Value Based Purchasing, Changes
for ICD-10 and the Future of
Ophthalmology
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.
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 "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
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Hospital falls that lead to patient damage (fractures, etc.)
Mediastinitis post-CABG
Catheter-associated UTIs
Vascular catheter associated infections
Pressure ulcers
Iatrogenic pneumothorax following central line insertion
Object accidentally left in patient
Air embolism
Reaction from blood incompatibility
Goals of Implementation –
Prove You Are Value Based
• Exceptional severity adjusted data
• Reasonable occurrence of
PSIs/HACs
• Lower than average Readmissions for
Pneumonia, Heart Failure, AMI
• Cooperation with quality initiatives
• Patient satisfaction
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 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.
Documentation Needs:
What’s The Surgery For?
• Provide the diagnosis for which the
surgery is being performed
• Provide acuity, complexity
• Tell why it’s necessary for that diagnosis
• DON’T just say that the patient is being
admitted for the surgery
• DON’T just provide signs and symptoms
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
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?
Nutrition – over? mal?
Renal status – chr, ac.
Smoking, ETOH?
Hepatic fxn – name it
Immunocomp – how?
Use ster, insul, chemo
Lungs – chronic?
Diabetes – cont?
Malignancy?
Stroke – residua?
Encephalopathy?
Sepsis? Org fail?
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
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!
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
Strabismus/Esotropia ICD-9
378.0 Esotropia
Convergent concomitant strabismus
Excludes: intermittent esotropia (378.20-378.22)
378.00 Esotropia, unspecified
378.01 Monocular esotropia
378.02 Monocular esotropia with A pattern
378.03 Monocular esotropia with V pattern
378.04 Monocular esotropia with other noncomitancies
Monocular esotropia with X or Y pattern
378.05 Alternating esotropia
378.06 Alternating esotropia with A pattern
378.07 Alternating esotropia with V pattern
378.08 Alternating esotropia with other noncomitancies
Alternating esotropia with X or Y pattern
Strabismus/Esotropia ICD-10
6th digits
1 – right eye
2 - left eye
3 – bilateral
9 - unspecified
H50.00 Unspecified esotropia
H50.01 Monocular esotropia
H50.011 Monocular esotropia, right eye
H50.012 Monocular esotropia, left eye
H50.02 Monocular esotropia with A pattern
H50.021 Monocular esotropia with A pattern, right eye
H50.022 Monocular esotropia with A pattern, left eye
H50.03 Monocular esotropia with V pattern
H50.031 Monocular esotropia with V pattern, right eye
H50.032 Monocular esotropia with V pattern, left eye
H50.04 Monocular esotropia with other noncomitancies
H50.041 Monocular esotropia with other noncomitancies, right eye
H50.042 Monocular esotropia with other noncomitancies, left eye
H50.05 Alternating esotropia
H50.06 Alternating esotropia with A pattern
H50.07 Alternating esotropia with V pattern
H50.08 Alternating esotropia with other noncomitancies
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.)
Diabetic Retinopathy ICD-9
Up to 3 codes for a patient
362.0 Diabetic retinopathy
Code first diabetes (249.5 for DM due to other cause,
250.5 for Type 1 or Type 2 DM)
362.01 Background diabetic retinopathy
362.02 Proliferative diabetic retinopathy
362.03 Nonproliferative diabetic retinopathy NOS
362.04 Mild nonproliferative diabetic retinopathy
362.05 Moderate nonproliferative diabetic retinopathy
362.06 Severe nonproliferative diabetic retinopathy
362.07 Diabetic macular edema
Note: 362.07 must be used with a code for diabetic
retinopathy (362.01-362.06)
Diabetic Retinopathy ICD-10
Only one combinmation code for a patient
E11.3 Type 2 diabetes mellitus with ophthalmic
complications
E11.31 Type 2 diabetes mellitus with unspecified
diabetic retinopathy
E11.32 Type 2 diabetes mellitus with mild
nonproliferative diabetic retinopathy
E11.33 Type 2 diabetes mellitus with moderate
nonproliferative diabetic retinopathy
E11.34 Type 2 diabetes mellitus with severe
nonproliferative diabetic retinopathy
E11.35 Type 2 diabetes mellitus with proliferative
diabetic retinopathy
E11.36 Type 2 diabetes mellitus with diabetic
cataract
E11.39 Type 2 diabetes mellitus with other
diabetic ophthalmic complication
6th digit for .31
through .35
1 – with macular
edema
9 – without macular
edema
E08.3 series for
other cause of DM
E09.3 series drug
or chemical
induced DM
E10 series for Type 1
DM
E11 series for Type 2
DM
Cataract ICD-9
366.0 Infantile, juvenile, and
366.1 Senile cataract
presenile cataract
366.10 Senile cataract, unspecified
366.00 Nonsenile cataract,
366.11 Pseudoexfoliation of lens
unspecified
capsule
366.01 Anterior subcapsular polar
366.12 Incipient cataract
cataract
366.02 Posterior subcapsular polar 366.13 Anterior subcapsular polar
cataract
senile cataract
366.03 Cortical, lamellar, or
366.14 Posterior subcapsular polar
zonular cataract
senile cataract
366.04 Nuclear cataract
366.15 Cortical senile cataract
366.09 Other and combined forms
366.16 Nuclear sclerosis
of nonsenile cataract
366.17 Total or mature cataract
366.18 Hypermature cataract
366.19 Other and combined forms
of senile cataract
Cataract ICD-10
H26.0 Infantile and juvenile
cataract
H26.00 Unspecified infantile
and juvenile cataract
H26.01 Infantile and juvenile
cortical, lamellar, or zonular
cataract
H26.03 Infantile and juvenile
nuclear cataract
H26.04 Anterior subcapsular
polar infantile and juvenile
cataract
H26.05 Posterior subcapsular
polar infantile and juvenile
cataract
H26.06 Combined forms of
infantile and juvenile cataract
H26.09 Other infantile and
juvenile cataract
6th digits
1 – right eye
2 - left eye
3 – bilateral
9 - unspecified
H25.0 Age-related incipient
cataract
H25.01 Cortical age-related
cataract
H25.03 Anterior subcapsular
polar age-related cataract
H25.04 Posterior subcapsular
polar age-related cataract
H25.09 Other age-related
incipient cataract
H25.1 Age-related nuclear
cataract
H25.2 Age-related cataract,
morgagnian type
H25.8 Combined forms of agerelated cataract
Corneal Ulcer ICD-9
370.0 Corneal ulcer
370.00 Corneal ulcer, unspecified
370.01 Marginal corneal ulcer
370.02 Ring corneal ulcer
370.03 Central corneal ulcer
370.04 Hypopyon ulcer
Serpiginous ulcer
370.05 Mycotic corneal ulcer
370.06 Perforated corneal ulcer
370.07 Mooren's ulcer
Corneal Ulcer ICD-10
H16.0 Corneal ulcer
H16.00 Unspecified corneal ulcer
H16.01 Central corneal ulcer
H16.02 Ring corneal ulcer
H16.03 Corneal ulcer with hypopyon
H16.04 Marginal corneal ulcer
H16.05 Mooren's corneal ulcer
H16.06 Mycotic corneal ulcer
H16.07 Perforated corneal ulcer
6th digits
1 – right eye
2 - left eye
3 – bilateral
9 - unspecified
Blindness Categories ICD-9
369.4 Legal blindness, as defined in U.S.A.
Blindness NOS according to U.S.A. definition
Excludes: legal blindness with specification of impairment level (369.01369.08, 369.11-369.14, 369.21-369.22)
369.6 Profound impairment, one eye
369.60 Impairment level not further specified
369.61 One eye: total impairment; other eye: not specified
369.62 One eye: total impairment; other eye: near-normal vision
369.63 One eye: total impairment; other eye: normal vision
369.64 One eye: near-total impairment; other eye: not specified
369.65 One eye: near-total impairment; other eye: near-normal vision
369.66 One eye: near-total impairment; other eye: normal vision
369.67 One eye: profound impairment; other eye: not specified
369.68 One eye: profound impairment; other eye: near-normal vision
369.69 One eye: profound impairment; other eye: normal vision
Blindness Categories ICD-10
H54.8 Legal blindness, as defined in USA
Blindness NOS according to USA definition
Excludes1: legal blindness with specification of impairment level
(H54.0-H54.7)
H54.1 Blindness, one eye, low vision other eye
Visual impairment categories 3, 4, 5 in one eye, with categories 1
or 2 in the other eye.
H54.10 Blindness, one eye, low vision other eye, unspecified
eyes
H54.11 Blindness, right eye, low vision left eye
H54.12 Blindness, left eye, low vision right eye
H54.4 Blindness, one eye
Visual impairment categories 3, 4, 5 in one eye [normal vision in
other eye]
H54.40 Blindness, one eye, unspecified eye
H54.41 Blindness, right eye, normal vision left eye
H54.42 Blindness, left eye, normal vision right eye
Retinal Detachment ICD-9
361.0 Retinal detachment with retinal defect
Excludes: detachment of retinal pigment epithelium (362.42-362.43)
retinal detachment (serous) (without defect) (361.2)
361.00 Retinal detachment with retinal defect, unspecified
361.01 Recent detachment, partial, with single defect
361.02 Recent detachment, partial, with multiple defects
361.03 Recent detachment, partial, with giant tear
361.04 Recent detachment, partial, with retinal dialysis
361.05 Recent detachment, total or subtotal
361.06 Old detachment, partial
361.07 Old detachment, total or subtotal
361.3 Retinal defects without detachment
Excludes: chorioretinal scars after surgery for detachment (363.30-363.35)
peripheral retinal degeneration without defect (362.60-362.66)
361.30 Retinal defect, unspecified
361.31 Round hole of retina without detachment
361.32 Horseshoe tear of retina without detachment
361.33 Multiple defects of retina without detachment
361.8 Other forms of retinal detachment
361.81 Traction detachment of retina
361.89 Other
361.9 Unspecified retinal detachment
Retinal Detachment ICD-10
H33.0 Retinal detachment with retinal break
Excludes1: serous retinal detachment (without retinal break) (H33.2-)
H33.00Unspecified retinal detachment with retinal break
H33.01 Retinal detachment with single break
6th digits
H33.02 Retinal detachment with multiple breaks
1 – right eye
H33.03 Retinal detachment with giant retinal tear
2 - left eye
H33.04 Retinal detachment with retinal dialysis
3 – bilateral
H33.05 Total retinal detachment
9 - unspecified
H33.3 Retinal breaks without detachment
Excludes1: chorioretinal scars after surgery for detachment (H59.81-)
peripheral retinal degeneration without break (H35.4-)
H33.30 Unspecified retinal break
H33.31 Horseshoe tear of retina without detachment
H33.32 Round hole of retina without detachment
H33.33 Multiple defects of retina without detachment
Retinoblastoma
ICD-9
190.5 Differentiated
190.5 Undifferentiated
same code
Add 198.4 for invasion of
optic nerve or choroid
Add 365.7x for
neovascular glaucoma
ICD-10
C69.2 Differentiated
C69.2 Undifferentiated
same code
Add C79.49 for invasion of
optic nerve or choroid
Add H40.5xx for glaucoma
due to neoplasm of eye
Severity of glaucoma 5th digit:
1 mild
2 moderate both ICD-9
3 severe
and ICD-10
6th digits for C69.2
1 – right eye
2 - left eye
3 – bilateral
9 - unspecified
Malignant Neoplasm Choroid
ICD-9
190.6 Melanoma
190.6 Nonmelanoma
malignancies of choroid
198.4 Malignancy
metastatic to choroid –
Secondary malignant
neoplasm other parts of
nervous system
ICD-10
C69.3 Melanoma
C69.3 Nonmelanoma
malignancies of choroid
C79.49 Malignancy
metastatic to choroid –
Secondary malignant
neoplasm other parts of
nervous system
5th digits for C69.3
1 – right eye
2 - left eye
3 – bilateral
9 - unspecified
Ophthalmic Manifestations of
Systemic Diseases
M31.0 Hypersensitivity angiitis
Goodpasture's syndrome
M31.1 Thrombotic microangiopathy
Thrombotic thrombocytopenic purpura
M31.2 Lethal midline granuloma
M31.3 Wegener's granulomatosis
Necrotizing respiratory granulomatosis
M31.30 Wegener's granulomatosis
without renal involvement
M31.31 Wegener's granulomatosis
with renal involvement
M31.4 Aortic arch syndrome [Takayasu]
M31.5 Giant cell arteritis with
polymyalgia rheumatica
M31.6 Other giant cell arteritis
M31.7 Microscopic polyangiitis
M31.8 Other specified necrotizing
vasculopathies
Assign the code for the
ophthalmic disorder
Assign the code for the systemic
disease
Despite the fact that up to 60%
of Wegener’s patients have
ophthalmic manifestations,
there is no combination code
… yet.
• Proptosis
• Conjunctivitis
• Dacryocystitis
• Orbital retraction syndrome
Use Problem List for Systemic
Disorder Codes
• Genetic and chromosomal disorders, eg:
– Cri du chat
– Patau’s trisomy 13
• Viral disorders, eg:
– Herpes simplex
– Adenovirus diseases
• Bacterial disorders, eg:
– Lyme disease
– Metastatic bacterial endophthalmitis
• Fungal disorders
• Collagen diseases
• Skin disorders
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 (thyrotoxicosis, 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
6th digits
1 – right eye
2 - left eye
3 – bilateral
9 - unspecified
N18.1, 2, 3, 4, 5, 6, 9 for CKD stages 1, 2, 3, 4, 5, ESRD,
unspecified
Hypertensive retinopathy – H35.03x plus code for HTN
• H35.031 Hypertensive retinopathy, right eye
• H35.032 Hypertensive retinopathy, left eye
• H35.033 Hypertensive retinopathy, bilateral
• H35.039 Hypertensive retinopathy, unspecified eye
Craniofacial Fractures I-9
801 series for base of skull fractures included:
fossa:
anterior
middle
posterior
occiput bone
orbital roof
sinus:
ethmoid
frontal
sphenoid bone
temporal bone
Subclassified into closed fracture
with
801.0 No brain injury
801.1 Cerebral contusion or
laceration
801.2 Subarachnoid, subdural or
extradural hemorrhage
801.3 Other intracranial hemorrhage
801.4 Other intracranial injury
801.5 Open fracture with no brain
injury
Craniofacial Fractures I-9
5th digit breakdown into level and state of consciousness
801.x0 unspecified state of consciousness
801.x1 with no loss of consciousness
801.x2 with brief [less than one hour] loss of
consciousness
801.x3 with moderate [1-24 hours] loss of consciousness
801.x4 with prolonged [more than 24 hours] loss of
consciousness and return to pre-existing conscious level
801.x5 with prolonged [more than 24 hours] loss of
consciousness, without return to pre-existing conscious
level
801.x6 with loss of consciousness of unspecified duration
801.x9 with concussion, unspecified
CranioFacial Fractures
S02.19 Other fracture of base of skull
Fracture of anterior fossa of base of skull
Fracture of ethmoid sinus
Fracture of frontal sinus
Fracture of middle fossa of base of skull
Fracture of orbital roof
Fracture of posterior fossa of base of skull
Fracture of sphenoid
Fracture of temporal bone
But must add separate code for intracranial injury and
additional code for Glasgow coma scale
CranioFacial Fractures
S02.2 Fracture of nasal bones
S02.3 Fracture of orbital floor
S02.2 Fracture of nasal bones
S02.3 Fracture of orbital floor
S02.4 Fracture of malar, maxillary and zygoma bones
S02.40 Fracture of malar, maxillary and zygoma bones
S02.400 Malar fracture
S02.401 Maxillary fracture
S02.402 Zygomatic fracture
S02.41 LeFort Fracture
S02.411 LeFort I fracture
S02.412 LeFort II fracture
S02.413 LeFort III fracture
S02.42 Fracture of alveolus of maxilla
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.)
Seventh Digits
A initial encounter for closed fracture
B initial encounter for open fracture
D subsequent encounter for fracture with routine
healing
G subsequent encounter for fracture with
delayed healing
K subsequent encounter for fracture with
nonunion
S Sequela
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
Anemia Designations
D62
D50.0
D63.1
D63.0
D63.8
285.1 – anemia due to acute blood loss
FROM … name it
280.0 – anemia due to chronic blood loss
FROM … name it
285.21 – anemia due to chronic renal
failure and what caused the renal
failure?
285.22 – anemia due to malignant
disease – effect of the tumor!
285.29 – anemia due to a specific chronic
illness – and name that illness (chronic
hepatitis, lupus, osteomyelitis, etc.)
Anemia/Cytopenias in Malignancy
There is no code for “anemia of chronic disease”
280.0 D50.0 anemia due to chronic blood loss from
bleeding colon cancer
284.11 D61.810 pancytopenia from chemo
284.12 D61.811 pancytopenia from other drugs
284.2 D61.82 pancytopenia from cancer taking over bone
marrow (myelophthisis) – code the cancer causing it
284.89 D61.1 aplastic anemia due to chemo, other drugs
284.89 D61.2 radiation induced aplastic anemia
285.22 D63.0 anemia due to neoplastic disease – code
the cancer causing it
285.3 D64.81 antineoplastic chemotherapy induced
anemia
Sickle Cell Disease
H34.81+ Central retinal vein
occlusion
H34.82+ Venous engorgement
H34.83+ Tributary (branch)
retinal vein occlusion
H35.02+ Exudative retinopathy
Sixth digits
1 = OD
2 = OS
3 = OU
9 = unspec
Identify the manifestation
then identify the disease
Ocular manifestations of sickle cell
disease result from vascular
occlusion, which may occur in the
conjunctiva, iris, retina, and
choroid. Because the ocular
changes produced by SCD can
be seen in other diseases, it is
important to rule out other causes
of occlusion, including central
retinal vein occlusion, Eales
disease, and retinopathy
secondary to diabetes and other
disorders.
Other causes of ocular changes that
should also be considered
include familial exudative
vitreoretinopathy, polycythemia
vera, talc and cornstarch emboli,
and uveitis.
Sickle Cell Disease
D57.0 Hb-SS disease with crisis
D57.1 Sickle-cell disease without crisis
D57.2 Sickle-cell/Hb-C disease
D57.20 Sickle-cell/Hb-C disease without
crisis
D57.21 Sickle-cell/Hb-C disease with
crisis
D57.3 Sickle-cell trait
D57.4 Sickle-cell thalassemia
D57.40 Sickle-cell thalassemia without
crisis
D57.41 Sickle-cell thalassemia with crisis
D57.8 Other sickle-cell disorders
D57.80 Other sickle-cell disorders without
crisis
D57.81 Other sickle-cell disorders with
crisis
5th or 6th digits for crisis
1 – acute chest
syndrome
2 – splenic
sequestration
0 or 9 – unspecified
crisis
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
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
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.
75
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
76
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.
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