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Value Based Purchasing, Changes for ICD-10 and the Future of Orthopaedic Surgery Robert S. Gold, MD. Medicine Under the Microscope. Morbidity Mortality Cost per patient Resource utilization Length of stay Complications Outcomes ARE YOU SAFE – avoiding harm, avoidable readmissions?.

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Medicine under the microscope

Value Based Purchasing, Changes for ICD-10 and the Future of Orthopaedic SurgeryRobert S. Gold, MD

Medicine under the microscope

Medicine Under the Microscope



Cost per patient

Resource utilization

Length of stay



ARE YOU SAFE – avoiding harm, avoidable readmissions?

Value based purchasing program

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 includes a complete list of the 13 measures.

Where does this data come from

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


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

World Health Organization and ICD Codes

Is there a diagnosis

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 diagnosis1

Is There a Diagnosis?


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

So What’s the Difference?

What is an index

What Is An Index?

What is an index1

Mortality index

Complication index

Length of stay index

Cost per patient index

What Is An Index?

Observed Rate of Some Thing

Severity Adjusted Expected Rate of That Thing


Profiles come from severity adjusted statistics

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 - 

Patient safety

Patient Safety

Surgery bundling test model

Surgery Bundling Test Model

  • 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

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

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

Aetna, Baptist Memorial Health Care Announce Collaborative Care Agreement

Thursday, April 25, 2013 4:11 pm EDT

MEMPHIS, Tenn.--(BUSINESS WIRE)--Aetna (NYSE: AET) and Baptist Memorial Health Care today announced a collaborative care agreement to bring a new health care model to Aetna members and introduce Aetna Whole HealthSM, a commercial health care product.

This collaboration will give employers and their workers access to highly coordinated care from physicians and facilities in the Baptist Select Health Alliance. The Baptist Select Health Alliance is a clinically integrated group of physicians focused on tracking outcomes, sharing data and measuring clinical standards to improve quality and efficiency.

In collaborative care models, a group of health care providers delivers more coordinated care for patients to drive better quality and lower overall costs. Through Baptist Memorial Health Care, Aetna members will receive an enhanced level of coordinated care in addition to the member benefits of their current Aetna plan.

Getting studies paid for laboratory radiographic

Getting Studies Paid ForLaboratory/Radiographic

  • Bundled payment modes rely on payment being made for lab or x-ray studies

  • Validation of reason for performing any procedure or test depends on Medical Necessity

  • Local Medical Review Policies (LMRPs), Local or National Coverage Determinations (LCDs, NCDs)

  • Not giving a reason for a test you order (symptom or diagnosis) could result in:

    • Advance Beneficiary Notification (ABN) saying patient may have to pay for the test

    • Somebody bugging you for a reason for the test

Clinical integration

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 "G-codes" to pay for revision of care plans, communication with other treating professionals, and medication management over 90-day periods.

  • These code payments would require that beneficiaries have an annual wellness visit, that a single practitioner furnish these services, and that the beneficiary consent to this arrangement over a one-year period.

Readmissions initiative

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


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.


Patient safety indicators

Patient Safety Indicators

Hospital acquired preventable diagnoses

Hospital falls that lead to patient damage (fractures, etc.)

Mediastinitis post-CABG

Catheter-associated UTIs

Vascular catheter associated infections

Pressure ulcers

Object accidentally left in patient

Air embolism

Reaction from blood incompatibility

What does this mean

What Does This Mean?

  • Properly identify complication of care when complication – specify when due to a disease

  • We don’t want to assign complication codes when not complication

    • If event due to disease, not a complication

    • If even doesn’t exist, not a complication

  • Don’t use the word “post-op” in the post-op period!

Is an adverse event always a complication

Is an Adverse Event Always a Complication?

  • Not at all.

  • Stuff happens.

  • Diseases cause adverse effects

  • Anemia due to blood loss is usually due to the disease and not to the surgery

    State so: anemia of chronic blood loss due to right colon cancer; anemia of acute blood loss due to femur fracture

  • Adverse effects are easily explained and defended in a patient with more risk factors. If you didn’t name these, you lose.

Not acute respiratory failure

NOT Acute Respiratory Failure

  • Patients being purposely maintained on the ventilator after surgery because of weakness, chronic lung disease, massive trauma are NOT in acute respiratory failure – unless they are

  • Abdominal compartment syndrome is a well-known complication after abdominal trauma and is increasingly recognized as a potential risk factor for renal failure and mortality after adult orthotopic liver transplantation (OLT).

  • Prevention of acute respiratory failure from angioedema, stroke, trauma when patient does NOT HAVE acute respiratory failure when intubated for airway protection

Participation and success in reporting of core measures

Participation and Success in Reporting of Core Measures

  • Acute MI

  • Heart failure

  • Pneumonia

  • Postoperative wound infections

  • Venous thromboembolism

  • Stroke

  • Asthma in children’s hospitals

Goals of implementation prove you are value based

Goals of Implementation – Prove You Are Value Based

  • Low incidence of HACs

  • Reasonable occurrence of PSIs

  • Lower than average Readmissions for Pneumonia, Heart Failure, AMI

  • Cooperation with quality initiatives

  • Decent responses to a new questionnaire on discharge

Change in the entire system

Change in the Entire System



Notable changes

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

Don’t Wait Till Tomorrow for ICD-10

Example specificity

Example - Specificity

Category 1–3

Etiology, anatomic site, severity, other detail 4–6

Extension 7

S52: Fracture of forearm

S52.5: Fracture of lower end of radius

S52.52: Torus fracture of lower end of radius

S52.521: Torus fracture of lower end of right radius

S52.521A: Torus fracture of lower end of right radius, initial encounter for closed fracture

Be acquainted with second digit

Be Acquainted with Second Digit


  • Neck

  • Thorax

  • Abd/low back/pelv

  • Shoulder/upper arm

  • Elbow/forearm

  • Wrist/hand

  • Hip/thighs

  • Knee/lower leg

  • Ankle/foot/toes

Third digit 4 5 greater specificity general type of injury of location of injury


Open wound



Injury nerves

Injury vessels


Crush injury

Traumatic amputation


Proximal or distal

Displaced or nondisplaced

Eponyms of specific fracture types (Colles, Barton’s, etc.)

Third Digit 4/5 Greater SpecificityGeneral type of injury of location of injury

Be acquainted with sixth digit

Be Acquainted with Sixth Digit

And then there were seven digits for injuries

And Then There Were Seven (Digits) … for Injuries

Seventh digit code extension

Seventh Digit - Code extension

Type of Encounter for Injuries – Chapter 19

Initial Encounter

Active treatment



E/M by new phys

Subsequent Encounter

Routine care

Healing or recovery phase


Complications or

conditions that

arise as a direct

result of the injury

Identifies injury

responsible for


Example specificity1

Example - Specificity

Category 1–3

Etiology, anatomic site, severity, other detail 4–6

Extension 7

S52: Fracture of forearm

S52.5: Fracture of lower end of radius

S52.52: Torus fracture of lower end of radius

S52.521: Torus fracture of lower end of right radius

S52.521A: Torus fracture of lower end of right radius, initial encounter for closed fracture

7 th digit understanding

7th Digit Understanding

A, B, C Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and treatment by a new physician. The appropriate 7th character for initial encounter should also be assigned for a patient who delayed seeking treatment for the fracture or nonunion.

D, E, F Fractures are coded using the appropriate 7th character for subsequent care for encounters after the patient has completed active treatment of the fracture and is receiving routine care for the fracture during the healing or recovery phase. Examples of fracture aftercare are: cast change or removal, removal of external or internal fixation device, medication adjustment, and follow-up visits following fracture treatment.

Medicine under the microscope

A  Initial encounter for closed fracture

B  Initial encounter for open fracture type I or II

C  Initial encounter for open fracture type IIIA, IIIB, or IIIC

D  Subsequent encounter for closed fracture with routine healing

E  Subsequent encounter for open fracture type I or II with routine healing

F  Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing

G  Subsequent encounter for closed fracture with delayed healing

H  Subsequent encounter for open fracture type I or II with delayed healing

Medicine under the microscope

J  Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing

K Subsequent encounter for closed fracture with nonunion

M Subsequent encounter for open fracture type I or II with nonunion

N Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion

P Subsequent encounter for closed fracture with malunion

Q Subsequent encounter for open fracture type I or II with malunion

R Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion

S  Sequela

7 th digit understanding1

7th Digit Understanding

  • Care of complications of fractures, such as malunion and nonunion, should be reported with the appropriate 7th character for subsequent care with nonunion (K, M, N,) or subsequent care with malunion (P, Q, R).

  • Closed fracture code

  • Open fracture with Gustilo classification designation

Open fractures

Forearm (S52), Femur (S72) and lower leg (S82)

Open Fractures

Seventh character extensions to identify open fractures (Gustilo classification)

I Low energy, wound less than 1 cm

II Greater than 1 cm with moderate soft tissue damage

III High energy wound greater than 1 cm with extensive soft tissue damage

IIIAAdequate soft tissue cover

IIIBInadequate soft tissue cover

IIICAssociated with arterial injury

Gustilo open fracture classification

Gustilo Open Fracture Classification

Allay the fears

Allay the Fears

  • Think about the fracture and how you would describe it to an internist

    • Name the bone

    • Name the part of the bone involved

    • Name the kind of fracture (Colles, Barton’s) if there is a common name

    • Identify if it’s displaced or not, open or closed

    • If open, describe how extensive is the local damage

  • Choose the code that has those words in it

Clavicle fractures

Clavicle Fractures

  • According to the American Academy of Family Physicians (AAFP), the anatomic site of the clavicle fracture is typically described using the Allman classification, which divides the clavicle into thirds.

  • Group I (midshaft) fractures occur on the middle third of the clavicle;

  • Group II fractures on the lateral (distal) third; and

  • Group III fractures on the medial (proximal) third.

Clavicle fractures1

Clavicle Fractures

  • According to the American Academy of Family Physicians (AAFP), the anatomic site of the clavicle fracture is typically described using the Allman classification, which divides the clavicle into thirds.

  • Group I (midshaft) fractures occur on the middle third of the clavicle;

  • Group II fractures on the lateral (distal) third; and

  • Group III fractures on the medial (proximal) third.

Coding clavicles

Coding Clavicles

S42.0       Fracture of clavicle

S42.01     Fracture of sternal end of clavicle

S42.011 anterior displaced right – 5th digits

S42.012 anterior displaced left

S42.014 posterior displaced right

S42.015 posterior displaced left

S42.017 nondisplaced right

S42.018 nondisplaced left

S42.02     Fracture of shaft of clavicle

S42.03     Fracture of lateral end of clavicle

Should never use 4th digit of 0 for unspecified part of clavicle nor 5th digit of 3, 6 or 9 for not knowing if right or left clavicle

How do you describe it

How Do You Describe It?

Posterior displaced left midshaft clavicular fracture – then is it involving the vessels? Which?

Femoral neck fractures 9 vs 10

820.0 Transcervical fracture, closed

820.00 Intracapsular section, unspec.

820.01 Epiphysis (separation) (upper)

820.02 Midcervical section

820.03 Base of neck

820.09 Other (head, subcapital)

820.1 Transcervical fracture, open

820.10 Intracapsular section, unspec.

820.11 Epiphysis (separation) (upper)

820.12 Midcervical section

820.13 Base of neck

820.19 Other

820.2 Pertrochanteric fracture, closed

820.20 Trochanteric section, unspecified (greater, lesser, etc.)

820.21 Intertrochanteric section

820.22 Subtrochanteric section

820.3 Pertrochanteric fracture, open

820.30 Trochanteric section, unspec.

820.31 Intertrochanteric section

820.32 Subtrochanteric section

S72.00 Fracture unspec part neck of femur

S72.01 Unspecified intracapsular fracture R/L

S72.02 Fracture (separation) epiphysis femur (displaced, nondisplaced digits, R/L)

S72.03 Midcervical fracture (d, nonD, R/L)

S72.04 Base of neck fracture (d, nonD, R/L)

S72.05 Unspecified fracture head R/L

S72.06 Articular fracture head of femur (d, nonD, R/L)

S72.09 Other fx head and neck of femur R/L

S72.10 Unspec trochanteric fracture R/L

S72.11 Fracture greater trochanter (d, nonD, R/L)

S72.12 Fracture lesser trochanter (d, nonD, R/L)

S72.13 Apophyseal fracture (d, nonD, R/L)

S72.14 Intertrochanteric fracture (d, nonD, R/L)

S72.2 Subtrochanteric fracture (d, nonD, R/L)

Femoral Neck Fractures – 9 vs 10

Femoral neck fractures

Femoral Neck Fractures

  • Name the part of the neck as usual

  • Identify if it’s nondisplaced or displaced

  • State which side of the body

  • It just makes sense

Traumatic fracture vs pathologic

Traumatic Fracture vs Pathologic

  • M84.3 Stress fracture

  • M84.4 Pathologic fracture NEC

  • M84.5 Pathologic fracture in neoplastic disease

  • M84.6 Pathologic fracture in other specified disease – name the disease, too (eg., osteoporosis M80.x)

Now the fifth digit for the bone

Now The Fifth Digit for the Bone


  • Neck

  • Thorax

  • Abd/low back/pelv

  • Shoulder/upper arm

  • Elbow/forearm

  • Wrist/hand

  • Hip/thighs

  • Knee/lower leg

  • Ankle/foot/toes

Example integration

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

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



Identify acuity




Identify location(s)–each individual

Specify laterality

Identify when:

With draining sinus

With hematologic spread

Osteomyelitis coding

Osteomyelitis Coding

Characters 1–3

Characters 4-6 Etiology, anatomic site, severity, other detail

Character 7 Extension

M86: Osteomyelitis

M86.0: Acute hematogenous osteomyelitis

M86.02: Acute hematogenous osteomyelitis, humerus

M86.021 Acute hematogenous osteomyelitis, righthumerus


M 8 6 ● 0 2 1



May be due to trauma or to pathologic condition – specify which (e.g., due to osteoporotic defect, due to aseptic necrosis of femur)

May be single event or recurrent

Identify specific joint

Identify laterality

Back deformities

Back Deformities

Name condition, deformity and part of spine involved

For scoliosis, identify part of spine involved and patient’s age at origin






Specificity is not always possible

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.

What s the surgery for

What’s The Surgery For?

  • Provide the diagnosis for which the surgery is being performed

  • 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

Complexity of patient

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

Medicine under the microscope

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

Surgical Risk Stratification

  • NSQIP databases depend on identification of risk factors

Risk stratification for pulmonary complications

Risk Stratification for Pulmonary Complications

Modified nsqip data sheet

Modified NSQIP Data Sheet

The mayo model of preoperative medical evaluation

The Mayo Model ofPreOperative Medical Evaluation

  • Initial medical evaluation for risk stratification – fill out POME

  • Lab and radiographic studies as indicated – fill out POME

  • Consultative visits and tests as needed – fill out POME

  • Visit to Anesthesiology with recommendations and results – fill out preop anesthesia forms

  • Visit to surgeon with all needed risk factors complete – complete H&P

  • Eliminate cancelled surgeries, delays

Was it present on admission

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!

Kdigo kidney disease improving global outcomes

KDIGOKidney Disease Improving Global Outcomes

Aki or arf insufficiency is not a synonym

AKI or ARFInsufficiency is NOT a synonym



  • The writings of the AKIN state that, in cases of dehydration (and dehydration is still, truly the number one cause of acute renal failure in the US), it is imperative to NOT CALL changes in creatinine AKI until the patient has been volume repleted for at least six hours. If creatinine bump persists after fluid resuscitation, there was likely AKI. If not, there was NOT AKI.

  • “Acute kidney injury should be both abrupt (within 1–7 days) and sustained (more than 24 hours).”

Primary and metastatic cancer

Primary and Metastatic Cancer

  • Tell where the primary is (was) and if it was previously removed or treated and treatment is over or currently under treatment

  • State where the metastatic sites are and if they (any) are symptomatic and if they are currently under treatment

  • State if new site is found and if it led to the symptoms that required admission – ALWAYS LINK SYMPTOMS TO THE CANCER, when you can

The future must be started now


995.91 Sepsis (SIRS due to infection without organ dysfunction

995.92 Severe sepsis (SIRS due to infection with organ dysfunction

995.93 SIRS due to noninfection without organ dysfunction

995.94 SIRS due to noninfection with organ dysfunction



R65.20 Severe sepsis without septic shock

R65.21 Severe sepsis with septic shock

R65.10 SIRS due to noninfection without organ dysfunction

R65.11 SIRS due to noninfection with organ dysfunction

The Future Must Be Started Now

Conditions related to

Sepsis due to:






Infected dialysis cath

Subphrenic abscess

All are infections!

SIRS due to:

Hemorrh pancreatitis

Burns (not infected)

Pulmonary embolism (clot, fat, amniotic fluid)

Multiple trauma


None are infections!

Conditions Related to …

Severe sepsis

Severe Sepsis

Sepsis with distant organ failure:

  • Acute renal failure (due to sepsis)

  • ARDS or acute respiratory failure

  • Acute hepatic failure (due to sepsis)

  • Encephalopathy (metabolic – due to sepsis)

  • DIC (Disseminated intravascular coagulopathy)

  • Critical care myopathy

  • Circulatory system failure – inability to maintain a blood pressure to perfuse vital organs – CALLED SEPTIC SHOCK

What we are seeing






Hb – 6.8





Acute renal failure

Chronic systolic failure

CKD stage 3


Anemia – cause?

Shock – cause?

The names of the failed organs

Acute liver failure

What We Are Seeing

Anemia and complexity of medical decision making

Non Specific



Anemia DUE TO chronic renal failure

Anemia DUE TO chronic blood loss from a fungating cecal lesion

Anemia DUE TO acute blood loss from a hip fracture

Anemia DUE TO chronic osteo/hepatitis

Anemia DUE TO antineoplastics

Anemiaand Complexity of Medical Decision Making

Multiple fractures

Multiple Fractures

  • There is no code for multiple fractures – each must be named individually

  • Rib fractures are classified for severity by NUMBER of ribs fractured

  • Fractures at joints are defined by which bones

  • Fractures are defined as open or closed – specify which is which

Classification of hemorrhagic shock


HypovolemiaHemorrhagic shock



  • 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.



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.)



  • Malnutrition, not specified

    • Mild (<10% loss)

    • Moderate (10-20% loss)

    • Severe (nutritional atrophy - marasmus)

      • Consider this with chronic disease, massive weight loss, cachexia (>20% weight loss)

  • Consider the acute malnutrition of surgery, trauma and sepsis

    All of the above add risk to any disease and any surgery

Clinical what it is

Clinical: What it IS!

Excisional debridement

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.


Non excisional debridement

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




  • Documentation Specialists

  • Chart - Explanation tool

  • Pocket Documentation Tools

  • Powerpoint library

Post op progress notes

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 notes1

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.

Paint the picture of the patient properly with words

Paint the picture of the patient properly with WORDS

What you want…

what you might get.

may notbe…

So the coder can paint the same picture with codes.

Motto for the age

Motto For The Age

“If you don’t look good, we don’t look good”Vidal sassoon, ca 1985

Father of modern medical economics

Handling the problem list

Handling the Problem List

It’s an Epic Task

Example changes in epic to support icd 10

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.

Questions: Contact Dr. Jason Lyman, ICD-10 Physician Champion,

Beware of cloned documentation

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.

Medicine under the microscope

  • 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

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?

Medicine under the microscope

If the docs

don't get it,

nothing else


Questions and answers your ideas and comments

Questions and Answers Your Ideas and Comments

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