Value Based Purchasing, Changes for ICD-10 and the Impact of Pathology Robert S. Gold, MD

1. Value Based Purchasing, Changes for ICD-10 and the Impact of PathologyRobert S. Gold, MD

2. Medicine Under the Microscope Morbidity Mortality Cost per patient Resource utilization Length of stay Complications Outcomes ARE YOU SAFE – avoiding harm, avoidable readmissions?

3. Value-Based Purchasing Program • Beginning in FY 2013 and continuing annually, CMS will adjust hospital payments under the VBP program based on how well hospitals perform or improve their performance on a set of quality measures. The initial set of 13 measures includes three mortality measures, two AHRQ composite measures, and eight hospital-acquired condition (HAC) measures. The FY 2012 IPPS final rule (available at http://tinyurl.com/6nccdoc) includes a complete list of the 13 measures.

4. 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

5. Semantics Coding guidelines and conventions Use of signs, symbols, arrows Accuracy and specificity Relationship between accuracy and specificity of code assignment and Complexity of Medical Decision Making World Health Organization and ICD Codes

7. 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.

8. Is There a Diagnosis? Assessment/Plan 82 YO F patient presented to ER with: 1. Sepsis, 2. Septic Shock, 3. Acute Hypercapnic Respiratory Failure, 4. Acute Renal Failure due to #2, (don’t forget CKD and stage, if present) 5. Aspiration Pneumonia, 6. Metabolic Encephalopathy Will transfer to ICU, continue Dopamine and monitor respiratory status for possible ARDS, renal status with hydration and initiate Cefapime/clindamycin for possible aspiration pneumonia CC time 1hr 45 minutes John Smith MD

9. So What’s the Difference?

10. What Is An Index?

11. 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 =1

12. 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 - 

14. Patient Safety

15. 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

16. 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.

17. CMS Bundled Payment Plans September 2, 2011 Bundles physician and hospital payment into one lump sum could represent a long-term, revolutionary solution to that age-old question. Testing four new bundled payment plans, according to a Fact Sheet released August 23 Three models involve retrospective payment, one a prospective payment determined by MS-DRG Aggregate Medicare payment for the episode will be reconciled against the target price. Savings beyond the discount reflected in the target price will be paid to the participants to share among the participating providers.

18. 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.

19. Readmissions Initiative Identify hospitals with excess readmissions for certain selected conditions beginning in FY 2013 for discharges on or after October 1, 2012. Acute myocardial infarction (i.e., heart attack) Heart failure Pneumonia Definition of readmission: “occurring when a patient is discharged from the applicable hospital and then is admitted to the same or another acute care hospital within a specified time period from the time of discharge from the index hospitalization.” The specified time period would be 30 days. 19

20. Patient in Proper EnvironmentOutpatient, OBS, Impatient Care • Extended postop management in same day surgery cases • Inappropriate admissions for workup of symptoms in stable patient • Inappropriate admissions for treatment of diseases expected to resolve in hours • Closed system, protocol driven OBS unit efficient and cost effective

21. 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.

22. Interdisciplinary Approach • Management of malignancy is now in the domain of the multi-disciplinary team and all members of the cancer team must work together. • Conventional radiology, general or oncologic surgery or IR input begins with establishing the initial diagnosis of cancer • Involvement extends to major or minimally invasive treatment of malignancy, often in combination with other modalities. • All members of the team have to assume an important place in the management of the complications of malignancy, which may result from malignancy itself or secondary to treatment. • And it involves other disciplines working together.

23. Patient Safety Indicators Hospital acquired preventable diagnoses Hospital falls that lead to patient damage (fractures, etc.) Mediastinitis post-CABG (36.10 – 36.19 + 519.2) Catheter-associated UTIs (996.64 + 599.0)* Vascular catheter associated infections (996.62) vs 999.31 Pressure ulcers (707.00 – 707.09) NEVER Events Object accidentally left in patient (998.4) Air embolism (999.1) Reaction from blood incompatibility (999.6)

24. Participation and Success in Reporting of Core Measures • Acute MI • Heart failure • Pneumonia • Postoperative wound infections • Venous thromboembolism • Stroke • Asthma in children’s hospitals

25. Goals of Implementation – Prove You Are Value Based • Exemplary severity adjusted mortality statistics • Reasonable occurrence of PSIs, HACs • Lower than average Readmissions for Pneumonia, Heart Failure, AMI • Cooperation with quality initiatives • Patient satisfaction

26. Coding Guidelines for Path Pathology claims for biopsy specimens Coding Clinic, First Quarter 1990 Page: 22 Effective with discharges: March 15, 1990 Question: How should the pathologist code a biopsy specimen which turns out to be normal after examination? Most specimens do not include any information from the referring physician, so including a secondary diagnosis is difficult. Answer: Pathology claims will start with the code V72.6, Laboratory examination. The secondary diagnosis should reflect any diagnostic information from the referring physician, if it is available. If a diagnosis, symptom, or condition is absolutely not available, and the specimen turns out to be normal, the pathologist can use the code 799.9, Other ill-defined and unknown causes of morbidity and mortality, Other unknown and unspecified causes. Biopsies are not included in patient screening, and therefore reflect concern on the part of the referring physician that something is amiss.

27. Unexpected Findings on Path Coding Clinic, Second Quarter 2002 Page: 18 Effective with discharges: August 1, 2002 Question: A patient is admitted to the hospital where she undergoes a hysterectomy for possible endometriosis. The pathology report revealed adenocarcinoma of the endometrium. The discharge summary was not available at the time of coding. Is it appropriate for the coder to assign a diagnosis code for the adenocarcinoma based on the pathology report? Answer: As previously stated, the advice published in Coding Clinic, First Quarter 2000, was only intended for coding and reporting for outpatient services, where physician documentation is sometimes quite limited. It does not apply to inpatient coding. For inpatient coding, if the attending physician does not confirm the pathological findings, query the attending physician regarding the clinical significance of the findings and request that appropriate documentation be provided.

28. Metastatic Sites from Path Report Coding Clinic, Second Quarter 2002 Page: 18 Effective with discharges: August 1, 2002 Question: A patient is admitted to the hospital where she undergoes a hysterectomy for possible endometriosis. The pathology report revealed adenocarcinoma of the endometrium. The discharge summary was not available at the time of coding. Is it appropriate for the coder to assign a diagnosis code for the adenocarcinoma based on the pathology report? Answer: For inpatient coding, if the attending physician does not confirm the pathological findings, query the attending physician regarding the clinical significance of the findings and request that appropriate documentation be provided.

29. Change in the Entire System ICD-9 ICD-10

30. 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)

31. 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

32. 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)

33. 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

34. 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.

35. Don’t Wait Till Tomorrow for ICD-10

36. 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

37. ICD-O-3 for Malignancies Purpose/Definition Used principally in tumor or cancer registries for coding the site (topography) and the histology (morphology) of neoplasms, usually obtained from a pathology report. Classification structure A multi-axial classification of the site, morphology, behaviour, and grading of neoplasms. The topography axis uses the ICD-10 classification of malignant neoplasms (except those categories which relate to secondary neoplasms and to specified morphological types of tumours) for all types of tumours, thereby providing greater site detail for non-malignant tumours than is provided in ICD-10. In contrast to ICD-10, the ICD-O includes topography for sites of haematopoietic and reticuloendothelial tumours.

38. Lung Cancer I-9 162 Malignant neoplasm of trachea, bronchus, and lung 162.0 Trachea 162.2 Main bronchus 162.3 Upper lobe, bronchus or lung 162.4 Middle lobe, bronchus or lung 162.5 Lower lobe, bronchus or lung 162.8 Other parts of bronchus or lung 162.9 Bronchus and lung, unspecified

39. Laterality of Lung Cancer I-10 C34.0 Malignant neoplasm of main bronchus C34.00 Malignant neoplasm of unspec main bronchus C34.01 Malignant neoplasm of right main bronchus C34.02 Malignant neoplasm of left main bronchus C34.1 Malignant neoplasm of upper lobe, bronchus or lung C34.10 Malignant neoplasm of upper lobe, unspec bronchus or lung C34.11 Malignant neoplasm of upper lobe, right bronchus or lung C34.12 Malignant neoplasm of upper lobe, left bronchus or lung C34.2 Malignant neoplasm of middle lobe, bronchus or lung C34.3 Malignant neoplasm of lower lobe, bronchus or lung C34.30 Malignant neoplasm of lower lobe, unspec bronchus or lung C34.31 Malignant neoplasm of lower lobe, right bronchus or lung C34.32 Malignant neoplasm of lower lobe, left bronchus or lung C34.8 Malignant neoplasm of overlapping sites of bronchus and lung C34.80 Malignant neoplasm of overlapping sites of unspec bronchus and lung C34.81 Malignant neoplasm of overlapping sites of right bronchus and lung C34.82 Malignant neoplasm of overlapping sites of left bronchus and lung

40. Pleural Effusion • Distinguish causative disease • Malignancy and origin • Trauma or postsurgical • Liver or renal failure • Chylothorax • Peripneumonic effusion – exudative or transudative • Empyema (pyothorax) • Other cause of exudative identifiable • Etc.

41. Adrenal Gland Malignancy I-9 194.0Adrenal gland Adrenal cortex Adrenal medulla Suprarenal gland All in one

42. Laterality/Specificity I-10 C74.0 Malignant neoplasm of cortex of adrenal gland C74.00 Malignant neoplasm of cortex of unspecified adrenal gland C74.01 Malignant neoplasm of cortex of right adrenal gland C74.02 Malignant neoplasm of cortex of left adrenal gland C74.1 Malignant neoplasm of medulla of adrenal gland C74.10 Malignant neoplasm of medulla of unspecified adrenal gland C74.11 Malignant neoplasm of medulla of right adrenal gland C74.12 Malignant neoplasm of medulla of left adrenal gland

43. Colon Cancer I-9 153 Malignant neoplasm of colon 153.0Hepatic flexure 153.1Transverse colon 153.2Descending colon 153.3Sigmoid colon 153.4Cecum 153.5Appendix 153.6Ascending colon 153.7Splenic flexure 153.8Other specified sites of large intestine 153.9Colon, unspecified 154 Malignant neoplasm of rectum, rectosigmoid junction, and anus 154.0Rectosigmoid junction 154.1Rectum 154.2 Anal canal

44. Colon Cancer I-10 C18 Malignant neoplasm of colon C18.0Malignant neoplasm of cecum C18.1Malignant neoplasm of appendix C18.2Malignant neoplasm of ascending colon C18.3Malignant neoplasm of hepatic flexure C18.4Malignant neoplasm of transverse colon C18.5Malignant neoplasm of splenic flexure C18.6Malignant neoplasm of descending colon C18.7Malignant neoplasm of sigmoid colon C18.8Malignant neoplasm of overlapping sites of colon C18.9Malignant neoplasm of colon, unspecified Malignant neoplasm of large intestine NOS C19Malignant neoplasm of rectosigmoid junction Malignant neoplasm of colon with rectum Malignant neoplasm of rectosigmoid (colon)

45. ICD-9 190.5 Differentiated 190.5 Undifferentiated Same code for melanoma of retina ??? Add 198.4 for invasion of optic nerve or choroid Add 365.7x for neovascular glaucoma ICD-10 C69.2 Differentiated C69.2 Undifferentiated Same code for melanoma of retina ??? Add C79.49 for invasion of optic nerve or choroid Add H40.5xx for glaucoma due to neoplasm of eye Retinoblastoma 6th digits 1 – right eye 2 - left eye 3 – bilateral 9 - unspecified Severity of glaucoma5th digit: 1 mild 2 moderate both ICD-9 3 severe and ICD-10

46. Renal Malignancies ICD-9 189.0 Kidney, except pelvis (includes Wilms tumor, renal cell carcinoma, urothelial cell ca) 189.1 Renal pelvis 189.2 Ureter 189.3 Urethra 189.4 Paraurethral glands 189.8 Other specified sites of urinary organs Malignant neoplasm of contiguous or overlapping sites of kidney and other urinary organs whose point of origin cannot be determined 189.9 Urinary organ, site unspecified

47. Renal Malignancies ICD-10 C64.1 Malignant neoplasm of right kidney, except renal pelvis (includes all cell types) C64.2 Malignant neoplasm of left kidney, except renal pelvis (includes all cell types) C64.9 Malignant neoplasm of unspecified kidney, except renal pelvis (includes all cell types) C65 Malignant neoplasm of renal pelvis C65.1 Malignant neoplasm of right renal pelvis C65.2 Malignant neoplasm of left renal pelvis C65.9 Malignant neoplasm of unspecified renal pelvis C66Malignant neoplasm of ureter C66.1 Malignant neoplasm of right ureter C66.2 Malignant neoplasm of left ureter C66.9 Malignant neoplasm of unspecified

48. Registered Concerns • No breakdown as to cell types • Wilms tumor (nephroblastoma), renal cell carcinoma and urothelial cell carcinoma all assigned to C64, malignant neoplasm of kidney • C65 dedicated to malignancy of renal pelvis but urothelial cell carcinoma (Transitional Call Carcinoma - TCC), a renal pelvis cancer, groups to C64

49. ICD-9 198.5Bone and bone marrow ICD-10 C79.51 Bone C79.52 Bone marrow Mets to Bone

50. ICD-9 530.85 Barrett's esophagus ICD-10 K22.70 Barrett's esophagus without dysplasia K22.71 Barrett's esophagus with dysplasia K22.710 Barrett's esophagus with low grade dysplasia K22.711 Barrett's esophagus with high grade dysplasia K22.719 Barrett's esophagus with dysplasia, unspecified Barrett’s Esophagus Expansion