of kidney
with calculus of ureter
N20.9 Urinary calculus,
unspecified
Benign Prostatic Disease – ICD-9
600.0 Hypertrophy (benign) of prostate
600.00 Hypertrophy (benign) of prostate
without urinary obstruction and other lower
urinary tract symptoms (LUTS)
600.01 Hypertrophy (benign) of prostate
with urinary obstruction and other lower
urinary tract symptoms (LUTS)
600.1 Nodular prostate
600.10 Nodular prostate without obstruction
600.11 Nodular prostate with urinary
obstruction
600.2 Benign localized hyperplasia prostate
600.20 Benign localized hyperplasia of
prostate without urinary obstruction and
other lower urinary tract symptoms (LUTS)
600.21 Benign localized hyperplasia of
prostate with urinary obstruction and other
lower urinary tract symptoms (LUTS)
600.3 Cyst of prostate
Use additional code to
identify symptoms:
incomplete bladder emptying
(788.21)
nocturia (788.43)
straining on urination (788.65)
urinary frequency (788.41)
urinary hesitancy (788.64)
urinary incontinence (788.30788.39)
urinary obstruction (599.69)
urinary retention (788.20)
urinary urgency (788.63)
weak urinary stream (788.62)
Benign Prostatic Disease ICD-10
N40.0 Enlarged prostate
without lower urinary tract
symptoms
N40.1 Enlarged prostate with
lower urinary tract symptoms
N40.2 Nodular prostate without
lower urinary tract symptoms
N40.3 Nodular prostate with
lower urinary tract symptoms
No code for benign localized
hyperplasia prostate
N42.83 Cyst of prostate
Use additional code for
associated symptoms,
when specified:
incomplete bladder emptying
(R39.14)
nocturia (R35.1)
straining on urination (R39.16)
urinary frequency (R35.0)
urinary hesitancy (R39.11)
urinary incontinence (N39.4-)
urinary obstruction (N13.8)
urinary retention (R33.8)
urinary urgency (R39.15)
weak urinary stream (R39.12)
Adhesions
• Specify in females if due to pelvic
inflammatory diseases or post uterine or
adnexal surgery
• General adhesions, male or female, due
to other than diseases of the female
pelvic organs are assigned the same
code
• Distinguish with or without obstruction
Endocrine Complications or Metabolic
Disorders After Endocrine Surgery or
Other Surgery
• Postop hypoadrenalism, hypothyroidism,
hypoparathyroidism, hypopituitrism,
ovarian failure (symptomatic or
asymptomatic)
• Specify when these are desired outcomes
of (integral to) the surgery performed
• Identify accidental puncture or laceration
and hematoma or hemorrhage in renal,
adrenal surgeries
Nephritis
• Identify cause (disease) and if hereditary
• Identify when acute
– Identify when rapidly progressive
– With or without persistent hematuria
• Identify when chronic
– Identify when with nephrotic syndrome
Nephritic Syndrome (acute)
1. Hematuria
2. Oliguria
3. Azotemia
4. Hypertension
Nephrotic Syndrome (chronic)
1. Massive proteinuria
2. Hypoalbuminemia
3. Edema
4. Hyperlipidemia/hyperlipiduria
Cystitis
• Provide specificity
– Acute cystitis
– Interstitial cystitis
– Trigonitis
– Radiation cystitis
• Specify if with or without hematuria and
microscopic or gross hematuria
Urethral Stricture
• Identify cause
– Posttraumatic
– Postinfectious
– Other
• Identify sex of patient – in female, if due
to childbirth
• Identify part of urethra involved as
appropriate
– Meatus
– Bulbous urethra
Urinary Incontinence
•
•
•
•
•
•
•
Stress incontinence
Urge incontinence
Incontinence without sensory awareness
Post-void dribbling
Nocturnal enuresis
Continuous leakage
Mixed incontinence (stress and urge)
GU Surgery Complications
• Urethral stricture
• Vaginal adhesions, prolapse
• Postop pelvic adhesions from pelvic
surgery
• Complications of cystostomy, other
external or internal stoma of urinary tract
(hemorrhage, infection, malfunction)
• Hemorrhage, hematoma, accidental
puncture or laceration in genitourinary
surgery–specify if identified during or after
surgery
KDIGO Kidney Disease Improving Global Outcomes
Stage
GFR
1
90+
2
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.
AKI or ARF
Insufficiency is NOT a synonym
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
Caveat
• The writings of the AKIN state that, in cases of
dehydration (and dehydration is still, truly the
number one cause of acute renal failure in the
US), 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
Diabetes
• Juvenile (IDDM) –Type
1 diabetes occurs in a
state of insulin
deficiency resulting from
pancreatic beta cell
destruction
• Adult (NIDDM) – Type 2
diabetes results from
increased resistance to
the effects of insulin.
These patients may
require insulin for
control.
Diabetes
• Identify type 1, type 2, due to other
secondary cause, gestational
• In type 2 or secondary cause, identify when
using insulin long term
• Identify all body systems affected by the
diabetes (neuropathy and its manifestation,
retinopathy and proliferative or
nonproliferative, nephropathy and stage of
CKD, dermopathy, vasculopathy,
periodontopathy)
• Identify all manifestations (ulcer, coma,
gangrene, osteomyelitis, etc.)
Hypertension – ICD-10
Essential hypertension (I10) – includes high
blood pressure, hypertension, malignant
hypertension, accelerated hypertension,
benign hypertension
Secondary hypertension (I15)
– I15.0 – renovascular
– I15.1 – hypertension secondary to other renal
disorders
– I15.2 – hypertension secondary to endocrine
disorders (carcinoid, pheochromocytoma, etc.)
– I15.8 – other secondary hypertension
– I15.9 – secondary hypertension, unspecified
Hypertension – ICD-10
Hypertensive heart disease - I11
•
I11.0 - with heart failure
•
I11.9 - without heart failure
Hypertensive kidney disease - I12
•
I12.0 - with stage 5 CKD or ESRD
•
I12.9 - with CKD stages 1–4
N18.1, 2, 3, 4, 5, 6, 9 for CKD stages 1, 2, 3,
4, 5, ESRD, unspecified
Nutritional Status
• Malnutrition – dietary consult or estimate
– Mild (<10% loss)
– Moderate (10-20% loss)
– Severe (>20% weight loss)
• Consider the acute malnutrition of surgery,
trauma and sepsis
• Morbid obesity and all of its manifestations
and risks for surgery and anesthesia
–
–
–
GER
Sleep apnea
Cellulitis
- Obesity Hypoventilation Syndrome
- Secondary hypercoagulable state
- Hypertensive heart disease
- Hypertension
- Diabetes with …
- Chronic cor pulmonale
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
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
Cholangitis
Decubitus
Osteomyelitis
Infected dialysis 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
Sepsis with distant organ failure:
– Acute renal failure (due to sepsis)
– ARDS or acute respiratory failure
– Acute hepatic failure (due to sepsis)
– Encephalopathy (metabolic – due to sepsis)
– DIC (Disseminated intravascular
coagulopathy)
– Critical care myopathy
– Circulatory system failure – inability to
maintain a blood pressure to perfuse vital
organs – CALLED SEPTIC SHOCK
What We Are Seeing
BAD
ARI
CHF
CRF
Na
Hb – 6.8
BP
MODS
Transaminitis
NEEDED
Acute renal failure
Chronic systolic failure
CKD stage 3
Hyponatremia
Anemia – cause?
Shock – cause?
The names of the
failed organs
Acute liver failure
Anemia
and Complexity of Medical Decision Making
Non Specific
Anemia
Specific
Anemia DUE TO chronic renal
failure
Anemia DUE TO chronic
blood loss from a fungating
cecal lesion
Anemia DUE TO acute blood
loss from a hip fracture
Anemia DUE TO chronic
osteo/hepatitis
Anemia DUE TO
antineoplastics
Encephalopathies
• Metabolic encephalopathy G93.41
– Includes due to sepsis, hyper and
hyponatremia, uremic encephalopathy
– Hepatic encephalopathy K72
• Toxic encephalopathy G92
– Lead encephalopathy, bromidism
– Polypharmacy over prolonged periods
leading to CNS damage
Encephalopathies
• Hypoxic ischemic encephalopathy
– P91.61 mild, P91.62 moderate, P91.63
severe
• Other encephalopathy G93.49
– Lyme encephalopathy + A69.21 Lyme
disease
– Wiernicke’s nutritional encephalopathy
E51.2
– Alcoholic (Wiernicke-Korsakoff psychosis)
F10.26
– Hypertensive encephalopathy I67.4
Post-Op Progress Notes
• We were all taught to examine certain
parts of the body on every post-op visit.
• No matter how many times you did it, if
you don’t document it, YOU DIDN’T DO
IT.
• VS, labs, I&O, mental status, chest,
belly, legs, wound, ambulation, bowel
activity – every visit.
Post-Op Progress Notes
Prosecuting attorneys LOVE:
6/17 Doing well
6/18 No new problems
6/19 Events of last night noted
6/20 Called to see patient in full code.
Pronounced dead at 17:15.
Handling the Problem List
It’s an Epic Task
Is the EHR a Friend or Foe?
• State that the programs are ready for ICD9, ICD-10 and SnoMED
• State that they provide “meaningful use”
• State that they aid with “pick lists”
• State that they help with “problem lists”
• State that they help with physician
professional billing because you can cut
and paste
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
Progress Note Management
• Copy and paste of massive amounts of
trash leads to
– useless notes,
– inability of others to determine what is
wrong with the patient NOW
– inability to validate that ANYTHING YOU
DID WAS EFFECTIVE! And
– inability to assign ICD codes – what was
ruled out what was ruled in
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.
Progress Note Needs
• What was the problem that brought the
patient to your attention (one to two
sentences)
• What did you see today? Labs, x-rays,
physical findings, consults, other tests
• What are the diagnoses?
• What has changed? Worse? Better?
More specific? Ruled in or ruled out?
• What are you going to do today?
Three Major Sections
Active diseases, decompensated for which
inpatient care required – update as
issues resolve
Chronic stable conditions that are currently
under treatment
Past Medical Historical conditions, not
currently affecting health status nor
being treated (appy age 12, s/p
hysterectomy, Gr3/Para3, left hip
replaced)
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.
Motto For The Age
“If you don’t
look good, we
don’t look
good” Vidal sassoon, ca 1985
Father of modern medical economics
Questions
and Answers
Your Ideas and
Comments
Question #1 – Which is True?
A. ICD-10 shows a totally different appreciation
of diseases than ICD-9
B. ICD-10 codes are exact walkovers from the
ICD-9 codes – they just look different
C. ICD-10 codes may look different but the
diseases didn’t change – proper
documentation will lead to proper code
assignment
D. ICD-10 codes are different from ICD-9 only
by adding the differentiation of Right vs Left
Question #2 – Which is False?
A. Value of purchasing of healthcare is
dependent on data streams derived from ICD
codes
B. Specific documentation of diseases in ICD-9
will be all that is necessary for specific code
assignments in ICD-10
C. Bundled payments for healthcare will lead to
cooperation between practitioners and
facilities
D. We are the only country in the world billing
for healthcare by ICD codes