AHIMA Game of documentation - dance with the icd10 dragon

@DrNic1 #DrHITDell - Internal Use - Confidential
Nick van Terheyden, MD (aka @drnic1)
Chief Medical Officer
Dell Health and Life Sciences
Game of Documentation:
Dance with the ICD-10 Dragon

Spoiler alert
This presentation may contain details
from the Game of Thrones series and may
spoil your enjoyment

You too can tame the
ICD-10 Dragon like
Daenerys Targaryen

Agenda
• A quick recap
• So it’s happening – really
• Basic changes from ICD9 to ICD10
• What it means to you
• The impact to patients
• Tips on surviving
• What’s next

ICD-10 history
ICD-10 adopted by the World
Health Organization in 1990
United Kingdom: 1995
Australian Mods: 1998
Canadian: 2001
U.S. development began in 1994
• Multiple versions final implantation date October 1,
2014
• SGR Bill signed April 1, 2014
• Final implementation deadline October 1, 2015
ICD-11 not likely until 2017,
earliest
• 2 years for U.S. to consider, 2 year
review, 2 year mandated wait
• ICD-11-CM not before 2023 (with
the same structure as ICD-10)

Survey question
Where are you on the continuum of preparing
your office for ICD-10?
A. We’re ready
B. We have a plan and are on our way to being ready
C. We might be ready because
D. We’ve talked about it
E. Uh, when do we have to start?
F. No need to prepare... it will be delayed again

Jon Snow
Expect the
unexpected
It ain’t over till
it’s over

High level message
• ICD-10 implementation will improve patient care
• ICD-10 is not being imposed on physicians by the hospital
• The hospital is collaborating to reduce impact on physicians
by building knowledgeable infrastructure
• Independent physicians need to focus now on their practice,
specifically their systems and staff
• Further education will be coming at the appropriate time for
every specialty and subspecialty

Should we really replace ICD-9?
• ICD-9-CM is 35 years old – when it was put in use:
• Margaret Thatcher, Ronald Reagan, and Mikhail Gorbachev were the
leaders of that time and Russian Olympics were boycotted but the U.S.
Won the Miracle on Ice
• Rubik’s Cube was all the rage
• John Lennon was shot dead
• CNN went worldwide
• Music: Celebration/ Another One Bites the Dust
• SmallPox was declared eradicated
• And doctors could still smoke in room with
patients

Should we really replace ICD-9?
• Much of the terminology and
classification of conditions are
outdated and even obsolete
• Increasingly demonstrates lack
of specificity especially for EHR
and population data tracking
• Problematic for international
comparison

Intake
Select chief
complaint
Enter vitals
Review of symptoms
Review past medical
and social history
Review medications
and allergies
Exam
Review Intake
Document
patient exam
Select diagnosis
Enter orders
Review quality
measures
Sign-off
Review assessment
and plan
Sign off on orders
Complete
billing slip
Generate letters
Review charges
Close the patient
encounter
Check-in
Verify
appointment,
demographic,
insurance
information
Collect patient
payments
Print billing slip
Forms
Check-out
Schedule follow up
appointments
Collect
outstanding
balances
Distribute patient
education
materials
Enter charges
The ICD-10 transition broadly affects
the patient visit

Coders Physicians
The Coder / Physician dichotomy
• ICD-9 is 35 years old with
outdated terminology
• Coders must learn current
anatomy, pathophysiology,
terminology, etc.
• Coders must understand
the entire ICD-10 system
• Coders must think
expansively of all possible
code options
• The burden on coders is
tremendous
• ICD-10 includes modern
terminology
• Physician practice has
evolved even though the
coding system was stagnant
• Physicians need to learn
what is applicable to their
specialty
• Physicians tend to be linear
and hierarchical
• The burden on physicians
is manageable

Some ICD-10 new features
• Combination codes (etiology and manifestation)
– Type 1 diabetes with diabetic nephropathy
• Laterality
– Left, right, bilateral, unspecified (4)
• Episode of care
– Initial (open, closed), subsequent (routine, delayed,
nonunion, malunion), treatment of sequela
• Trimesters for obstetrical care
• Clinical changes
– Time frames for acute myocardial infarctions

Changes to the codes
• Condensation
of codes
• Expansion of
codes
• Changes to
terminology

ICD-9-CM ICD-10-CM
Acute Myocardial Infarction
Acute Myocardial Infarction
(30 codes)
• Primary axis: Site involved
(10)
– Anterolateral, other anterior
wall, inferior wall,
inferoposterior wall, other
inferior, other lateral, true
posterior, subendocardial,
other, unspecified
• Secondary axis: episode of
care (3)
– initial, subsequent,
unspecified
Acute Myocardial Infarction (14 codes)
• Axes of classification: Initial MI (9)
• STEMI (8) (by site)
–Anterior (3)
» L main, L anterior descending, other coronary
artery
–Inferior (2)
» Right coronary artery, other
–Other (2)
» Left circumflex, other sites
–Unspecified (1)
• NSTEMI (1)
–Subsequent MI (5)
• Anterior wall
• Inferior wall
• Non-STEMI
• Other sites
• Unspecified
Subsequent AMI
AMI occurring
within 4 weeks of
previous AMI,
regardless of site

Changes to terminology

Asthma classification
Asthma 14 codes
Type/etiology/cause (12 types)
• Extrinsic
• Intrinsic
• Chronic obstructive
• Asthma, Unspecified
– Severity (for above types)
• Unspecified
• With (acute) exacerbation
• With status asthmaticus
Other forms of asthma (2 types)
• Exercise induced
bronchospasm
• Cough variant asthma
Asthma 18 codes
Severity / type
• Mild intermittent (3)
• Mild persistent (3)
• Moderate persistent (3)
• Severe persistent (3)
– Presentation (for each above)
• Uncomplicated
• With acute exacerbation
• With status asthmaticus
Other and unspecified asthma
• Unspecified (3)
– With 3 presentations above
• Other asthma (3)
– Exercise induced bronchospasm
– Cough variant asthma
– Other asthma
ICD-9-CM ICD-10-CM

Benefits of ICD-10
The new, up-to-date classification system will provide much better data needed to:
• Measure the quality, safety, and efficacy of care
• Improve quality reporting and scoring
• Reduce the need for additional documentation to explain the patient’s condition
• Design payment systems and process claims for reimbursement
• Conduct research, epidemiological studies, and clinical trials
• Set health policy
• Support operational and strategic planning
• Design healthcare delivery systems
• Monitor resource utilization
• Improve clinical, financial, and administrative performance
• Prevent and detect healthcare fraud and abuse
• Track public health and risks

Why physicians are liking ICD-10
• Codes are more specific
– They link etiology to disease (staph pneumonia)
– They link manifestation to etiology (hypertensive heart
disease)
• They make more clinical sense
– Injuries grouped by anatomical site rather than type of
injury
– Laterality has been added to relevant codes
• They are up to date
– Code titles reflect new technology & recent terminology
– Codes have been added to describe postoperative or
post-procedural conditions
• ICD-10 is essential for clinical research and
epidemiology

329 major small and large bowel
procedure W MCC
Rel wt Exp
mort
Exp
LOS
Exp cost Exp
readmit
Exp
payment
Secondary DX acute systolic failure 5.26 9.51% 13.59 $30,302 18.69% $34,716
330 major small and large bowel
procedure W CC
Rel wt Exp
mort
Exp
LOS
Exp
cost
Exp
readmit
Exp
payment
Secondary DX chronic systolic failure 2.57 0.73% 7.79 $16681 12.25% $16,962
*Exp outcome values based on specific population with proprietary analysis of severity may vary with different population and assessment
methods for illustrative purposes only based on real data
331 major small and large
bowel procedure WO CC/MCC
Rel wt Exp
mort
Exp
LOS
Exp cost Exp
readmit
Exp
payment
Secondary DX CHF 1.64 0.13% 5.67 $12851 8.93% $10,824
Effect of accurate documentation on outcomes

Philosophy
• Physicians do not need to learn coding
• Physicians need to work in a
collaborative process to achieve
accurate documentation on every
patient
• The process must increase efficiency
• The documentation process should be
“owned” by physicians

Basic concepts
Coding solutions, alone, cannot
resolve the issue of inadequate
physician documentation
Physician leaders must be able to engage
their colleagues in a proactive manner,
establishing the appropriate motivation &
sharing necessary knowledge to achieve
success under Coding and Continuous
Documentation Improvement Programs
Inadequate physician documentation
has been a challenge for accurate
coding under ICD-9
If uncorrected, that challenge
continues to increase

Clinical documentation is everything

“Feds to allow use of Medicare data to rate doctors”
– USA Today 12/5/11
The federal government announced that
Medicare will now allow use of its extensive
medical claims database by employers,
insurance companies and consumer groups
to produce report cards on local doctors
and hospitals.
…By analyzing masses of billing records, experts can
glean such critical information as how often a doctor
has performed a particular procedure and get a
general sense of problems such as preventable
complications.
Compiled in an easily understood format and released
to the public, medical report cards could become a
very powerful tool for promoting quality care and
reducing waste…
Announced by Marilyn Tavenner
Acting Administrator of CMS

MCOs ALSO measure MD Performance…
UnitedH Physician Locator Website…

UnitedH Physician Locator Website…
• Quality and cost efficiency
• Cost efficiency and not enough data to assess quality
• Quality and not enough data to assess cost efficiency
• Quality and did NOT meet cost efficiency
• Did NOT meet quality and cost efficiency
Members in health plans that offer tiered benefits may pay lower copays and coinsurance
amounts for services provided by UnitedHealth Premium® Tier 1 physicians.
UnitedHealth Premium® Tier 1 physicians have received the premium designation for quality and cost
efficiency…

“…We believe our networks will continue to exceed accessibility
standards – right down to the county level," McElrath-Jones said.
“…We have conducted outreach to area providers that will remain in network to confirm
their capacity to take on additional patients."

The risk to providers
• The only way clinical performance is
adjudicated is through billing data
• If you do not get the billing data correct
then your performance will be
adjudicated incorrectly…

Post implementation
Review
documentation
and coding
quality post-
October 1,
2015
Provide team
member,
clinician, and
physician
education, as
needed
Conduct
financial
impact
analysis
Update risk
and
monitoring
plan
Support
accounts
receivable
billing and
collection
backlog and
activity, as
needed

Conduct 3, 5,
6, 9 and 12-
month post-
conversion
optimization
assessments
Reassess/
update
training for
coding
personnel
Validate
future state
workflows
Perform post-
implementation
project
training and
documentation
audits
Develop
medical coding
tests for Health
System new
hire screening
Post implementation

Risks
• Education/documentation gaps
• Productivity losses
• Lack of resources
• Changes in reimbursement
– Limited immediate but as ICD10 data arrives at CMS they
will likely refine MS-DRG
– Not limited to this: patient care outcomes, quality of care,
profiling providers, P4P, medical necessity
• Expect audits to focus on clinical documentation to
determine if it supports the specificity of ICD-10 codes
• Unspecified = unpaid
!

International lessons
• Australians love ICD-10 because not working with so many “dump” codes or unspecified
• Coders were back to old output rates w/in 3 months
• Education is key
• Providers still adjusting billing because of what they are learning from their ICD-10 data
• See ICD-10 as a “must do” and a benefit

Value-based payment
Two shifts
1. Increasing accountability for quality and total
cost of care
2. Timeline:
a) 30% of Medicare payments in alternative payment
models (categories 3 & 4) by the end of 2016
b) 50% of Medicare payments in alternative payment
models (categories 3 & 4) by the end of 2018
c) Overall, 85% of payments in categories 2 through 4 by
2016 and 90% by 2018

Principles
Education, particularly on clinical
issues, must be peer-to-peer
Physicians are interested in their
specialty, not material unrelated
to their practice
Physicians will commit
minimal time
Physicians should learn the
documentation principles and
specific changes relevant to their
specialty
Physicians should never attempt
to memorize ICD-10-CM codes –
there are simply too many
Specific examples should
be utilized

Nick van Terheyden, MD CMO, Dell Health and Life Sciences
AboutMe http://about.me/obiwan
Twitter http://twitter.com/drnic1
LinkedIn http://www.linkedin.com/in/nickvt
Blog http://drnick.vanterheyden.com/
FaceBook http://www.facebook.com/drnic1
E-Mail DrNick@dell.com, drnic1@gmail.com
Google Voice (301) 355-0877
Where you can find me

Resources
CMS ICD10 Website
http://www.cms.gov/Medicare/Coding/ICD10/index.html
ICD10 MS-DRG Conversion Project (GEMS)
http://www.cms.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html
Updated ICD10 Implementation Information (MLN)
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-
MLN/MLNMattersArticles/Downloads/SE1239.pdf
ICD10 Myths and Facts
http://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD-10MythsandFacts.pdf
Medicare Fee-For-Service Provider Resources
http://www.cms.gov/Medicare/Coding/ICD10/Medicare-Fee-for-Service-Provider-Resources.html
Provider Resources
http://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html
The Road to ICD10
www.RoadTo10.org

AHIMA Game of documentation - dance with the icd10 dragon

Recommended

Recommended

More Related Content

What's hot

What's hot (19)

Viewers also liked

Viewers also liked (20)

Similar to AHIMA Game of documentation - dance with the icd10 dragon

Similar to AHIMA Game of documentation - dance with the icd10 dragon (20)

More from Nick van Terheyden

More from Nick van Terheyden (20)

Recently uploaded

Recently uploaded (20)

AHIMA Game of documentation - dance with the icd10 dragon

Editor's Notes