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


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    1. Value Based Purchasing, Changes for ICD-10 and the Future of OphthalmologyRobert 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

    6. 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.

    7. 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

    8. So What’s the Difference?

    9. What Is An Index?

    10. 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

    11. 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 - 

    12. Patient Safety

    13. 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

    14. 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.

    15. 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.”

    16. 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.

    17. 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

    18. 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.

    19. 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 Iatrogenic pneumothorax following central line insertion Object accidentally left in patient Air embolism Reaction from blood incompatibility

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

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

    22. 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)

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

    24. How Close Are We?

    25. 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.

    26. Documentation Needs:What’s The Surgery For? • Provide the diagnosis for which the surgery is being performed • Provide acuity, complexity • 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

    27. Documentation Needs: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

    28. 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.

    29. Surgical Risk Stratification • NSQIP databases depend on identification of risk factors

    30. Risk Stratification for Pulmonary Complications

    31. Modified NSQIP Data Sheet

    32. 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!

    33. 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)

    34. 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

    35. Strabismus/Esotropia ICD-9 378.0 Esotropia Convergent concomitant strabismus Excludes: intermittent esotropia (378.20-378.22) 378.00 Esotropia, unspecified 378.01 Monocular esotropia 378.02 Monocular esotropia with A pattern 378.03 Monocular esotropia with V pattern 378.04 Monocular esotropia with other noncomitancies Monocular esotropia with X or Y pattern 378.05 Alternating esotropia 378.06 Alternating esotropia with A pattern 378.07 Alternating esotropia with V pattern 378.08 Alternating esotropia with other noncomitancies Alternating esotropia with X or Y pattern

    36. Strabismus/Esotropia ICD-10 6th digits 1 – right eye 2 - left eye 3 – bilateral 9 - unspecified H50.00 Unspecified esotropia H50.01 Monocular esotropia H50.011 Monocular esotropia, right eye H50.012 Monocular esotropia, left eye H50.02 Monocular esotropia with A pattern H50.021 Monocular esotropia with A pattern, right eye H50.022 Monocular esotropia with A pattern, left eye H50.03 Monocular esotropia with V pattern H50.031 Monocular esotropia with V pattern, right eye H50.032 Monocular esotropia with V pattern, left eye H50.04 Monocular esotropia with other noncomitancies H50.041 Monocular esotropia with other noncomitancies, right eye H50.042 Monocular esotropia with other noncomitancies, left eye H50.05 Alternating esotropia H50.06 Alternating esotropia with A pattern H50.07 Alternating esotropia with V pattern H50.08 Alternating esotropia with other noncomitancies

    37. Diabetes • 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.

    38. Diabetes 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.)

    39. Diabetic Retinopathy ICD-9Up to 3 codes for a patient 362.0 Diabetic retinopathy Code first diabetes (249.5 for DM due to other cause, 250.5 for Type 1 or Type 2 DM) 362.01 Background diabetic retinopathy 362.02 Proliferative diabetic retinopathy 362.03 Nonproliferative diabetic retinopathy NOS 362.04 Mild nonproliferative diabetic retinopathy 362.05 Moderate nonproliferative diabetic retinopathy 362.06 Severe nonproliferative diabetic retinopathy 362.07 Diabetic macular edema Note: 362.07 must be used with a code for diabetic retinopathy (362.01-362.06)

    40. Diabetic Retinopathy ICD-10Only one combinmation code for a patient E11.3 Type 2 diabetes mellitus with ophthalmic complications E11.31 Type 2 diabetes mellitus with unspecified diabetic retinopathy E11.32 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy E11.33 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy E11.34 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy E11.35 Type 2 diabetes mellitus with proliferative diabetic retinopathy E11.36 Type 2 diabetes mellitus with diabetic cataract E11.39 Type 2 diabetes mellitus with other diabetic ophthalmic complication 6th digit for .31 through .35 1 – with macular edema 9 – without macular edema E08.3 series for other cause of DM E09.3 series drug or chemical induced DM E10 series for Type 1 DM E11 series for Type 2 DM

    41. 366.0 Infantile, juvenile, and presenile cataract 366.00 Nonsenile cataract, unspecified 366.01 Anterior subcapsular polar cataract 366.02 Posterior subcapsular polar cataract 366.03 Cortical, lamellar, or zonular cataract 366.04 Nuclear cataract 366.09 Other and combined forms of nonsenile cataract 366.1 Senile cataract 366.10 Senile cataract, unspecified 366.11 Pseudoexfoliation of lens capsule 366.12 Incipient cataract 366.13 Anterior subcapsular polar senile cataract 366.14 Posterior subcapsular polar senile cataract 366.15 Cortical senile cataract 366.16 Nuclear sclerosis 366.17 Total or mature cataract 366.18 Hypermature cataract 366.19 Other and combined forms of senile cataract Cataract ICD-9

    42. H26.0 Infantile and juvenile cataract H26.00 Unspecified infantile and juvenile cataract H26.01 Infantile and juvenile cortical, lamellar, or zonular cataract H26.03 Infantile and juvenile nuclear cataract H26.04 Anterior subcapsular polar infantile and juvenile cataract H26.05 Posterior subcapsular polar infantile and juvenile cataract H26.06 Combined forms of infantile and juvenile cataract H26.09 Other infantile and juvenile cataract H25.0 Age-related incipient cataract H25.01 Cortical age-related cataract H25.03 Anterior subcapsular polar age-related cataract H25.04 Posterior subcapsular polar age-related cataract H25.09 Other age-related incipient cataract H25.1 Age-related nuclear cataract H25.2 Age-related cataract, morgagnian type H25.8 Combined forms of age-related cataract 6th digits 1 – right eye 2 - left eye 3 – bilateral 9 - unspecified Cataract ICD-10

    43. Corneal Ulcer ICD-9 370.0 Corneal ulcer 370.00 Corneal ulcer, unspecified 370.01 Marginal corneal ulcer 370.02 Ring corneal ulcer 370.03 Central corneal ulcer 370.04 Hypopyon ulcer Serpiginous ulcer 370.05 Mycotic corneal ulcer 370.06 Perforated corneal ulcer 370.07 Mooren's ulcer

    44. Corneal Ulcer ICD-10 H16.0 Corneal ulcer H16.00 Unspecified corneal ulcer H16.01 Central corneal ulcer H16.02 Ring corneal ulcer H16.03 Corneal ulcer with hypopyon H16.04 Marginal corneal ulcer H16.05 Mooren's corneal ulcer H16.06 Mycotic corneal ulcer H16.07 Perforated corneal ulcer 6th digits 1 – right eye 2 - left eye 3 – bilateral 9 - unspecified

    45. Blindness Categories ICD-9 369.4 Legal blindness, as defined in U.S.A. Blindness NOS according to U.S.A. definition Excludes: legal blindness with specification of impairment level (369.01-369.08, 369.11-369.14, 369.21-369.22) 369.6 Profound impairment, one eye 369.60 Impairment level not further specified 369.61 One eye: total impairment; other eye: not specified 369.62 One eye: total impairment; other eye: near-normal vision 369.63 One eye: total impairment; other eye: normal vision 369.64 One eye: near-total impairment; other eye: not specified 369.65 One eye: near-total impairment; other eye: near-normal vision 369.66 One eye: near-total impairment; other eye: normal vision 369.67 One eye: profound impairment; other eye: not specified 369.68 One eye: profound impairment; other eye: near-normal vision 369.69 One eye: profound impairment; other eye: normal vision

    46. Blindness Categories ICD-10 H54.8 Legal blindness, as defined in USA Blindness NOS according to USA definition Excludes1: legal blindness with specification of impairment level (H54.0-H54.7) H54.1 Blindness, one eye, low vision other eye Visual impairment categories 3, 4, 5 in one eye, with categories 1 or 2 in the other eye. H54.10 Blindness, one eye, low vision other eye, unspecified eyes H54.11 Blindness, right eye, low vision left eye H54.12 Blindness, left eye, low vision right eye H54.4 Blindness, one eye Visual impairment categories 3, 4, 5 in one eye [normal vision in other eye] H54.40 Blindness, one eye, unspecified eye H54.41 Blindness, right eye, normal vision left eye H54.42 Blindness, left eye, normal vision right eye

    47. Retinal Detachment ICD-9 361.0 Retinal detachment with retinal defect Excludes: detachment of retinal pigment epithelium (362.42-362.43) retinal detachment (serous) (without defect) (361.2) 361.00 Retinal detachment with retinal defect, unspecified 361.01 Recent detachment, partial, with single defect 361.02 Recent detachment, partial, with multiple defects 361.03 Recent detachment, partial, with giant tear 361.04 Recent detachment, partial, with retinal dialysis 361.05 Recent detachment, total or subtotal 361.06 Old detachment, partial 361.07 Old detachment, total or subtotal 361.3 Retinal defects without detachment Excludes: chorioretinal scars after surgery for detachment (363.30-363.35) peripheral retinal degeneration without defect (362.60-362.66) 361.30 Retinal defect, unspecified 361.31 Round hole of retina without detachment 361.32 Horseshoe tear of retina without detachment 361.33 Multiple defects of retina without detachment 361.8 Other forms of retinal detachment 361.81Traction detachment of retina 361.89Other 361.9Unspecified retinal detachment

    48. Retinal Detachment ICD-10 H33.0 Retinal detachment with retinal break Excludes1: serous retinal detachment (without retinal break) (H33.2-) H33.00Unspecified retinal detachment with retinal break H33.01 Retinal detachment with single break H33.02 Retinal detachment with multiple breaks H33.03 Retinal detachment with giant retinal tear H33.04 Retinal detachment with retinal dialysis H33.05 Total retinal detachment H33.3 Retinal breaks without detachment Excludes1: chorioretinal scars after surgery for detachment (H59.81-) peripheral retinal degeneration without break (H35.4-) H33.30 Unspecified retinal break H33.31 Horseshoe tear of retina without detachment H33.32 Round hole of retina without detachment H33.33 Multiple defects of retina without detachment 6th digits 1 – right eye 2 - left eye 3 – bilateral 9 - unspecified