Value Based Purchasing, Changes
for ICD-10 and the Future of
Neurology
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
- 
U n iv. V A
2009
R e s p ira to ry D is e a s e s
P n e u m o n ia
H o s p p lu s 6 m o n th s
COPD
H o s p p lu s 6 m o n th s
C ritic a l C a re
R e s p ira to ry F a ilu re
H o s p p lu s 6 m o n th s
S e p s is
H o s p p lu s 6 m o n th s
C a rd ia c D is e a s e s
H e a rt F a ilu re
H o s p p lu s 6 m o n th s
A c u te M I
H o s p p lu s 6 m o n th s
C a rd ia c S u rg e ry
CABG
H o s p p lu s 6 m o n th s
In te rv C a rd io lo g y
H o s p p lu s 6 m o n th s
H e a rt V a lve
H o s p p lu s 6 m o n th s
S u rg e ry
O R IF H ip M a j C o m p l
G I S u rg e ry
H o s p p lu s 6 m o n th s
TH A M aj C om pl
C h o le c ys te c to m y M a j C
U n iv V A
2013
VCU
2013
R e tre a t
D o c to rs
M a rth a
J e ffe rs o n
A u g u s ta
H e a lth
R o c k in g h a m
M e m o ria l
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
Banner Announces Joint Venture with
Blue Cross Blue Shield of Arizona
Banner Health and Blue Cross Blue Shield of Arizona have entered
into a new joint venture, Blue Cross Blue Shield of Arizona
Advantage, which will bring enhanced Medicare services to
Arizonans. This collaboration brings together two premier
organizations with the common goal of improving the quality of
patient care, enhancing wellness and assuring affordability.
"The activities of this joint venture will be a further demonstration of
how Banner is rapidly transitioning to population health
management models to enhance care and control costs through
an emphasis on wellness and care coordination," said Banner
Health President and CEO Peter S. Fine.
"This and our other partnerships with Aetna, HealthNet and United
Healthcare in Arizona and Kaiser Permanente in Colorado, as
well as our selection as a Medicare Pioneer ACO organization,
are helping to position Banner for continued success in a
challenging and transformational health care environment."
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.
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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 "G-codes" 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.
Goals of Implementation –
Prove You Are Value Based
• 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
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
How Ready 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%
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
Overall Stroke ICD-9
430 Subarachnoid hemorrhage
431 Intracerebral hemorrhage
Hemorrhage (of) Basilar, bulbar,
cerebellar, cerebral, etc.
432 Other and unspecified
intracranial hemorrhage
432.0 Nontraumatic extra(epi)dural
hemorrhage
432.1 Subdural hemorrhage
432.9 Unspecified intracranial
hemorrhage
433 Occlusion and stenosis of
precerebral arteries
433.01 Basilar artery with cerebral
infarction
433.11 Carotid artery with cerebral
infarction
433.21 Vertebral artery with
cerebral infarction
433.31 Multiple and bilateral with
cerebral infarction
433.81 Other specified precerebral
artery with cerebral infarction
433.91 Unspecified precerebral
artery with cerebral infarction
434 Occlusion of cerebral arteries
434.01 Cerebral thrombosis with
cerebral infarction
434.11 Cerebral embolism with
cerebral infarction
434.91 Cerebral artery occlusion,
unspecified with cerebral
infarction
Intracerebral Bleed
• Specify if traumatic
or nontraumatic
• Specify by location
in brain (cortical,
subcortical,
brainstem,
intraventricular)
Intracerebral Bleed I-9
431 Intracerebral hemorrhage (nontraumatic)
Hemorrhage (of):
basilar
bulbar
cerebellar
cerebral
cerebromeningeal
cortical
internal capsule
intrapontine
pontine
subcortical
ventricular
Intracerebral Bleed I-10
I61.0 Nontraumatic intracerebral hemorrhage in hemisphere,
subcortical
Deep intracerebral hemorrhage (nontraumatic)
I61.1 Nontraumatic intracerebral hemorrhage in hemisphere,
cortical
Cerebral lobe hemorrhage (nontraumatic)
Superficial intracerebral hemorrhage (nontraumatic)
I61.2 Nontraumatic intracerebral hemorrhage in hemisphere,
unspecified
I61.3 Nontraumatic intracerebral hemorrhage in brain stem
I61.4 Nontraumatic intracerebral hemorrhage in cerebellum
I61.5 Nontraumatic intracerebral hemorrhage, intraventricular
I61.6 Nontraumatic intracerebral hemorrhage, multiple localized
I61.8 Other nontraumatic intracerebral hemorrhage
I61.9 Nontraumatic intracerebral hemorrhage, unspecified
Subdural Bleed
• Specify traumatic or nontraumatic
• Specify acute, subacute or chronic
• Specify
laterality
Cerebral Infarct
• Specify artery involved
• Specify precerebral vessel and which
one
• Specify when embolic and origin
(ulcerated plaque, heart)
• Specify right vs left
side of brain (and
patient’s handedness)
Glasgow Coma Scale
The coma scale codes (R40.2-) can be used in conjunction with
traumatic brain injury codes, acute cerebrovascular disease or
sequelae of cerebrovascular disease codes. These codes are
primarily for use by trauma registries, but they may be used in any
setting where this information is collected. The coma scale codes
should be sequenced after the diagnosis code(s).
These codes, one from each subcategory, are needed to complete the
scale. The 7th character indicates when the scale was recorded.
The 7th character should match for all three codes.
At a minimum, report the initial score documented on presentation at
your facility. This may be a score from the emergency medicine
technician (EMT) or in the emergency department. If desired, a
facility may choose to capture multiple coma scale scores.
Assign code R40.24, Glasgow coma scale, total score, when only the
total score is documented in the medical record and not the
individual score(s).
R40.20 Unspecified coma
Coma NOS
Unconsciousness NOS
7th digit – when analyzed
R40.21 Coma scale, eyes open (4 levels)
0 – unspecified time
R40.211 Coma scale, eyes open, never
1 – in the field (EMT or ambulance
R40.212 Coma scale, eyes open, to pain
2 – at arrival in ED
R40.213 Coma scale, eyes open, to sound
3 – at hospital admission
R40.214 Coma scale, eyes open, spontaneous
4 – 24 hours or more after admission
R40.22 Coma scale, best verbal response (5 levels)
R40.221 Coma scale, best verbal response, none
R40.222 Coma scale, best verbal response, incomprehensible words
R40.223 Coma scale, best verbal response, inappropriate words
R40.224 Coma scale, best verbal response, confused conversation
R40.225 Coma scale, best verbal response, oriented
R40.23 Coma scale, best motor response (6 levels)
R40.231 Coma scale, best motor response, none
R40.232 Coma scale, best motor response, extension
R40.233 Coma scale, best motor response, abnormal
R40.234 Coma scale, best motor response, flexion withdrawal
R40.235 Coma scale, best motor response, localizes pain
R40.236 Coma scale, best motor response, obeys commands
R40.24 Glasgow coma scale, total score
Use codes R40.21 - through R40.23 - only when the individual score(s) are documented
R40.241Glasgow coma scale score 13-15
R40.242Glasgow coma scale score 9-12
R40.243Glasgow coma scale score 3-8
R40.244 Other coma, without documented Glasgow coma scale score, or with partial score
reported
Late Effect Issues
• Deficits on this admission are coded as new
• Deficits that were from a previous admission
or are used to admit to post-acute care are
late effects
• Note dominant side or handedness in
hemiparesis
• Late effects designate as DUE TO:
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Old stroke
Old CNS infection
Old trauma
Old CNS surgery
Severity of Intracranial Bleed
• Unconscious
– Glasgow Coma Scale determinations at
site, in ED, after 24 hours, etc.
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Spastic or flaccid paralysis
Quadriplegic
Cerebral edema
Brain herniation
Brain dead
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
Hypertensive Emergency?
Out the Window
I67.4 – Hypertensive encephalopathy (benign,
malignant, accelerated, essential, systemic,
idiopathic)
• Hypertensive acute kidney injury?
• Hypertensive acute diastolic heart failure?
With ICD-9, identify accelerated or malignant
hypertension (401.0) and the stroke (434.91),
or acute heart failure (428.21), or acute renal
failure (584.9)
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
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
NOT Acute Respiratory Failure
• Patients being purposely maintained on
the ventilator after heart surgery or any
surgery because of weakness, chronic lung
disease, massive trauma are NOT in acute
respiratory failure
• Prevention of acute respiratory failure from
angioedema, stroke, trauma when patient
does NOT HAVE acute respiratory failure
when intubated for airway protection
Hydrocephalus
• Be as specific as possible
– Default 331.4 – acquired,
noncommunicating, obstructive, etc.
– Due to stricture of aqueduct 742.3
• With spina bifida 741.0
– Normal pressure 331.3
Hydrocephalus ICD-9
742.3 Congenital hydrocephalus – ONE CODE
Aqueduct of Sylvius:
anomaly
obstruction, congenital
stenosis
Atresia of foramina of Magendie and Luschka
Hydrocephalus in newborn
331.3 Communicating (secondary NP hydrocephalus)
331.4 Obstructive acquired hydrocephalus
331.5 Idiopathic normal pressure hydrocephalus
Excludes:
due to congenital toxoplasmosis (771.2)
with any condition classifiable to 741.9 (741.0)
Congenital Hydrocephalus – ICD-10
Q03.9 Congenital (external) (internal)
Q05.0 Cervical spina bifida with hydrocephalus
Q05.1 Thoracic (dorsal/thoracolumbar) spina bifida
with hydrocephalus
Q05.2 Lumbar (LS) spina bifida with hydrocephalus
Q05.3 Sacral spina bifida with hydrocephalus
Q05.4 Unspecified spina bifida with hydrocephalus
Q05.5 Cervical spina bifida without hydrocephalus
Q05.6 Thoracic (dorsal/thoracolumbar) spina bifida
without hydrocephalus
Q05.7Lumbar (LS) spina bifida without hydrocephalus
Q05.8Sacral spina bifida without hydrocephalus
Acquired Hydrocephalus ICD-10
G91.0 Communicating hydrocephalus
Secondary normal pressure hydrocephalus
G91.1 Obstructive acquired hydrocephalus
G91.2 (Idiopathic) normal pressure hydrocephalus
Normal pressure hydrocephalus NOS
G91.3 Post-traumatic hydrocephalus, unspecified
G91.4 Hydrocephalus in diseases classified
elsewhere
Code first underlying condition, such as:
congenital syphilis (A50.4-)
neoplasm (C00-D49)
due to congenital toxoplasmosis (P37.1)
Encephalopathies
• Metabolic encephalopathy G93.41
– Includes due to sepsis, hyper and
hyponatremia, diabetic 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
AMS is not Encephalopathy
When a patient is determined to have one of the
following as cause of AMS, specify as:
–
–
–
–
–
–
–
–
Hypoxic ischemic encephalopathy (at birth)
Alcoholic encephalopathy
Anoxic encephalopathy (after the birth process)
Hepatic encephalopathy
Hypertensive encephalopathy
Metabolic (internal source) encephalopathy
Toxic (external source) encephalopathy
Traumatic (post-concussive) encephalopathy
HIE – ICD-9
only for use for hypoxemia related to the birth process –
intrauterine or during the trip down the canal
768.7 Hypoxic-ischemic encephalopathy (HIE)
768.70 Hypoxic-ischemic encephalopathy,
unspecified
768.71 Mild hypoxic-ischemic encephalopathy
768.72 Moderate hypoxic-ischemic
encephalopathy
768.73 Severe hypoxic-ischemic
encephalopathy
HIE – ICD-10
only for use for hypoxemia related to the birth process –
intrauterine or during the trip down the canal
P91.6 Hypoxic ischemic encephalopathy [HIE]
P91.60 Hypoxic ischemic encephalopathy
[HIE], unspecified
P91.61 Mild hypoxic ischemic encephalopathy
[HIE]
P91.62 Moderate hypoxic ischemic
encephalopathy [HIE]
P91.63 Severe hypoxic ischemic
encephalopathy [HIE]
What ISN’T Encephalopathy
•
•
•
•
Coma after stroke or head trauma
Postictal state
Drunkenness
Effects of illicit drugs or poisoning with
overdosage of prescribed drugs
• Adverse effects or desired effects of
sedative medications
Seizures Convulsions Epilepsy
• The terms convulsion and seizure can be used
interchangeably.
• The term epilepsy is used to describe seizures that occur
repeatedly over time without an acute illness or brain
injury.
• A convulsion that involves the whole body (sometimes
called a “generalized tonic-clonic” or “grand mal” seizure)
is the most dramatic type of seizure, causing rapid, violent
movements and occasionally loss of consciousness.
Don’t call it grand mal epilepsy when it’s not epilepsy.
• By contrast, “absence” seizures (previously called “petit
mal” seizures) are momentary episodes with a vacant
stare or a brief lapse of attention.
Epilepsy ICD-9
345.0+ Generalized nonconvulsive epilepsy
345.1+ Generalized convulsive epilepsy
Fifth Digit
0 – Not intractable
345.2 Petit mal status
1 – Intractable
345.3 Grand mal status
345.4+ Localization-related (focal) (partial) epilepsy and
epileptic syndromes with complex partial seizures
345.5+ Localization-related (focal) (partial) epilepsy and
epileptic syndromes with simple partial seizures
345.6+ Infantile spasms
345.7+ Epilepsia partialis continua
345.8+ Other forms of epilepsy and recurrent seizures
345.9+ Epilepsy, unspecified
348.81 Hippocampal (temporal lobe) epilepsy
Epilepsy ICD-10
G40.0 Localization-related (focal) (partial)
idiopathic epilepsy and epileptic
syndromes with seizures of local onset
G40.1 Localization-related (focal) (partial)
symptomatic epilepsy and epileptic
syndromes with simple partial seizures
G40.2 Localization-related (focal) (partial)
symptomatic epilepsy and epileptic
syndromes with complex partial seizures
G40.3 Generalized idiopathic epilepsy and
epileptic syndromes
G40A Absence epileptic syndromes
G40B Juvenile myoclonic epilepsy
G40.4 Other generalized epilepsy
G40.5 Epileptic seizures related to external
causes (eg, alcohol, drugs)
G40.8 Other epilepsy and recurrent seizures
Fifth Digit
0 – Not intractable
1 – Intractable
Sixth Digit
0 – With status
9 – Without status
Other Seizures ICD-9
780.31 Simple febrile convulsions
780.32 Complex febrile convulsions
780.33 Post-traumatic seizure
780.39 Other convulsions
eg. alcohol withdrawal, adverse
reaction to a drug, neurocystocercosis
Other Seizures ICD-10
R56.0 Febrile convulsions
R56.00 Simple febrile convulsions
R56.01 Complex febrile convulsions
R56.1 Post traumatic seizures
R56.9Unspecified convulsions
DNR vs Comfort Measures Z51.5
(ICD-9 V66.7)
When it’s time to give up hope:
“The physician documentation in the medical
record must substantiate that end of life care is
being given. Terms such as comfort care, endof-life care are appropriate. These, or similar
terms, need to be written in the record to support
the use of code V66.7. The care provided must
be aimed only at relieving pain and discomfort
for the palliative care code to be applicable.”
Palliative care consults are NOT the same!
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.
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 0.5 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).”
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.)
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
Bad Terms – Good Terms
• Low hematocrit
• Infiltrate
• Purulent drainage
• Point tenderness
• Hypotension
• Symptom or sign
• Anemia … due to
• Pneumonia or CHF
• Abscess or wound
infection
• Peritonitis
• Septic shock or
dehydration or
hypovolemia or
whatever cause
• A disease!
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