Effectiveness in Clinical Documentation - PowerPoint Presentation

Effectiveness in Clinical Documentation ICD-10 Around the Corner, Practical Steps for Physician Preparation 1

Objectives Understand and appreciate the underpinnings of the ICD-10 system Compare and contrast structural differences between ICD-9 and ICD-10 Learn how to best effectively prepare for ICD-10 in your office and hospital practice from a clinical documentation perspective Take away best practice clinical documentation strategies that can be immediately employed in your practice of medicine. 2

ICD-10 Vs. ICD-9 CM Outpatient vs. InpatientStill only need to be concerned with diagnoses Documentation is key Clinical specificity2014 ICD-9-CM: 14,567 codes 2015 ICD-10-CM: 69,832 codes ICD-10 more clinically relevant than ICD-9There is Constancy! 3

Practice of Medicine 4

Benefits of ICD-10 ICD-10-CM incorporates much greater clinical detail and specificity than ICD-9-CM. Terminology and disease classification are updated to be consistent with current clinical practice. The modern classification system will provide much better data needed for: Measuring the quality, safety, and efficacy of care; Reducing the need for attachments to explain the patient’s condition; Designing payment systems and processing claims for reimbursement; Conducting research, epidemiological studies, and clinical trials; Setting health policy; 5

Benefits of ICD-10 Operational and strategic planning;Designing health care delivery systems; Monitoring resource use; Improving clinical, financial, and administrative performance; Preventing and detecting health care fraud and abuse; and Tracking public health and risks. 6

Practice of Medicine Practice of medicine involves diagnosis, treatment, or correction of human conditions, ailments, diseases, injuries, or infirmities whether physical or mental, by any means, methods, devices, or instruments. The practice of medicine includes, but is not limited to: Undertaking to perform any surgical operation upon any person; and Performing any act or procedure that uses a biologic or synthetic material, or chemical application of any kind if it alters or damages or is capable of altering or damaging living tissue; and Performing any act or procedure using a mechanical device , or displaced energy form of any kind if it damages or is capable of damaging living tissue. 7

Practice of Medicine 8

Practice of Medicine Clinical analytical skillsProblem solving abilityClinical judgment Medical decision making Diagnoses DefinitiveDiagnostic considerations Presenting problem(s) Differential Diagnoses 9

Medical Decision Making Medical Decision MakingRefers to the complexity of establishing a diagnosis and/or selecting a management option. It is the E/M component in which providers assess, advise and assist their patients in managing their health. The end result is an individual plan of care. MDM- Three components Number of diagnoses and management options Amount and complexity of data Risk of significant complications, morbidity and/or mortality 10

Key to Medical Decision Making Documentation is KeyComplete, clear, succinct and legible medical records, supporting the medical necessity for the service performed .Medical observational information logically presented All problems directly addressed in the encounter should be used to determine the level of decision making Documented initiation of, or changes in, treatment MDM level billed depends on the status of the patient and/or the services performed by the provider 11

General Principles of MDM Medical decision making is generally easier for an already diagnosed problem than for an undiagnosed one. In addition, problems which are improving or resolving are less complex than those which are worsening or failing to change. Keep in mind that MDM should reflect the nature of the presenting problem 12

Major Point Beyond its clinical value, good documentation is a good business practice, and ICD-10 allows better documentation of patient complexity and level of care. Patient complexity, physician cognitive and physical work performed and standards of care Integral and fundamental to the business of the practice of medicine 13

Common Theme “Sign & Symptoms” Vs. “Diagnoses”Clinical Specificity vs Generic Culmination of Work Performed Clinical specificity and demonstrated relevance of diagnoses to medical decision making and presenting problem Generic terms misrepresent amount of work performed and complexity of the patient management Clinical Specificity Requirement Not optional Necessity today and October 1, 2015 14

Speaking of Specificity ICD-10Enhanced specificity in diagnoses selection Opportunity to report cause and effect relationship in diagnoses Laterality of disease processes 5 Character ICD-9 code vs. Up to 7 alphanumeric characters under ICD-10 Recording and Reporting of your clinical judgment, medical decision making and problem solving ability through effective documentation of encompassing, disease specific diagnoses that describe the true acuity and complexity of the patient assessment and plan of care is Good Medicine reflective of the quality of care provided 15

Clinical Specificity (Today and Tomorrow) Laterality (Left, Right, Bilateral) Examples : C50.511 – Malignant neoplasm of lower-outer quadrant of right female breast;H16.013 – Central corneal ulcer, bilateral; and L89.012 – Pressure ulcer of right elbow, stage II 16

Clinical Specificity (Today and Tomorrow) Combination Codes For Certain Conditions and Common Associated Symptoms and ManifestationsExamples: K57.21 – Diverticulitis of large intestine with perforation and abscess with bleeding; E11.341 – Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema; and I25.110 – Atherosclerotic heart disease of native coronary artery with unstable angina pectoris. 17

Clinical Specificity (Today and Tomorrow) Combination Codes for Poisonings and Their Associated External CauseExample: T42.3x2S – Poisoning by barbiturates, intentional self-harm, sequela. Obstetric Codes Identify Trimester Instead of Episode of Care Example: O26.02 – Excessive weight gain in pregnancy, second trimester. 18

Clinical Specificity (Today and Tomorrow) Inclusion of Clinical Concepts That Do Not Exist in ICD-9-CM (For Example, Underdosing, Blood Type, Blood Alcohol Level) Examples: T45.526D – Underdosing of antithrombotic drugs, subsequent encounter; Z67.40 – Type O blood, Rh positive; and Y90.6 – Blood alcohol level of 120 – 199 mg/100 ml. 19

Clinical Specificity (Today and Tomorrow) A Number of Codes Are Significantly Expanded (For Example, Injuries, Diabetes, Substance Abuse, Postoperative Complications) Examples: E10.610 – Type 1 diabetes mellitus with diabetic neuropathic arthropathy ;F10.182 – Alcohol abuse with alcohol-induced sleep disorder; and T82.02xA – Displacement of heart valve prosthesis, initial encounter. 20

Clinical Specificity (Today and Tomorrow) Codes for Postoperative Complications Are Expanded and a Distinction is Made Between Intraoperative Complications and Postprocedural Disorders Examples: D78.01 – Intraoperative hemorrhage and hematoma of spleen complicating a procedure on the spleen; and D78.21 – Postprocedural hemorrhage and hematoma of spleen following a procedure on the spleen. 21

Other Changes Laterality is a component of relevant codes Expanded use of combination codes Injuries are grouped by anatomical site rather than by the type of injury Specificity is greatly expanded More clinical concepts Timelines and episode of care is defined for relevant codes Modern medicine and today’s terms are utilized   22

Other Changes Borderline clinical conditionsDiabetes- R73.09Hypertension-R03.0 Osteopenia- M85.8 Pelvis, with obstruction during labor- O65.1 Personality-F60.3 23

Other Changes DM – New language regarding uncontrolled CD-10 diabetes codes are no longer classified as controlled or uncontrolled Index now tells us that inadequately controlled, out of control, and poorly controlled are coded to Diabetes, by Type, with hyperglycemia Diabetes with Hypoglycemia will be part of each DM type E.08 -Diabetes mellitus due to underlying condition Code first the underlying condition such as: Congenital rubella (P35.0) Malnutrition (E40-E46) Cushing’s syndrome (E24.-) Pancreatitis and other Cystic fibrosis (E84.-) diseases of the pancreas (K85- Malignant neoplasm (C00-C96) K86) 24

Increased Use of Combination Codes ICD-9 Steroid induced DM with diabetic peripheral angiopathy with gangrene of right calf, DM uncontrolled 249.71 Secondary DM uncontrolled 443.81 Peripheral angiopathy 785.4 Gangrene E932.0 Adverse effect of steroid ICD-10 Steroid induced DM with diabetic peripheral angiopathy with gangrene of right calf, DM uncontrolled T38.0x5D – Adverse effect of steroid subsequent encounter E09.52 - Secondary DM with peripheral angiopathy with gangrene

Rest Easy Complete, clinically accurate, relevant information in the chart best strategy to meet challenges and take advantage of ICD1-10 opportunities 26

Don’t Panic F41.0- Panic AttackF43.0- Panic reaction to exceptional stress I10- Essential (primary) hypertension (arterial, benign, essential, accelerated, malignant, primary, systemic) Use additional code to identify: Exposure to environmental tobacco smoke (Z77.22) History of tobacco use (Z87.891) Occupational exposure to environmental tobacco smoke ( Z57.31) Tobacco dependence (F17.-) Tobacco use (Z72.0) 27

Noncompliance Noncompliance Z91.19With dietary regimen Z91.11 Dialysis Z91.15 Medical treatment Z91.19 Medication regimen Z91.14Underdosing Z91.14 Intentional NEC Z91.128 Due to financial hardship of patient Z91.120 Unintentional NEC Z91.138Due to patient’s age related debility Z91.130 28

AMI Changes AMI changes AMI equal to or less than four weeks (28 days) including transfers to other acute settings is coded to I21 I22 (subsequent MI) is coded when a patient had a previous MI and has a new MI within the 4 week time frame from the initial MI –I22 will never be reported without I21 –Sequencing will depend on the circumstance of the encounter 29

AMI Detail Specific artery can be captured Left Main Left Anterior Descending Other Anterior wall artery Right coronary artery Other Inferior wall artery Left circumflex Other and unspecified site 30

Asthma Specificity Asthma now classified by WAO frequency indicators Greater Detail within our respiratory distress options 31

Asthma Documentation Expectations 32

Fractures have further 7th character extensions 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 P - Subsequent encounter for fracture with malunion S - Sequela 33

Injury Designation Initial Injury is actively treated Surgical treatment ED encounter Evaluation by new physician Subsequent Used after active treatment Now receiving only routine care for the injury Usually in healing or recovery phase 34

Injury Designation Initial - A Any new Fx Fx now requiring surgery Fx now requiring manipulation Fx now requiring consult by ortho MD Delayed treatment for fx or non-union Subsequent - D Cast change or removal Removal of IF/EF device Follow-up (ancillary) x-rays Rehab (PT/OT) Swing Bed encounters for healing fx/injury 35

Respiratory Failure ICD-9 518.81- Acute respiratory failure 518.83- Chronic respiratory failure 518.84- Acute-on-Chronic respiratory failure ICD-10 J96.00- Acute respiratory failure J96.02- ARF with hypercapnia J96.01- ARF with hypoxia

Respiratory Failure J96.20- Acute-on-Chronic Respiratory FailureWith Hypercapnia- J96.22With Hypoxia- J96.21 J96.10- Chronic Respiratory Failure With Hypercapnia- J96.12 With Hypoxia- J96.11

Overall Strategies to Meet ICD-10 Goals Focus upon accurate and effective capture of clinical thoughts, judgments, medical decision making and thought processes Capitalize and seize upon the opportunity to support your medical decision making with clinically specific diagnoses Avoid non-specific diagnostic terms Don’t fret over the coding rules and coding conventions Focus upon accurate reporting of patient acuity and clinical severity reflective of severity of illness, risk of morbidity/mortality supportive of physician work performed Good Luck! 38

Final Thoughts ICD-10 and clinical specificityBilling accuracyQuality measures Population management Risk Management Health care analyticsPQRS Patient Care Inadequate clinical documentation→ Inaccurate coding→ Increased denials Identify common clinical diagnosis codes in your practiceFocus upon and correct deficiencies relative to ICD-10 39

Final Thoughts….. Sound business principles and practicesEffective and complete clinical documentation reflective of good patient data Observation of all facts relevant to patient condition Translate into documentation of medical concepts relevant to current and future patient care Medical concepts related to ICD-10 not new to clinical practice Beyond its clinical value, good documentation is a good business practice, and ICD-10 allows better documentation of patient complexity and level of care. 40

Contact Information Glenn KraussGkrauss@accretivehealth.com(603) 303-3337 Thanks for attending 41

Appendix A- 42

Five Step ICD-10 Implementation Process Make a Transition Plan Determine where diagnosis codes are used in your practice Identify who on your staff will help with the ICD-10 transition Prepare a budget Train Your Staff Training needs will vary among practices and individuals Some practices may want to obtain an ICD-10 code book or software for staff to try before deciding whether more training is necessary Update Your Processes Confirm that good clinical documentation processes are in placeRevise paper forms/templates Modify policies and procedures 43

Five Step ICD-10 Implementation Process Talk to Your Vendors and Payers Contact your clearinghouses, EHR and practice management system vendors, billing services, and other vendorsTest Your Systems and Processes Perform internal testing of systems and work flow processes using ICD-10 diagnosis codes Conduct external testing with vendors and payers using data that contain ICD-10 diagnosis codes Practice coding in ICD-10 and validate supporting clinical documentation 44