Joseph Nichols, M.D.

Report
ICD-10
The Provider Perspective
Presented by: Joe Nichols MD
Date: May 3, 2014
Agenda
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2
ICD-10, the basic facts
How is ICD-10 different?
What are the business impacts?
Clinical documentation. What’s needed to
support proper coding in ICD-10?
What do I need to do to prepare?
Source: Health Data Consulting
ICD-10
What is it?
3
ICD10 Quick Facts
• ICD-10 international version
– Adopted by WHO in 1990
– Most countries other than the US currently use ICD-10
– ICD-10 (International version) ~ 12,500 diagnostic
codes
– ICD-10 used for mortality reporting in the US - 1999
• ICD-10-CM (US version)
Source: Health Data Consulting
– ~ 69,000 diagnostic codes
– Final rule published – 2009
– Compliance date – Oct 1, 2014
• ICD-10-PCS
–
–
–
–
4
~72,000 codes
Not part of an international standard
Inpatient procedures only
Compliance date – Oct 1, 2014
Health Data Consulting © 2012
ICD-9 Diagnosis Codes vs. ICD-10-CM (Diagnosis Codes)
ICD-9-CM Diagnosis Codes
ICD-10-CM Diagnosis Codes
3 to 5 digits
Alpha “E” and “V” on 1st character
No place holder characters
Terminology
Index and Tabular Structure
Coding Guidelines
Approximately 14,000 codes
Severity parameters limited
Does not include laterality
Combination codes limited
5
7 digits
Alpha or numeric for any character
Include place holder characters (‘x’)
Similar
Similar
Some what similar
Approximately 69,000 codes
Extensive severity parameters
Common definition of laterality
Combination codes common
Health Data Consulting © 2012
Same Condition – Different Codes
What’s the Difference?
September 2014
October 2014
Source: Health Data Consulting
ICD-9
ICD-10
82111:
Open fracture of Shaft of Femur
S72351C:
Displaced comminuted fracture of shaft
of right femur, initial encounter for
open fracture type IIIA, IIIB, or IIIC
All codes for femur fractures = 16
6
All codes for femur fractures = 1530
Health Data Consulting © 2012
ICD9 Comparison to ICD10-CM
Diagnosis Codes – Clinical Example
A patient is seen in the emergency room with. [severe] [persistent] [asthma] with
[acute exacerbation].
ICD9 Code
49312
ICD10 Code
J4551
Description
Intrinsic asthma with (acute) exacerbation
Description
Severe persistent asthma with (acute) exacerbation
Source: Health Data Consulting
7
Health Data Consulting © 2012
ICD9 Comparison to ICD10-CM
Diagnosis Codes – Clinical Example
A patient is seen in the emergency room with. [severe] [persistent] [asthma] with
[acute exacerbation].
ICD9 Code
49312
ICD10 Code
J4551
8
Description
Intrinsic asthma with (acute) exacerbation
Description
Severe persistent asthma with (acute) exacerbation
Health Data Consulting © 2012
ICD9 Comparison to ICD10-CM
Diagnosis Codes – Clinical Example
A patient is admitted as the result of [rupture of the cardiac wall without bleeding
into the pericardium]. The patient is [within 4 weeks] of a [myocardial infarction].
ICD9 Code
42979
ICD10 Code
I233
9
Description
Certain sequelae of myocardial infarction, not elsewhere classified,
other
Description
Rupture of cardiac wall without hemopericardium as current
complication following acute myocardial infarction
Health Data Consulting © 2012
ICD9 Comparison to ICD10-CM
Diagnosis Codes – Clinical Example
A patient is admitted as the result of [rupture of the cardiac wall without bleeding
into the pericardium]. The patient is [within 4 weeks] of a [myocardial infarction].
ICD9 Code
42979
ICD10 Code
I233
10
Description
Certain sequelae of myocardial infarction, not elsewhere classified,
other
Description
Rupture of cardiac wall without hemopericardium as current
complication following acute myocardial infarction
Health Data Consulting © 2012
Nature of the Changes
Volume
Diagnosis
Procedure
80,000
Source: Health Data Consulting
70,000
60,000
50,000
Diagnosis
40,000
Procedure
30,000
20,000
10,000
0
ICD-9-CM
11
ICD-10-CM
ICD-10 (WHO)
ICD-9-CM
ICD-10-PCS
Health Data Consulting © 2012
ICD-10 (WHO)
“There are too many Codes”
• There are lots of words in the dictionary, but that doesn’t
seem to trouble authors…
• 34,250 (50%) of all ICD-10CM codes are related to the
musculoskeletal system
• 17,045 (25%) of all ICD-10CM codes are related to fractures
• 10,582 (62%) of fracture codes to distinguish ‘right’ vs. ‘left’
• There are over 1800 codes for fractures of the radius
(forearm) but only ~ 50 concepts used repeatedly in different
patterns
• Only a very small percentage of the codes will be used most
providers
12
Health Data Consulting © 2012
Current Distribution of ICD-9 diagnosis codes
3 Years of Data - All claims - All lines of business - 1million Lives
Total Charges by Code
3years - $10 Bill
80.0%
70.0%
60.0%
50.0%
40.0%
Charge %
30.0%
20.0%
10.0%
0.0%
5%
next
5%
…
…
13 Source: Health Data Consulting
…
…
…
…
…
…
…
…
…
Health Data Consulting © 2012
…
…
…
…
…
…
…
Lots of Codes, Lots of Repetition
2466 codes for
fractures of the
femur
14
Documentation Requirements
Recurring Concepts
15
Concept
Number of Codes
Initial Encounter
13,932
Subsequent Encounter
21,389
Sequela
11,974
Right
12,704
Left
12,393
Routine Healing
2,913
Delayed Healing
2,913
Nonunion
2,895
Malunion
2,595
Assault
1096
Self-harm
1057
Accidental
1262
Health Data Consulting © 2013
Varying Code Volume
By Clinical Area
Clinical Area
ICD-9 Codes
ICD-10 Codes
Fractures
747
17099
Poisoning and toxic effects
244
4662
Pregnancy related conditions
1104
2155
Brain Injury
292
574
Diabetes
69
239
Migraine
40
44
Bleeding disorders
26
29
Mood related disorders
78
71
Hypertensive Disease
33
14
End stage renal disease
11
5
Chronic respiratory failure
7
4
16 Source: Health Data Consulting
Health Data Consulting © 2012
Other Key Changes
Code Example – Down’s Syndrome
17
ICD-9 Code
ICD-9 Description
7580
Down’s Syndrome
ICD-10 Code
ICD-10 Description
Q909
Down syndrome, unspecified
Q900
Trisomy 21, nonmosaicism (meiotic nondisjunction)
Q901
Trisomy 21, mosaicism (mitotic nondisjunction)
Q902
Trisomy 21, translocation
Health Data Consulting © 2012
Other Key Changes
Code Examples – Benign neoplasms of the colon:
18
ICD-9 Code
ICD-9 Description
2113
Benign neoplasm of colon
ICD-10 Code
ICD-10 Description
D120
Benign neoplasm of cecum
D121
Benign neoplasm of appendix
D122
Benign neoplasm of ascending colon
D123
Benign neoplasm of transverse colon
D124
Benign neoplasm of descending colon
D125
Benign neoplasm of sigmoid colon
D126
Benign neoplasm of colon, unspecified
K635
Polyp of colon
Health Data Consulting © 2012
Other Key Changes
Code Examples – Leukemia:
19
ICD-9 Code
ICD-9 Description
20501
Acute myeloid leukemia, in remission
ICD-10 Code
ICD-10 Description
C9201
Acute myeloblastic leukemia, in remission
C9241
Acute promyelocytic leukemia, in remission
C9251
Acute myelomonocytic leukemia, in remission
C9261
Acute myeloid leukemia with 11q23-abnormality in remission
C92A1
Acute myeloid leukemia with multilineage dysplasia, in remission
Health Data Consulting © 2012
The Challenge
Current Physician thinking on ICD-10
20
“There are a bunch of dumb codes that make no sense.”
• Clinician organizations have used codes like; “Hit by a
spacecraft” or “Suicide by paintball gun” as examples
of the “stupidity” of the ICD-10 codes.
• Interesting to note however is that the codes noted
above are ICD-9 codes and have been around for a
long time.
• The bottom line; don’t use the codes that don’t make
sense or don’t accurately represent your patient’s
condition. They may mean something to someone,
but shouldn’t bother you.
21
Health Data Consulting © 2012
“ICD-10 won’t help me take care of my patients.”
• Difficult to make the case about how ICD-10 will help
Dr. Smith with his encounter with Mary Jones
• Healthcare goes crosses the boundary of time and
providers
• Improving healthcare requires a broad understanding
of what works and what doesn't work
• Clinicians should be leaders in the healthcare
industry by providing accurate data, accurate analysis
of the data and change in healthcare to continuously
improve the value their patients receive
22
“Documentation for ICD-10 is an unnecessary burden.”
• The number and type of new concepts required for
ICD-10 are not foreign to clinicians
• The focus of documentation is good patient care
• Patients deserve to have accurate and complete
documentation of their conditions
• If other industries understand the value of accurate
and complete documentation of data about
encounters; shouldn’t we?
23
Health Data Consulting © 2013
“ICD diagnosis codes are irrelevant to my business.”
• ICD-10 codes are likely to factor into:

Changes in reimbursement based on both “what” was
done and “why”
 Managing financial risks for contracted populations
(ACO’s)
 Changes in reimbursement based on more robust
models of payment adjusted for risk and severity
 More sophisticated weighting of payments based on
DRGs, episodes or other groupers of care.
24
Health Data Consulting © 2013
Business Impacts
It’s bigger than you think
25
Business Impacts
• Coding




EHR updates
Super Bill???
Training
Coding software
• Contracting



Scope of services
Case rates
Carve outs
• Billing



Billing code updates
Charge masters
Billing Edits
• Benefits and coverage determinations
26
Business Impacts (Cont.)

Compliance






 National
 State
 Regional Initiatives
Contract requirement
Accreditation
Reimbursement




Pay for performance
POA, “never events”, re-admissions, HACs, tiered payment models
Network inclusion
Denials
Audits



27
HIPAA
Reporting
RAC
Fraud and abuse
Coding
Health Data Consulting © 2013
Coding ICD-10-CM - Challenges
Getting there
Example look up for “Coronary Artery Disease” + “Angina”
28
Health Data Consulting © 2012
Coding ICD-10 CM - Challenges
Same concept in many places
Condition
Tabular Category
Hypertension
Hypertensive Disease
14
Other Categories (14)
115
Influenza and Pneumonia
38
Other Categories (18)
42
Diseases of the Genitourinary System
587
Other Categories (14)
535
Pneumonia
Genitourinary Disorders
29
Health Data Consulting © 2012
Number of codes
Coding ICD-10 CM - Challenges
Relevant Quote
"If you don't find it in the index, look very
carefully through the entire catalogue."
-- Unknown
30
Business Impacts
• Coding




EHR updates
Super Bill???
Training
Coding software
• Contracting



Scope of services
Case rates
Carve outs
• Billing



Billing code updates
Charge masters
Billing Edits
• Benefits and coverage determinations
31
Health Data Consulting © 2010
Business Impacts
• Compliance


HIPAA
Reporting
 National
 State
 Regional Initiatives


Contract
Accreditation
• Reimbursement




Pay for performance
POA, “Never Events”, Tier Models
Network inclusion
Denials
• Audits



32
RAC
Fraud and abuse
Coding
Quality Measures Impacts
AMI example
• Definition of acute myocardial infarction (MI) has
changed


ICD-9 – Eight weeks from initial onset
ICD-10 – Four weeks from initial onset
• Subsequent vs. Initial episode of care


ICD-9 – Fifth character defines initial vs. subsequent episode of
care
ICD-10 – No ability to distinguish initial vs. subsequent episode
of care
• Subsequent (MI)


33
ICD-9 – No ability to relate a subsequent MI to an initial MI
ICD-10 – Separate category to define a subsequent MI occurring
within 4 weeks of an initial MI
Health Data Consulting © 2013
Fraud Waste and Abuse
If you can’t stop expenditures upfront …
Fraud, Waste and Abuse
Enough money to take care of a
lot of need.
The Office of Management and
Budget estimates that every $1
invested to fight fraud results in
approximately $17 in savings.
$60,000,000,000/Year
Source: National Health Care Anti-Fraud Association / OMB
34
Coding: The Prime Directive
The goal of coding is to reflect as accurately as possible
key parameters of the patient health condition and/or
the procedures done to maintain or improve that
condition.
Coding focused on maximizing payment over accurate
definition of the condition begins to cross the boundary
of fraud and abuse.
35
Health Data Consulting © 2012
Fraud, Waste and Abuse
Medicare Definition
Source: CMS
36
Fraud, Waste and Abuse
Don’t get caught in the trap…
With increasing challenges to control cost, the intensity
of audits related to fraud, waste and abuse is
increasing. In the “Justification of Estimates for
Appropriations Committees” CMS states:
“Although the ICD-10 code set will not eliminate all
fraud, waste, and abuse, CMS believes that its
increased specificity will make it much more difficult
for fraud, waste and abuse to occur.”
Source: CMS
37
Fraud, Waste and Abuse
Don’t get caught in the trap…
4 Billion
Recovered
in 2013
Source: CMS
38
Healthcare on the “RAC”
Getting tighter…
Collected Overpayments
$3,500
$3,000
Corrections in Millions
$2,500
$2,000
$1,500
$1,000
$500
$Series1
FY -2010
FY -2011
FY -2012
Fy-2013 (Q1)
(Q1)X4
$75
$797
$2,291
$745
$2,979
Source: CMS
39
Health Data Consulting © 2012
The Super Bill
Not That Super Really…
[Note] For all codes related to fractures of the radius:
•ICD-9 codes = 33
•ICD-10 codes = 1818
40
Health Data Consulting © 2010
Cash Flow
Impacts inbound and outbound
Coding Challenges
Payment Delays
Increased Cost
41
Health Data Consulting © 2012
Cash Flow
Impacts inbound and outbound
Source: CMS
42
Health Data Consulting © 2012
Documentation and Coding – The Patient Interface
Where it all begins
Physical Exam
Internal Record Review
History
External Record Review
Studies
Assessment/Diagnosis
43
Documentation
It could be better…
Bad Mojo
is not a diagnosis
• Poor quality documentation is bad for Payers, Providers and
Patients.






44
Billing accuracy
Quality measures
Population management
Risk management
Healthcare analytics
Patient Care
Documentation
1889
45
Documentation
1889
46
Documentation
1889
47
Documentation
1889
48
Documentation
2013
Progress?
49
50
Documentation
Why is it important?
•
•
•
•
•
•
•
Supports proper payment reduced denials
Assures accurate measures of quality and efficiency
Assures accountability and transparency
Captures the level of risk and severity
Provides better business intelligence
Supports clinical research
Enhances communication with hospital and other
providers
• It’s just good care!
Source: Health Data Consulting
51
Health Data Consulting © 2012
Good patient data
It’s all about good patient care…
1. Complete observation of all objective and
subjective facts relevant to the patient
condition
2. Documentation of all of the key medical
concepts relevant to patient care currently
and in the future
3. Coding that includes all of the key medical
concepts supported by the coding standard
and guidelines
52
Health Data Consulting © 2012
Medical Concepts
Expressing the patient condition in codes.
Medical Scenario:
A [27 year old] [male] patient is seen in [follow-up] for a [Smith’s
fracture] on the [right] that was exposed through an [open
wound] with [minimal opening and minimal tissue damage]. The
fracture has [not healed after 6 months].
Though not explicitly stated in this scenario certain expressions
imply other concepts:
“Smith’s fracture” >> [fracture], [radius], [distal], [dorsal angulation], [extraarticular], [displaced]
“minimal opening and minimal tissue damage” >> [Gustilo classification I]
“not healed after 6 months” >> [nonunion]
53
Health Data Consulting © 2012
54
Health Data Consulting © 2012
Coding ICD-10 CM
Diabetes Concepts
Diabetes = 276 ICD-10 Codes / 83 ICD-9 Codes
Unique concepts within in ICD-10 codes = 62
Diabetes Type
Pregnancy
Type 1 diabetes
First trimester
Neurological complication
Type 2 diabetes
Second trimester
Neuropathy
Underlying condition
Third trimester
Mononeuropathy
Drug or chemical induced
Childbirth
Polyneuropathy
Pre-existing
Puerperium
Autonomic (poly)neuropathy
Gestational
Antepartum
Amyotrophy
Poisoning by insulin and oral hypoglycemic
Postpartum
Coma
Adverse effect of insulin and oral
hypoglycemic
Underdosing of insulin and oral
hypoglycemic
Neonatal
Secondary
55
Health Data Consulting © 2012
Neurologic complications
Coding ICD-10 CM
Diabetes Concepts
Lab Findings
Renal complications
Ophthalmologic Complications
Ketoacidosis
Nephropathy
Retinopathy
Hyperosmolarity
Chronic kidney disease
Macular edema
Hypoglycemia
Kidney complication
Cataract
Hyperglycemia
Ophthalmic complication
Mild nonproliferative retinopathy
Moderate nonproliferative retinopathy
Severe nonproliferative retinopathy
Proliferative retinopathy
Background neuropathy
56
Health Data Consulting © 2012
Coding ICD-10 CM
Diabetes Concepts
Vascular Complications
Skin Complications
Circulatory complications
Dermatitis
Neuropathic arthropathy
Peripheral angiopathy
Foot Ulcer
Arthropathy
Gangrene
Skin complications
Skin ulcer
57
Joint Complications
Health Data Consulting © 2012
Coding ICD-10 CM
Diabetes Concepts
Oral Complications
Diabetic Control
Encounter
Other Concepts
Oral complications
Diet-controlled
Initial encounter
Complications
Periodontal
disease
Insulin controlled
Subsequent encounter
Right
Uncontrolled
Sequela
Left
Controlled
Accidental
Intentional self-harm
Assault
Family history
Personal history
Screening
58
Health Data Consulting © 2012
Source: Health Data Consulting
Otitis Media
59
Health Data Consulting © 2012
ICD-10 Relevant Documentation
Otitis Media Concepts:
Type:
•
•
•
•
•
•
60
Serous
Supparative or non-supparative
Tubotympanic
Atticoantral
Allergic
Mucoid
Health Data Consulting © 2012
ICD-10 Relevant Documentation
Otitis Media Concepts:
Type (alternate terms):
•
•
•
•
•
•
•
•
•
61
Sanguinous
Seromucinous
Exudative
Transudative
Secretory
with effusion (non-purulent)
Catarrhal
Purulent
Myringitis
Health Data Consulting © 2012
ICD-10 Relevant Documentation
Otitis Media Concepts:
Associated with:
•
•
•
•
With spontaneous rupture of the TM
Without spontaneous rupture of the TM
Infectious or other external agent…
Smoking



Exposure to environmental tobacco smoke
History of tobacco use
Occupational exposure to environmental tobacco
smoke
 Tobacco dependence
 Tobacco use
•
62
Allergic or non-allergic
Health Data Consulting © 2012
ICD-10 Relevant Documentation
Otitis Media Concepts:
Temporal Factors:
•
•
Acute or subacute or chronic
Recurrent
Laterality:
•
•
63
Left or right
Bilateral or unilateral
Health Data Consulting © 2012
ICD-10 Relevant Documentation
Code Examples – Otitis Media:
ICD-10 Code
Description
B053
Measles complicated by otitis media
H6501
Acute serous otitis media, right ear
H65113
Acute and subacute allergic otitis media (mucoid) (sanguinous) (serous), bilateral
H65194
Other acute nonsuppurative otitis media, recurrent, right ear
H6532
Chronic mucoid otitis media, left ear
H66012
Acute suppurative otitis media with spontaneous rupture of ear drum, left ear
H6613
Chronic tubotympanic suppurative otitis media, bilateral
H6622
Chronic atticoantral suppurative otitis media, left ear
J1183
Influenza due to unidentified influenza virus with otitis media
64
Health Data Consulting © 2012
Source: Health Data Consulting
Fractures
Radius
Femur
65
Health Data Consulting © 2013
ICD-10 Relevant Documentation
Fracture Concepts:
Type of Fracture:
•
•
•
•
•
66
Pathologic fracture
Stress fracture
Torus fracture
Greenstick fracture
Osteoporosis related
Health Data Consulting © 2013
ICD-10 Relevant Documentation
Fracture Concepts:
Type of Fracture:
• Open or Closed
 Gustillo type I or II
 Gustillo type IIIA, IIIB, or IIIC
• Physeal Fracture
 Salter Harris I
 Salter Harris II
 Salter Harris III
 Salter Harris IV
67
Health Data Consulting © 2013
Open Fractures
Gustilo Classification
Grade I:
- wound less than 1 cm w/ minimal soft tissue injury;
- wound bed is clean
- bone injury is simple w/ minimal comminution;
- w/ IM nailing, average time to union is 21-28 weeks;
Grade II:
- wound is greater than 1 cm w/ moderate soft tissue injury;
- wound bed is moderately contaminated;
- fracture contains moderate comminution;
- w/ IM nailing, average time to union is 26-28 weeks;
*Source: Duke Orthopedics
68
Health Data Consulting © 2013
Open Fractures
Gustilo Classification
Grade III:
- following frx automatically results in classification as type III:
- segmental frx w/ displacement
- frx w/ diaphyseal segmental loss;
- frx w/ associated vascular injury requiring repair;
- farmyard injuries or highly contaminated wounds;
- high velocity BSW;
- frx caused by crushing force from fast moving vehicle
*Source: Duke Orthopedics
69
Health Data Consulting © 2012
Open Fractures
Gustilo Classification
Grade III A:
- wound less than 10 cm w/ crushed tissue and contamination;
- soft tissue coverage of bone is usually possible;
- w/ IM nailing, average time to union is 30-35 weeks;
Grade III B:
- wound greater than 10 cm w/ crushed tissue and contamination;
- soft tissue is inadequate and requires regional or free flap;
- w/ IM nailing, average time to union is 30-35 weeks;
Grade III C:
- is frx in which there is a major vascular injury requiring repair for limb salvage;
- fractures can be classified using the MESS:
- in some cases it will be necessary to consider BKA following tibial frx
*Source: Duke Orthopedics
70
Health Data Consulting © 2013
Growth Plate Fractures
Salter-Harris Classification
71
Health Data Consulting © 2013
ICD-10 Relevant Documentation
Fracture Concepts:
Laterality:
• Left
• Right
• Unilateral
• Bilateral
Spatial Localization:
• Proximal
• Distal
• Medial
• Lateral
72
Health Data Consulting © 2013
ICD-10 Relevant Documentation
Fracture Concepts:
Encounter:
• Initial
• Subsequent
• Sequela
Healing pattern:
• Routine Healing
• Delayed healing
• Nonunion
• Malunion
73
Health Data Consulting © 2013
ICD-10 Relevant Documentation
Fracture Concepts:
Fracture Patterns:
• Displace/Non-displaced
• Transverse, Oblique, Spiral
• Simple , Comminuted, Segmental 3 part..,
• Intra-articular/Extra-articular
• Avulsion
74
Health Data Consulting © 2013
ICD-10 Relevant Documentation
Fracture Concepts:
Fracture Patterns:
• Osteochondral or Articular
• Blowout Fracture
• Longitudinal
• Pilon Fracture
• Compression Fracture
• Wedge Fracture
75
Health Data Consulting © 2012
ICD-10 Relevant Documentation
Fracture Concepts - Radius:
Parts of the Bone:
• Radius
 Radial Head
 Radial Styloid
 Shaft
 Neck
 Radius and ulna
 Radial tuberosity
76
ICD-10 Relevant Documentation
Fracture Concepts-Radius:
Named Fractures of the Radius:
• Colles’
• Smith’s
• Galeazzi’s
• Barton’s
• Chauffeur’s
77
ICD-10 Relevant Documentation
Code Example – Radial Fractures:
ICD-10 Code
Description
M84534G
Pathological fracture in neoplastic disease, left radius, subsequent encounter for
fracture with delayed healing
S52121B
Displaced fracture of head of right radius, initial encounter for open fracture type I or II
S52112P
Torus fracture of upper end of left radius, subsequent encounter for fracture with
malunion
S52321A
Displaced transverse fracture of shaft of right radius, initial encounter for closed
fracture
S52331J
Displaced oblique fracture of shaft of right radius, subsequent encounter for open
fracture type IIIA, IIIB, or IIIC with delayed healing
S52549M
Smith's fracture of unspecified radius, subsequent encounter for open fracture type I
or II with nonunion
S59111S
Salter-Harris Type I physeal fracture of upper end of radius, right arm, sequela
S52516K
Nondisplaced fracture of unspecified radial styloid process, subsequent encounter for
closed fracture with nonunion
78
Health Data Consulting © 2013
The Femur
Anatomy
79
Health Data Consulting © 2013
The Femur
Fracture Patterns
Sub Capital
Inter-Trochanteric
Sub-Trochanteric
Oblique
Supra-Condylar
Transverse
Spiral
Medial Condylar
Lateral Condylar
Intra-Condylar
80
ICD-10 Relevant Documentation
Code Example – Femur:
ICD-10 Code
Description
M80052A
Age-related osteoporosis with current pathological fracture, left femur, initial
encounter for fracture
M84351D
Stress fracture, right femur, subsequent encounter for fracture with routine healing
S72032H
Displaced midcervical fracture of left femur, subsequent encounter for open fracture
type I or II with delayed healing
S72051P
Unspecified fracture of head of right femur, subsequent encounter for closed fracture
with malunion
S72142K
Displaced intertrochanteric fracture of left femur, subsequent encounter for closed
fracture with nonunion
S72322A
Displaced transverse fracture of shaft of left femur, initial encounter for closed fracture
S72335B
Nondisplaced oblique fracture of shaft of left femur, initial encounter for open fracture
type I or II
S72422G
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Displaced fracture of lateral condyle of left femur, subsequent encounter for closed
fracture with delayed healing
Health Data Consulting © 2013
Getting Specific
When is unspecified OK?
82
Coding specificity
What’s an unspecified code?
• Does specificity require more than one code?
• When is unspecified the right choice?
• When should unspecified change to specified?
83
Health Data Consulting © 2012
Poorly Specified Coding
A proposed definition
“Coding that does not fully define important
parameters of the patient condition that could
otherwise be defined given information available to the
observer (clinician) and the coder.”
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Health Data Consulting © 2012
Coding specificity
More than one code.
• Beyond the primary code, accurate representation of the
patient’s health condition may require other codes to
represent:
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Causation
Infectious, chemical, physical or other agents
Location of Injury
External causes of injury
Manifestations
Comorbid condition or contributing factors
Sequela
Findings
Multiple other factors associated with the primary condition
being treated or evaluated
Health Data Consulting © 2012
Coding specificity
A place for “unspecified” codes
• Sometimes unspecified makes sense…
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The patient may be early in the course of evaluation
 The claim may be coming from a provider who is not
directly related to diagnosis of the patients condition
 The clinician seeing the patient may be more of a
generalist and not able to define the condition at a level
of detail expected by a specialist
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Source: Health Data Consulting
Coding specificity
No place for “unspecified” codes
• If there is sufficient information available to more accurately
define the condition
• For basic concepts such as:
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Laterality (Right, Left, Bilateral, Unilateral)
Anatomical locations
Trimester
Type of diabetes
Known complications or comorbidities
Description of severity, acute or chronic or other known
parameters…
• Where care is implemented that demands a more specific
level of detail
• At specialty level that should be able to define the detail
required
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Health Data Consulting © 2012
Clinical / Business/Coding Relationships
Creating a new working relationship
Source: Health Data Consulting
88
1. The role of the clinician is to
document as accurately as
possible the nature of the patient
conditions and services done to
maintain or improve those
conditions
2. The role of the coding professional
is to assure that coding is
consistent with the documentation
3. The role of the business manager
is to assure that all billing is
accurately coded and supported
by the documented facts.
Health Data Consulting © 2012
Implementation
Getting your ducks in a row
89
Implementation Strategy
• Short term goals with a long term visions
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What solution do I need today?
Will that solution extend to tomorrows needs?
• Awareness of touch points with other initiatives
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Overlap and conflicts
• Down Stream Impacts
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What works well for one business area, may bring another business
area to it’s knees
• Positioning for competitive advantage
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Can you predict risk better than you competitor?
Are you perceived as a supporter and facilitator for the transition
challenge to providers and other stakeholders?
Can you manage the “burden of illness” of your population better
than your competitors?
Health Data Consulting © 2012
Phases of Transition
1.Assessment
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Inventory of impacted systems and processes
Identifying risk
2.Analysis/Planning
Prioritizing focus
Establishing business area specific approaches
Creating specifications for mapping to support implementation
3.Implementation and Operations
Translating codes from 9 to 10 and from 10 to 9 using crosswalks
Changing analytic models to support both codes
Operationalization of coding to ICD10 from source information
Changing processing logic to operate directly from ICD10 codes
4.Leveraging ICD10 capabilities
Using the enhanced information within ICD10 codes to improve processing
and analysis based on improved concepts buried within the ICD10 codes
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Health Data Consulting © 2012
Scenario-Based Testing
What is it?
• The scenario:

The identification of some event or condition that we are
familiar with today
 Recreating that event virtually through some verbal or
data representation
 Defining a variety of assumptions and variables around
this virtual representation
• Applying one or more of these scenarios in a
Reference Implementation Model (RIM).
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92
Walk through current systems or processes using these
scenarios with varying assumptions and variables to
determine if expected results can be achieved and the
required changes to achieve those expected results.
Health Data Consulting © 2012
Leveraging ICD10
A changing world of cost containment
Accurate and complete documentation and coding provides
opportunities to support the transition into a “value-based”,
“accountable care” reimbursement environment.
• Better representation of severity and risk
• Recognition of varying levels of complexity
• Better claim information to support automated
processing and more rapid reimbursement
• Opportunities to reduce audit risk exposure
• Improved business intelligence to support population risk
management
• More accurate measures of quality and efficiency
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Health Data Consulting © 2012
Summary
Key Points
• ICD-10 will be a substantial change in the standard for
defining the patient’s health state and the institutional
procedures performed to maintain or improve that health
state.
• There are significant impacts and changes to both the clinical
Source: Health Data Consulting
and business side of the practice.
• Coding accuracy and productivity will be substantially
impacted during the transition and will impact both cost and
revenue.
• There are significant new opportunities to leverage ICD-10 in
a new payment environment (ACO).
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Health Data Consulting © 2012
Summary
Action Items
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Establish awareness across members of your organization
Clearly define strategic goals
Identify internal and external dependencies
Identify and prioritized key risks
Clearly define all business requirements and
implementation tasks
• Create a realistic project plan and support it as a priority
• Test early and often.
• Get started now!!
Source: Health Data Consulting
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Health Data Consulting © 2012
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Online Resources
• CMS - https://www.cms.gov/ICD10/
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Coding Documentation (Indexes, Coding Guidelines, Code Files)
General Equivalency Mapping [GEM] (Mapping files, Guidelines, Procedure and
Diagnosis)
FAQ, Coordination and maintenance Committee minutes
• WEDI - http://www.wedi.org/
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List serves
Workgroups
White papers
Implementation forums
Industry advocacy and issue
Access to standards leaders
Source: Health Data Consulting
• AHIMA - http://ahima.org/
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Training and certification
Extensive documentation libraries
Bookstore
Communities of practices
ICD-10 focused conferences
Online Resources
• HIMSS- http://www.himss.org/
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White papers
Bookstore
Webinars
Source: Health Data Consulting
• Vendors
• Consulting Organization
• Online news
• ICD-10 watch -http://www.icd10watch.com/
• Blogs
98
Online Resources
• Health Data Consulting white papers:
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ICD-10 Vendor Evaluation
ICD-10 A Primer
ICD-10 Physician Impacts
ICD-10 Hospital Impacts
Source: Health Data Consulting
Scenario Based Testing
ICD-10 The Case for Moving Forward
Transition to ICD-10: Getting Started
Reconciling Analytics Across the ICD-10 Transition
Contingency Planning
http://healthdataconsulting.com/resources/white-papers/
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