Value Based Purchasing, Changes
for ICD-10 and the Future of
Physical Medicine and Rehab
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
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.
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.
21
Patient Safety Indicators
Hospital acquired preventable diagnoses
• Hospital falls that lead to patient damage (fractures,
etc.)
• Mediastinitis post-CABG
• Catheter-associated UTIs
• Vascular catheter associated infections
• Pressure ulcers
• Object accidentally left in patient
• Air embolism
• Reaction from blood incompatibility
Participation and Success in
Reporting of Core Measures
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Acute MI
Heart failure
Pneumonia
Postoperative wound infections
Venous thromboembolism
Stroke
Asthma in children’s hospitals
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
Inpatient Rehab Coding
Coding Clinic, Third Quarter 2006 Page 3:
The Central Office on ICD-9-CM has continued to receive questions regarding
the coding and sequencing of diagnoses in inpatient rehabilitation facilities
(IRF). These facilities are required to complete a data collection instrument
called Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRFPAI), as well as a claim form. The IRF-PAI requires the assignment of ICD-9CM diagnosis codes for the etiologic diagnosis to indicate the condition for
which the patient is receiving rehabilitation, as well as other comorbid
conditions. As stated in Coding Clinic, First Quarter 2002, pages 18-19, a
different set of instructions/rules apply to the IRF-PAI. Hospitals should be
guided by the Medicare IRF-PAI Manual for the coding and reporting of the
etiologic diagnosis and comorbidities for the IRF-PAI.
A code from category V57, Care involving use of rehabilitation procedures,
should be assigned as the principal diagnosis on the claim form when the
patient is admitted for rehabilitative services. The following questions and
answers apply to the coding and reporting of secondary diagnoses on the
claim form for IRF patients. This information is being published in order to
clarify some of the confusion that has resulted from dual reporting
requirements.
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
Rehab ICD-9
V57Care involving use of rehabilitation procedures
Use additional code to identify underlying condition
V57.0 Breathing exercises
V57.1 Other physical therapy
Therapeutic and remedial exercises, except breathing
V57.2 Occupational therapy and vocational rehabilitation
V57.21 Encounter for occupational therapy
V57.22 Encounter for vocational therapy
V57.3 Speech-language therapy
V57.4 Orthoptic training
V57.8 Other specified rehabilitation procedure
V57.81 Orthotic training
Gait training in the use of artificial limbs
V57.89 Other
Multiple training or therapy
V57.9 Unspecified rehabilitation procedure
Rehab ICD-10
PLUS . . .
Subarachnoid Bleed
• Specify when
traumatic
• Specify vessel of
origin - aneurysm
• Specify right or left
side of the brain
• If hemiparesis,
specify dominant
or nondominant
side
Intracerebral Bleed
• Specify when
traumatic or
nontraumatic
• Specify by location
in brain (cortical,
subcortical,
brainstem,
intraventricular)
Intracerebral Bleed I-9
431 Intracerebral hemorrhage
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
Stroke ICD-9
Caused by Occlusion Precerebral Artery
433.0 Basilar artery
433.00 without mention of
cerebral infarction
433.01 with cerebral infarction
433.1 Carotid artery
433.10 without mention of
cerebral infarction
433.11 with cerebral infarction
433.2 Vertebral artery
433.20 without mention of
cerebral infarction
433.21 with cerebral infarction
433.3 Multiple and bilateral
433.30 without mention of
cerebral infarction
433.31 with cerebral infarction
433.8 Other specified
precerebral artery
433.80 without mention of
cerebral infarction
433.81 with cerebral infarction
433.9 Unspecified precerebral
artery
433.90 without mention of
cerebral infarction
433.91 with cerebral infarction
Stroke ICD-9
Cerebral Artery
434.0 Cerebral thrombosis
434.00 without mention of cerebral infarction
434.01 with cerebral infarction
434.1 Cerebral embolism
434.10 without mention of cerebral infarction
434.11 with cerebral infarction
434.9 Cerebral artery occlusion, unspecified
434.90 without mention of cerebral infarction
434.91 with cerebral infarction
Stroke ICD-10
I63.0 Cerebral infarction due to thrombosis of precerebral arteries
I63.00 Cerebral infarction due to thrombosis of unspecified
precerebral artery
I63.01 Cerebral infarction due to thrombosis of vertebral artery
I63.011 Cerebral infarction due to thrombosis of right vertebral
artery
I63.012 Cerebral infarction due to thrombosis of left vertebral
artery
I63.02 Cerebral infarction due to thrombosis of basilar artery
I63.03 Cerebral infarction due to thrombosis of carotid artery
I63.031 Cerebral infarction due to thrombosis of right carotid
artery
I63.032 Cerebral infarction due to thrombosis of left carotid artery
I63.09 Cerebral infarction due to thrombosis of other
precerebral artery
Stroke ICD-10
I63.10 Cerebral infarction due to embolism of unspecified
precerebral artery
I63.11Cerebral infarction due to embolism of vertebral
artery
I63.111 Cerebral infarction due to embolism of right vertebral
artery
I63.112 Cerebral infarction due to embolism of left vertebral
artery
I63.12 Cerebral infarction due to embolism of basilar artery
I63.13Cerebral infarction due to embolism of carotid artery
I63.131 Cerebral infarction due to embolism of right carotid
artery
I63.132 Cerebral infarction due to embolism of left carotid
artery
Stroke I-10
I63.30 Cerebral infarction due to thrombosis of
unspecified cerebral artery
I63.31 Cerebral infarction due to thrombosis of
middle cerebral artery
I63.311 Cerebral infarction due to thrombosis of right
middle cerebral artery
I63.312 Cerebral infarction due to thrombosis of left
middle cerebral artery
I63.32 Cerebral infarction due to thrombosis of
anterior cerebral artery
I63.321 Cerebral infarction due to thrombosis of right
anterior cerebral artery
I63.322 Cerebral infarction due to thrombosis of left
anterior cerebral artery
Stroke I-10
I63.33 Cerebral infarction due to thrombosis of
posterior cerebral artery
I63.331 Cerebral infarction due to thrombosis of right
posterior cerebral artery
I63.332 Cerebral infarction due to thrombosis of left
posterior cerebral artery
I63.34 Cerebral infarction due to thrombosis of
cerebellar artery
I63.341 Cerebral infarction due to thrombosis of right
cerebellar artery
I63.342 Cerebral infarction due to thrombosis of left
cerebellar artery
I63.349 Cerebral infarction due to thrombosis of
unspecified cerebellar artery
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 Effects
• Identify specific late effects
– Aphasia, dysphagia, neglect,
hemiparesis (dominant or
nondominant), etc.
• Identify specific insult
– Late effect SAH, SDH, ICH
– Late effect embolic stroke or localized
occlusive stroke
– Identify when monoplegia, hemiplegia
Late Effects ICD-9
438.0 Cognitive deficits
438.1 Speech and language deficits
438.10 Speech and language deficit, unspecified
438.11 Aphasia
438.12 Dysphasia
438.13 Dysarthria
438.14 Fluency disorder
438.19 Other speech and language deficits
438.2 Hemiplegia/hemiparesis
438.20 Hemiplegia affecting unspecified side
438.21 Hemiplegia affecting dominant side
438.22 Hemiplegia affecting nondominant side
438.3 Monoplegia of upper limb
438.30 Monoplegia of upper limb affecting unspecified side
438.31 Monoplegia of upper limb affecting dominant side
438.32 Monoplegia of upper limb affecting nondominant side
438.4 Monoplegia of lower limb
438.40 Monoplegia of lower limb affecting unspecified side
438.41 Monoplegia of lower limb affecting dominant side
438.42 Monoplegia of lower limb affecting nondominant side
438.5 Other paralytic syndrome
Use additional code to identify type of paralytic syndrome, such as:
locked-in state (344.81)
quadriplegia (344.00-344.09)
438.50 Other paralytic syndrome affecting unspecified side
438.51 Other paralytic syndrome affecting dominant side
438.52 Other paralytic syndrome affecting nondominant side
438.53 Other paralytic syndrome, bilateral
438.6 Alterations of sensations
Use additional code to identify the altered sensation
438.7 Disturbances of vision
Use additional code to identify the visual disturbance
438.8 Other late effects of cerebrovascular disease
438.81 Apraxia
438.82 Dysphagia
Use additional code to identify the type of dysphagia, if known (787.20-787.29)
438.83 Facial weakness
438.84 Ataxia
438.85 Vertigo
438.89 Other late effects of cerebrovascular disease
Use additional code to identify the late effect
438.9 Unspecified late effects of cerebrovascular disease
Sequelae ICD-10
4th digits: 0 = nontraumatic subarachnoid hemorrhage, 1 =
nontraumatic intracerebral hemorrhage, 2 = nontraumatic
intracranial hemorrhage, 3 = cerebral infarction
I69.x0 Unspecified sequelae of specific type of stroke
I69.x1 Cognitive deficits following specific type of stroke
I69.x2 Speech and language deficits following specific type of
stroke
I69.x20 Aphasia following specific type of stroke
I69.x21 Dysphasia following specific type of stroke
I69.x22 Dysarthria following specific type of stroke
I69.x23 Fluency disorder following specific type of stroke
I69.x28 Other speech and language deficits following
specific type of stroke
I69.x3 Monoplegia of upper limb following specific type of
stroke plus 6th digit for side
I69.x4 Monoplegia of lower limb following specific type of
stroke plus 6th digit for side
1 = right
dominant side
2 = left
dominant side
3 = right
nondominant
side
4 = left
nondominant
side
9 - unspecified
4th digits: 0 = nontraumatic subarachnoid hemorrhage, 1 =
nontraumatic intracerebral hemorrhage, 2 = nontraumatic
intracranial hemorrhage, 3 = cerebral infarction
I69.x5 Hemiplegia and hemiparesis following specific type of
stroke plus 6th digit for laterality
I69.x6 Other paralytic syndrome following specific type of
stroke plus 6th digit for laterality
I69.x9 Other sequelae of specific type of stroke
I69.x90 Apraxia following specific type of stroke
I69.x91 Dysphagia following specific type of stroke
Use additional code to identify the type of dysphagia, if known
(R13.1-)
I69.x92 Facial weakness following specific type of stroke
Facial droop following specific type of stroke
I69.x93 Ataxia following specific type of stroke
I69.x98 Other sequelae of specific type of stroke
1 = right
dominant side
2 = left
dominant side
3 = right
nondominant
side
4 = left
nondominant
side
9 - unspecified
Cardiac Rehab
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 failure
428.43 L50.43 Acute on chronic combined systolic and diastolic heart
failure
“Cardiomyopathy”
is not the same as
chronic LV systolic
failure
Cardiomyopathy
The Other Causes
• Hypertensive
• Infectious
myocarditis
• Collagen vascular
diseases
• Transplant rejection
• Sarcoidosis
• Alcohol toxicity
• 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
NYHA Classes of Heart Failure
All of these are Chronic Heart Failure
Class
Patient Symptoms
Class I (Mild)
No limitation of physical activity. Ordinary physical activity
does not cause undue fatigue, palpitation, or dyspnea
(shortness of breath).
Class II (Mild)
Slight limitation of physical activity. Comfortable at rest, but
ordinary physical activity results in fatigue, palpitation,
or dyspnea.
Class III
(Moderate)
Marked limitation of physical activity. Comfortable at rest,
but less than ordinary activity causes fatigue,
palpitation, or dyspnea.
Class IV
(Severe)
Unable to carry out any physical activity without
discomfort. Symptoms of cardiac insufficiency at rest.
If any physical activity is undertaken, discomfort is
increased.
Heart Failure Caveat
CODERS MAY NOT
Assign codes from Lab
results
Diastolic failure is only diastolic failure when you
CALL it diastolic failure … or heart failure due to
chronic diastolic dysfunction
Systolic failure is only systolic failure
when you CALL it systolic failure … or heart failure
due to chronic systolic dysfunction
Rehab for Fractures
Example – Specificity in Fractures
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
Be Acquainted with Second Digit
0
1
2
3
4
5
6
7
8
9
Head
Neck
Thorax
Abd/low back/pelv
Shoulder/upper arm
Elbow/forearm
Wrist/hand
Hip/thighs
Knee/lower leg
Ankle/foot/toes
http://www.ncbi.nlm.nih.gov
Third Digit
General type of injury
0
1
2
3
4
5
6
7
8
9
4/5 Greater Specificity
of location of injury
Contusion
Open wound
Fracture
Dislocation
Injury nerves
Injury vessels
Muscle/fascia/tendon
Crush injury
Traumatic amputation
Unspecified
Proximal or distal
Displaced or
nondisplaced
Eponyms of specific
fracture types (Colles,
Barton’s, etc.)
Be Acquainted with Sixth Digit
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
Seventh Digit - Code extension
Type of Encounter for Injuries – Chapter 19
Initial Encounter
Active treatment
Surgery
ED
E/M by new phys
Subsequent Encounter
Routine care
Healing or recovery
phase
Sequelae
Complications or
conditions that
arise as a direct
result of the injury
Identifies injury
responsible for
sequelae
7th Digit Understanding
A, B, C Examples of active treatment are: surgical
treatment, emergency department encounter, and
evaluation and treatment by a new physician. The
appropriate 7th character for initial encounter should also
be assigned for a patient who delayed seeking treatment
for the fracture or nonunion.
D, E, F Fractures are coded using the appropriate 7th
character for subsequent care for encounters after the
patient has completed active treatment of the fracture
and is receiving routine care for the fracture during the
healing or recovery phase. Examples of fracture aftercare
are: cast change or removal, removal of external or
internal fixation device, medication adjustment, and
follow-up visits following fracture treatment.
A Initial encounter for closed fracture
B Initial encounter for open fracture type I or II
C Initial encounter for open fracture type IIIA, IIIB,
or IIIC
D Subsequent encounter for closed fracture
with routine healing
E Subsequent encounter for open fracture type I
or II with routine healing
F Subsequent encounter for open fracture type
IIIA, IIIB, or IIIC with routine healing
G Subsequent encounter for closed fracture with
delayed healing
H Subsequent encounter for open fracture type I or
II with delayed healing
J Subsequent encounter for open fracture type
IIIA, IIIB, or IIIC with delayed healing
K Subsequent encounter for closed fracture with
nonunion
M Subsequent encounter for open fracture type I
or II with nonunion
N Subsequent encounter for open fracture type
IIIA, IIIB, or IIIC with nonunion
P Subsequent encounter for closed fracture with
malunion
Q Subsequent encounter for open fracture type I
or II with malunion
R Subsequent encounter for open fracture type
IIIA, IIIB, or IIIC with malunion
S Sequela
7th Digit Understanding
• Care of complications of fractures, such
as malunion and nonunion, should be
reported with the appropriate 7th
character for subsequent care with
nonunion (K, M, N,) or subsequent care
with malunion (P, Q, R).
• Closed fracture code
• Open fracture with Gustilo classification
designation
Open Fractures
Forearm (S52), Femur (S72) and lower leg (S82)
Seventh character extensions to identify open
fractures (Gustilo classification)
I
II
III
Low energy, wound less than 1 cm
Greater than 1 cm with moderate soft tissue
damage
High energy wound greater than 1 cm with
extensive soft tissue damage
IIIA
Adequate soft tissue cover
IIIB
Inadequate soft tissue cover
IIIC
Associated with arterial injury
Gustilo Open Fracture Classification
Complete version
Grade I
Grade II
Grade III
Grade IIIA
•Skin lesion < 1 cm
•clean
•simple bone fracture with minimal comminution
•Skin lesion > 1 cm
•no extensive soft tissue damage
•minimal crushing
•moderate comminution and contamination
•Extensive skin damage with muscle and neurovascular involvement AND/OR
•High-speed crush injury
•Segmental of highly comminuted fracture
•Segmental diaphyseal loss
•Wound from high velocity weapon
•Extensive contamination of the wound bed
•Any size open injury with farm contamination
•Extensive laceration of soft tissues with bone fragments covered
•usually high-speed traumas with severe comminution or segmental fractures
Grade IIIB
•Extensive lesion of soft tissues with periosteal stripping and contamination
•severe comminution due to high-speed traumas
•usually requires replacement of exposed bone with a local or free flap as a cover
Grade IIIC
•Exposed fracture with arterial damage that requires repair
Allay the Fears
• Think about the fracture and how you
would describe it to an internist
– Name the bone
– Name the part of the bone involved
– Name the kind of fracture (Colles, Barton’s) if
there is a common name
– Identify if it’s displaced or not, open or closed
– If open, describe how extensive is the local
damage
• Choose the code that has those words in it
Clavicle Fractures
• According to the American Academy of Family
Physicians (AAFP), the anatomic site of the
clavicle fracture is typically described using the
Allman classification, which divides the clavicle
into thirds.
• Group I (midshaft) fractures occur on the
middle third of the clavicle;
• Group II fractures on the lateral (distal) third;
and
• Group III fractures on the medial (proximal)
third.
Coding Clavicles
S42.0
S42.01
Fracture of clavicle
Fracture of sternal end of clavicle
S42.011 anterior displaced right – 5th digits
S42.012 anterior displaced left
Should never use 4th
S42.014 posterior displaced right digit of 0 for unspecified
part of clavicle nor 5th
S42.015 posterior displaced left
digit of 3, 6 or 9 for not
S42.017 nondisplaced right
knowing if right or left
S42.018 nondisplaced left
clavicle
S42.02
S42.03
Fracture of shaft of clavicle
Fracture of lateral end of clavicle
Femoral Neck Fractures – 9 vs 10
820.0 Transcervical fracture, closed
820.00 Intracapsular section, unspec.
820.01 Epiphysis (separation) (upper)
820.02 Midcervical section
820.03 Base of neck
820.09 Other (head, subcapital)
820.1 Transcervical fracture, open
820.10 Intracapsular section, unspec.
820.11 Epiphysis (separation) (upper)
820.12 Midcervical section
820.13 Base of neck
820.19 Other
820.2 Pertrochanteric fracture, closed
820.20 Trochanteric section,
unspecified (greater, lesser, etc.)
820.21 Intertrochanteric section
820.22 Subtrochanteric section
820.3 Pertrochanteric fracture, open
820.30 Trochanteric section, unspec.
820.31 Intertrochanteric section
820.32 Subtrochanteric section
S72.00 Fracture unspec part neck of femur
S72.01 Unspecified intracapsular fracture
R/L
S72.02 Fracture (separation) epiphysis
femur (displaced, nondisplaced digits,
R/L)
S72.03 Midcervical fracture (d, nonD, R/L)
S72.04 Base of neck fracture (d, nonD, R/L)
S72.05 Unspecified fracture head R/L
S72.06 Articular fracture head of femur (d,
nonD, R/L)
S72.09 Other fx head and neck of femur R/L
S72.10 Unspec trochanteric fracture R/L
S72.11 Fracture greater trochanter (d,
nonD, R/L)
S72.12 Fracture lesser trochanter (d, nonD,
R/L)
S72.13 Apophyseal fracture (d, nonD, R/L)
S72.14 Intertrochanteric fracture (d, nonD,
R/L)
S72.2 Subtrochanteric fracture (d, nonD,
R/L)
Femoral Neck Fractures
• Name the part of the
neck as usual
• Identify if it’s
nondisplaced or
displaced
• State which side of
the body
• It just makes sense
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)
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 (eg., osteoporosis M80.x)
Now the Fifth Digit for the Bone
0
1
2
3
4
5
6
7
8
9
Head
Neck
Thorax
Abd/low back/pelv
Shoulder/upper arm
Elbow/forearm
Wrist/hand
Hip/thighs
Knee/lower leg
Ankle/foot/toes
Be Acquainted with Sixth Digit
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.
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
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
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.)
What IS Encephalopathy?
• Internally produced toxins in liver disease
(hepatic encephalopathy), renal disease
(uremic encephalopathy), persistent effects
of lack of blood flow to the brain (hypoxic
brain damage), sepsis, hypertensive,
hypernatremic (>160), hypercalcemic
• Externally introduced toxins as bromidism,
lead encephalopathy, persistent effects of
long term alcohol use (Korsakoff’s,
Wernicke’s)
Other Encephalopathies
•
•
•
•
•
•
Mitochondrial encephalopathy
Hashimoto’s encephalopathy
Lyme encephalopathy
Transmissible spongiform encephalopathy
Lyme encephalopathy
Hypoxic ischemic encephalopathy (HIE)
newborns only
What ISN’T Encephalopathy
• Alzheimer’s, Pick’s, senile, presenile
dementia – with or without delirium, with or
without behavioral disturbances
• Coma after stroke or head trauma
• Drunkenness
• Effects of illicit drugs or poisoning with
overdosage of prescribed drugs
• Adverse effects or desired effects of
sedative medications
Other Encephalopathy ICD-9
349.82 Toxic encephalopathy
348.31 Metabolic encephalopathy
348.39 Other encephalopathy
291.2 Alcoholic
437.2 Hypertensive
Encephalopathy ICD-10
G92 Toxic encephalopathy
G93.41 Metabolic encephalopathy
G93.49 Other encephalopathy
F10.26 Alcoholic (Wiernicke-Korsakoff
psychosis)
E51.2 Wiernicke’s nutritional encephalopathy
I67.4 Hypertensive encephalopathy
P91.6X Hypoxic ischemic encephalopathy
P91.61 mild, P91.62 moderate, P91.63 severe
Hepatic Encephalopathy
Not Due to Viral Hepatitis
ICD-9
572.2 Hepatic
encephalopathy
ICD-10
K71.11 Toxic liver
disease with hepatic
necrosis, with coma
K72.01 Acute and
subacute hepatic
failure with coma
K72.11 Chronic hepatic
failure with coma
K72.91 Hepatic failure,
unspecified with coma
Intellectual Disability
Mental Retardation
• Identify cause (hypoxic ischemic
encephalopathy occurred at birth, anoxic
brain damage occurred after the birth
process–any other cause, other brain
damage or defect)
• Stratification
– Mild IQ level 50-55 up to about 70
– Moderate IQ level 35-40 up to about 50-55
– Severe IQ level 20-25 up to about 35-40
– Profound IQ level below 20-25
Malnutrition
• Malnutrition, not specified
– Mild (<10% loss)
– Moderate (10-20% loss)
– Severe (nutritional atrophy - marasmus)
• Consider this with chronic disease, massive weight
loss, cachexia (>20% weight loss)
• Consider the acute malnutrition of surgery,
trauma and sepsis
All of the above add risk to any disease and
any surgery
Subjective Global Assessment Scoring Sheet
Patient Name:_________________________Patient ID:_____________Date:_______________
Part 1: Medical History S GA Score
1. Weight Change A B C
A. Overall change in past 6 months: kgs.
B. Percent change: ______ gain - < 5% loss
_____ 5-10% loss
_____ > 10% loss
C. Change in past 2 weeks: ______ increase
______ no change
______ decrease
2. Dietary Intake
A. Overall change: _______no change
_______change
B. Duration: ______weeks
C. Type of change:
______suboptimal solid diet ________ full liquid diet
_______hypocaloric liquid ________ starvation
3. Gastrointestinal Symptoms (persisting for >2 weeks)
____none _______nausea _____vomiting____ diarrhea ________ anorexia
4. Functional Impairment (nutritionally related)
A. Overall impairment: none
moderate
severe
B. Change in past 2 weeks: improved
no change
regressed
Part 2: Physical Examination
S GA Score
Normal
Mild
Moderate
Severe
5. Evidence of: Loss of subcutaneous fat
Muscle wasting
Edema
Ascites (hemo only)
Part 3: SGA Rating (check one)
A􀀀. Well-Nourished B􀀀. Mildly-Moderately Malnourished C􀀀. Severely Malnourished
SGA / A.N.D.
A.S.P.E.N.
Stratification
Definitions of malnutrition
Classification
Gomez
Waterlow
WHO (wasting)
Definition
Weight below %
median WFA
z-scores (SD) below
median WFH
Grading
Mild (grade 1)
75%–90% WFA
Moderate (grade 2) 60%–74% WFA
Severe (grade 3)
<60% WFA
Mild
80%–90% WFH
Moderate
70%–80% WFH
Severe
<70% WFH
z-scores (SD) below Moderate
-3%</= z-score < -2
median WFH
z-score < -3
Severe
Classification
WHO (stunting)
Kanawati
Cole
Definition
Grading
z-scores (SD) below
Moderate
-3%</= z-score < -2
median HFA
Severe
z-score < -3
MUAC divided by
Mild
<0.31
occipitofrontal head
Moderate
<0.28
circumference
Severe
<0.25
Grade 1
BMI for age z-score < -1
Grade 2
BMI for age z-score < -2
Grade 3
BMI for age z-score < -3
z-scores of BMI for age
Classification of Malnutrition in Children
Mild Malnutrition Moderate Malnutrition Severe Malnutrition
Percent Ideal Body Weight
80-90%
70-79%
< 70%
Percent of Usual Body Weight
90-95%
80-89%
< 80%
Albumin (g/dL)
2.8-3.4
2.1-2.7
< 2.1
150 - 200
100 - 149
< 100
1200 - 2000
800 - 1199
< 800
Transferrin (mg/dL)
Total Lymphocyte Count (per µL)
Clinical: What it IS!
Excisional Debridement
• Is considered a “surgical” removal or cutting
away of devitalized tissue, necrosis, or slough
down to healthy tissue that can heal
– Surgical procedure with MS-DRG impact
• This includes burns, wounds or infection
• Depending on the circumstances, this can be
accomplished in the surgical suite, or at the
bedside, emergency room, etc.
95
Non-excisional Debridement
• Flushing, brushing and washing of the burn,
wound or infection (waterjet is included) nonoperative in nature
• Removal of devitalized tissue, necrosis, or
slough
• This could include minor snipping of tissue
followed by Hubbard Tank therapy
– Also includes minor removal of loose
fragments via scissors
• This includes wounds, burns and/or infection
96
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
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.
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?
Questions
and Answers
Your Ideas and
Comments