ICD-10 Preparation: Understanding your own data to create your ICD10 Strategy for Success
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ICD-10 Preparation: Understanding your own data to create your ICD10 Strategy for Success Data Analytics and Audit. Barbara Godbey-Miller, RHIA, CCS, CHC. Today’s Agenda. Step 1: Data Analytics : Aggregate information analysis Step 2: Audit Findings R eal results from clients

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Barbara godbey miller rhia ccs chc

ICD-10 Preparation: Understanding your own data to create your ICD10 Strategy for SuccessData Analytics and Audit

Barbara Godbey-Miller, RHIA, CCS, CHC


Today s agenda
Today’s Agenda your ICD10 Strategy for Success

  • Step 1: Data Analytics:

    • Aggregate information analysis

  • Step 2: Audit Findings

    • Real results from clients

  • Step 3: Education

    • What your team needs to know



Data variables
Data Variables Documentation Integrity

Clinical Documentation

Program

Physician

Clinical Documentation

Regulatory Change

Managing the I-10 CDI process will require additional staff to cover increased workload. Will staffing be adequate to cover 100% of cases & what percentage of queries will go unasked or unanswered?

Coding

Accuracy

Coding Quality Review

Data Normalization

Not all DRGs are created equal or have the same probability for DRG assignments errors. Data normalization without manipulation. What is your DRG risk population for change and what is the revenue impact?

With increase demand for coding resources and cash flow demands, will organizations have an internal coding quality review process to identify increased coding errors?

  • CMS givith and take it away. Regulatory factors should be included to determine revenue impact.

  • Documentation & Coding Adjustment Factor

  • Prospective Payment System Changes

  • ICD-10 Oncology Grouper Changes

Understanding the clinical documentation specificity of I-9, a system used for 30 years, required a CDI program to manage. What will the CDI error rate be?

ICD-10 coder errors will increase with use of new system and increased requirement to interpret physician documentation requirements. What will the coding error rate be of coders and contract personnel?


Clinical documentation integrity
Clinical Documentation Integrity Documentation Integrity

The HIM professional’s role is to combine emerging technologies with innovative processes to meet the aims of this strategy ─ improve the quality of healthcare, improve the health of the US population, and reduce the cost of quality healthcare.


What is data governance
What is Data Governance? Documentation Integrity

Making strategic and effective decisions regarding the organization’s information assets.

Includes:

  • Defining roles and responsibilities for data

  • Establishing data quality policies

  • Creating metadata management practices

  • Arbitrating shared data questions

  • Release of Information


The him professional s key to successful information governance
The HIM Professional’s Key to Successful Information Governance

  • Data or Information governance is the high-level, corporate, or enterprise policies or strategies that define the purpose for collecting data, ownership of data, and intended use of data. Accountability and responsibility flow from governance.

  • The Information Governance plan is the framework for the overall organizational approach to data governance.


Clinical documentation integrity1
Clinical Documentation Integrity Governance

The HIM professional’s role is to combine emerging technologies with innovative processes to meet the aims of this strategy ─ improve the quality of healthcare, improve the health of the US population, and reduce the cost of quality healthcare.


Icd 10 analytics approach
ICD-10 Analytics Approach Governance

Key activities and timing

Define assessment scope

Identify stakeholders

Initiate

ICD-10 revenue impact analysis

Documentation audit

Focus on high-risk MS-DRGs

Assess

Educational mapping

Recommended remediation or mitigation of risk

Recommend

Put plan into action

Plan


Icd 10 data analytics
ICD-10 Data Analytics Governance

ICD-10 data analytics will return higher probability rates if they are fact based using a set of variables that will influence the outcomes analysis for DRG assignment predictability

ICD-10 analytics are derived or analyzed using the GEMS file, which without audit is not a reliable tool to identify DRG shifts


Data analytics how its done
Data Analytics – How its Done Governance

  • 12 months of claims are processed through an analytics program for ICD-10 CM/PCS using GEMS and reimbursement maps

  • Data Analysts review each mapping to identify legitimate risks

    • Two scenarios – financial risk, operational risk

  • ICD-10 Auditors validate documentation on highest risk areas

    • Output – Physician and Coder education strategy


Data analytic analysis 2 sites post audit results
Data Analytic Analysis Governance 2 Sites - Post Audit Results



Scenarios

Scenarios Governance

Specific examples of MS-DRG changes discovered on I-10 re-code projects


Ms drg shift
MS-DRG SHIFT Governance

Cardiology: Patient was readmitted for treatment of post infarction angina & CAD, 1 week status post acute myocardial infarction


Icd 10 re code what we discovered
ICD-10 Re-Code: What We Discovered Governance

  • MS-DRG changed due to timeframe established within ICD-10 to indicate an acute myocardial infarction

    • Even as a secondary diagnosis, the AMI will “drive” this MS-DRG based on grouper logic with PDX from Circulatory MDC 5 and AMI

  • Category I21 (AMI) is coded up to 4 weeks following the AMI regardless of reason for admission

  • The terminology used in ICD-9 to capture “subsequent episode of care” for AMI does not exist in ICD-10

    • Subsequent AMI codes are used when a patient has a second AMI within 4 weeks of the initial AMI

    • NOTE: “Subsequent” refers to the MI and NOT the episode of care in ICD-10


Acute myocardial infarction
Acute Myocardial Infarction Governance

  • ICD-10-CM has decreased the acute phase of an acute myocardial infarction from 8 weeks or less to 4 weeks (28 days) or less.

  • ICD-10-CM classifies acute myocardial infarction in two separate categories. STEMI and NSTEMI

  • Clinical documentation will need to indicate laterality. Additional specificity is required to identify the anatomical site affected

    I21.02 ST elevation (STEMI) myocardial infarction involving

    left main coronary artery

Laterality


Subsequent myocardial infarction
Subsequent Myocardial Infarction Governance

  • ICD-10-CM has added a category for subsequent myocardial infarction.

  • Subsequent is identified as a myocardial infarction occurring within 4 weeks (28 days) of a previous myocardial infarction.

  • Clinical documentation must include the type of subsequent myocardial infarction

    Example:

    A patient is admitted with a subsequent STEMI of the anterior wall 7 days after being discharged for a STEMI of left main artery, anterior wall

    I22.0 subsequent STEMI myocardial infarction of anterior wall

    I21.01 STEMI myocardial infarction involving left main coronary artery of anterior wall

Code indicates this is the subsequent MI

Code indicates this was the first MI


Potential readmission flag
Potential Readmission Flag Governance

ICD-9 Acute Myocardial Infarction – 8 weeks

ICD-10 Acute Myocardial Infarction – 4 weeks

Readmission Risk if patient winds up back in the hospital in 30 days. Zero additional payment – potential gain may be lost in this instance


Ms drg shift1
MS-DRG SHIFT Governance

Cardiology: Patient was admitted with AMI and had coronary intervention with four drug-eluting stents.


Icd 10 re code what we discovered1
ICD-10 Re-Code: What We Discovered Governance

  • MS-DRG changed due to the fact that even though patient had four drug-eluting stents inserted there were only three sites being treated

  • In ICD-10- PCS, the code is assigned based on number of sites being treated rather than number of stents inserted

  • Occasionally, this will result in lower-weighted DRG assignment in ICD-10


Documenting procedures
Documenting Procedures Governance

  • Clinical documentation for all procedures will require documentation identifying the following:

    • General physiological system or anatomical region involved

    • What type of procedure was performed root operationadministration, dilation, drainage, biopsy, excision, resection, bypass, transplantation

    • The exact anatomical site of the procedure body part

  • Right, left, bilateral

    • The technique used to reach the site surgical appro achopen, closed, laparoscopic, percutaneous, endoscopic, needle

    • If adev ice was used, what site/area was the device placed (e.g. stent, graft, implant)

    • If the procedure was for diagnostic purposes

Body system

Root Operation

Body part

Laterality

Surgical approach

Device

Qualifier


Documenting procedures1
Documenting Procedures Governance

  • When a PTCA is performed, clinical documentation by the physician must indicate how many sites were dilated and what device was utilized for “each” site.

    Example:

    OR report indicates that patient had PTCA of both the left anterior descending artery and the right coronary artery. A drug-eluting stent was placed in the right coronary artery.

    02703ZZ Dilation, Artery, Coronary, One Site

    027034Z Dilation, Artery, Coronary, One Site

No stent inserted

Two codes required to identify procedure on each artery

Stent inserted


Ms drg shift2
MS-DRG SHIFT Governance

Medicine: Patient was admitted for treatment of anemia secondary to ESRD. Patient also has hypertension.


Icd 10 re code what we discovered2
ICD-10 Re-Code: What We Discovered Governance

  • MS-DRG changed due to change in principal diagnosis per sequencing instructions in ICD-10-CM Official Coding Guidelines

  • Anemia in chronic kidney disease is a classified as a manifestation of chronic kidney disease

    • Manifestation codes cannot be assigned as principal diagnosis

  • Notes instruct to code first the underlying disease of ESRD

  • Under ESRD, there is another instructional to code first any hypertensive chronic kidney disease


Chronic kidney disease
Chronic Kidney Disease Governance

ICD-10-CM uses the following table to identify the stage of kidney disease


Hypertensive diseases
Hypertensive GovernanceDiseases

  • Clinical documentation for hypertension in ICD-10-CM should be described as accelerated, benign, essential, idiopathic, malignant, and systemic

    I10 Essential (primary) hypertension

Documentation by physician indicates Essential


Hypertensive diseases1
Hypertensive Diseases Governance

  • ICD-10-CM presumes a cause-and-effect relationship between hypertension and chronic kidney disease. Clinical documentation will need to include the stage of chronic kidney disease.

    I12 Hypertensive Kidney Disease

    N18.5 Chronic Kidney Disease, Stage 5

Clinical documentation indicates hypertension and chronic kidney disease

Clinical documentation requires the correct staging of the chronic kidney diseases


Hypertensive diseases2
Hypertensive Diseases Governance

Example:

A 68-year-old gentleman is admitted with hypertension, heart disease, acute on chronic CHF, and stage 4 renal disease. The physician documents that the heart disease is associated with the hypertension.

I13.10 Hypertensive heart and chronic kidney disease with heart failure,

with stage I-IV CKD

N18.4 Chronic Kidney Disease, Stage 4, severe

I50.33 Acute on chronic diastolic heart failure

Code shows hypertension, heart disease, CHF, and stage 4 renal disease all combined in one code

Additional codes show stage of CKD and specificity of heart failure


Chronic kidney disease with hypertension
Chronic Kidney Disease with Hypertension Governance

  • ICD-10-CM presumes a relationship between chronic kidney disease and hypertension.

  • Clinical documentation for hypertensive kidney disease will also require identification of the stage of kidney failure

    I12 Hypertensive Kidney Disease

    N18.5 Chronic Kidney Disease, Stage 5

Disease

Stage of CKD


Hypertensive heart and ckd case study
Hypertensive Heart and CKD Case Study Governance

A 68-year-old gentleman is admitted with hypertension, heart disease, acute on chronic CHF, and stage 4 renal disease. The physician documents that the heart disease is associated with the hypertension.

I13.10 Hypertensive heart and chronic kidney disease with heart failure,

with stage I-IV CKD

N18.4 Chronic Kidney Disease, Stage 4, severe

I50.33 Acute on chronic diastolic heart failure

Disease

Stage of CKD

Type of Heart Failure


Ms drg shift3
MS-DRG SHIFT Governance

Medicine: Patient was admitted for treatment of anemia secondary to lung cancer


Icd 10 re code what we discovered3
ICD-10 Re-Code: What We Discovered Governance

  • MS-DRG changed due to change in principal diagnosis per sequencing instructions in ICD-10-CM Official Coding Guidelines

  • When the admission is for management of an anemia associated with malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis followed by code D63.0, Anemia in neoplastic disease


Anemia in chronic diseases
Anemia in Chronic Diseases Governance

  • ICD-10-CM classifies anemia in chronic diseases into several categories. Clinical documentation will be required to identify the type of chronic anemia as well as the associated cause

    • Anemia in neoplastic disease

      • Documentation will need be required to identify associated neoplasm

    • Anemia in chronic kidney disease

      • Documentation will be required to identify the stage of chronic kidney disease

    • Anemia in other chronic disease


Acquired aplastic anemia
Acquired Aplastic Anemia Governance

  • Clinical documentation for acquired aplastic anemia should indicate the cause as follows:

    • High-dose radiation or chemotherapy

    • Environmental toxins

    • Medications

    • Viral infections

    • Autoimmune disease

    • Paroxysmal nocturnal hemoglobinuria


Ms drg shift4
MS-DRG SHIFT Governance

Surgery: Patient was admitted with rectal bleeding and peritoneal abscess. Treatment included partial resection of ileum and lysis of peritoneal adhesions.


Icd 10 re code what we discovered4
ICD-10 Re-Code: What We Discovered Governance

  • MS-DRG changed due to the fact that a partial small bowel resection (ileum in this case) no longer groups to major small and large bowel procedures DRG in ICD-10

  • Surgical hierarchy dictates the principal procedure selection

    • In this case, the lysis of adhesions overrides any other procedure performed based on surgical hierarchy


Ms drg shift5
MS-DRG SHIFT Governance

Pulmonary: Patient was admitted with exacerbation of COPD. Patient also had accelerated hypertension which was treated.


Icd 10 re code what we discovered5
ICD-10 Re-Code: What We Discovered Governance

  • MS-DRG changed due to the fact that a specific code for accelerated or malignant hypertension does not exist in ICD-10 thereby, eliminating the ability to capture CC

  • There is only one code for hypertension in ICD-10 which encompasses all types and is NOT classified as a CC


Diseases of the gastroenterology system
Diseases of the Gastroenterology System Governance

  • Clinical terminology used to describe diseases of the digestive system and has been updated to reflect advances in diagnosis and procedures as well as greater specificity

    Example:

    ICD-9-CM

    555.1 Regional enteritis large intestine

    ICD10-CM

    K50.10 Crohn’s disease of large intestine without complications

    K50.111 Crohn’s disease of large intestine with rectal bleeding

    K50.112 Crohn’s disease of large intestine with intestinal obstruction

    K50.113 Crohn’s disease of large intestine with fistula

    K50.114 Crohn’s disease of large intestine with abscess

    K50.118 Crohn’s disease of large intestine with other complication

    K50.119 Crohn’s disease of large intestine with unspecified complications


Diseases of the digestive system
Diseases of the Digestive System Governance

  • Terminology for many of the categories in gastroenterologyhave been updated to reflect current terminology.

  • The gastroenterology category contains specific respiratory diagnosis codes for infections, inflammations, causative organisms, and external agents

  • The physician will be required to document details such as

    • Specific forms of the disease

    • Site of the disease/disorder

    • Laterality

    • Causative organism

    • External agents

    • Associated conditions

    • Acuity


Additional documentation for gastroenterology
Additional Documentation for Gastroenterology Governance

  • ICD-10-CM requires additional documentation to identify external factors attributing to diagnoses within this category. Clinical documentation will be required to show associated causes such as:

    • Alcohol abuse and dependence

    • Exposure to environmental tobacco smoke

    • Exposure to tobacco smoke in the perinatal period

    • History of tobacco use

    • Occupational exposure to environmental tobacco smoke

    • Tobacco dependence

    • Tobacco use


Regional enteritis crohn s disease
Regional Enteritis (Crohn’s Disease) Governance

  • ICD-10-CM categorizes regional enteritis (Crohn’s Disease) by site:

    • Small intestine

    • Large intestine

    • Both small and large intestine

  • Clinical documentation will also be required to identify any associated complications such as:

    • Abscess

    • Fistula

    • Intestinal obstruction

    • Rectal bleeding

    • Other specified complication

      K50.114 Crohn’s disease of large intestine with abscess

Disease

Location

Complication


Ulcerative colitis
Ulcerative Colitis Governance

  • Clinical documentation for ulcerative colitis in ICD-10-CM will require identification of the site of ulcerative colitis or other condition within this category, such as:

    • Inflammatory polyps

    • Left sided colitis

    • Panocolitis (enterocolitis, ileocolitis, universal colitis)

    • Proctitis

    • Rectosigmoiditis (proctosigmoiditis)

    • Other specified site

  • Additional documentation will be required to identify any associated complication, such as:

    • Abscess

    • Fistula

    • Intestinal obstruction

    • Rectal bleeding

    • Other specified complication


Diverticulosis diverticulitis
Diverticulosis/Diverticulitis Governance

  • Clinical documentation will be required to identify between diverticulosis and diverticulitis

  • Specificity will be required to identify the location of the disease as:

    • Small intestine

    • Large intestine

    • Both small and large intestine

  • Additional documentation will be required to identify any associated conditions such as:

    • Perforation

    • Abscess

    • Bleeding

      K57.32 Diverticulitis, large intestine, without perforation or abscess, without bleeding

Disease

No associated conditions

Location


Documenting procedures2
Documenting Procedures Governance

  • Clinical documentation for all procedures will require documentation identifying the following:

    • General physiological system or anatomical region involved

    • What type of procedure was performed root operationadministration, dilation, drainage, biopsy, excision, resection, bypass, transplantation

    • The exact anatomical site of the procedure body part

  • Right, left, bilateral

    • The technique used to reach the site surgical a open, closed, laparoscopic, percutaneous, endoscopic, needle

    • If ad evicwasused, what site/area was the device placed (e.g. stent, graft, implant)

    • If the procedure was for diagnostic purposes

Body system

Root Operation

Body part

Laterality

Surgical approach

Device

Qualifier


Partial large bowel resection
Partial Large Bowel Resection Governance

Operating Room Report indicates open right hemicolectomy with end-to-end anastomosis for treatment of large carcinoid tumor

No Device

Large Intestine, Right

ODT

F

0

Z

Z

No Device

Resection

Open Approach


Chronic obstructive pulmonary disease
Chronic Obstructive Pulmonary Disease Governance

  • The following conditions are classified in this category:

    • Asthma with chronic obstructive pulmonary disease

    • Chronic asthmatic (obstructive) bronchitis

    • Chronic bronchitis with airways obstruction

    • Chronic bronchitis with emphysema

    • Chronic emphysematous bronchitis

    • Chronic obstructive asthma

    • Chronic obstructive tracheobronchitis

  • Clinical documentation of chronic obstructive pulmonary disease should identify any associated acute exacerbation or lower respiratory infection

    J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection

    J20.2 Acute bronchitis due to streptococcus

Disease

Associated Condition/Organism


Emphysema
Emphysema Governance

  • Clinical documentation for emphysema should include a full description of the disease and document the specific types as:

    • Unilateral emphysema (MacLeod’s syndrome)

    • Centrilobular emphysema

    • Panlobular emphysema

    • Other emphysema

    • Unspecified emphysema

  • Clinical documentation should also include any associated exposures such as:

    • Exposure to environmental tobacco smoke

    • History of tobacco use

    • Occupational exposure to environmental tobacco smoke

    • Tobacco dependence

    • Tobacco use


  • Asthma
    Asthma Governance

    • Clinical documentation should identify additional diagnoses that could affect the current treatment of asthma, such as:

      • Exposure to environmental tobacco smoke

      • Exposure to tobacco smoke in the prenatal period

      • History of tobacco use

      • Occupational exposure to environmental tobacco smoke

      • Tobacco dependence

      • Tobacco use

      • Allergen induced

      • Exercise induced

      • Stress induced

      • Associated respiratory infections

    • Additional documentation should identify the long term use of steroids associated with asthma:

      • Long term (current) use of inhaled steroids

      • Long term (current) use of systemic steroids


    Asthma1
    Asthma Governance

    • Clinical documentation will require specificity to show whether the reported asthma is “uncomplicated”, “with acute exacerbation”, or “with status asthmaticus”

    • Clinical documentation of asthma should always include the following:

      • Acute exacerbation of asthma

      • With status asthmaticus

      • Type of asthma

        • Mild

          • Intermittent

          • Persistent

        • Moderate persistent

        • Severe persistent

        • Other specified type

        • Unspecified type

      • Intrinsic (nonallergic)

      • Extrinsic (allergic)

      • Associated external agents


    Asthma2
    Asthma Governance

    • Clinical documentation should identify the severity of asthma


    Asthma case study
    Asthma Case Study Governance

    40-year-old female presents with a diagnosis of acute asthma. She has a long history of moderate persistent asthma. She takes inhaled steroids daily. Final discharge diagnosis is documented as moderate persistent asthma with acute exacerbation.

    J45.41 Moderate persistent asthma with (acute) exacerbation

    Z79.51 Long term (current) use of inhaled steroids

    Acuity

    Severity

    Use of Steroids



    In summary clinical documentation integrity
    In Summary: GovernanceClinical Documentation Integrity

    • Integrity of health information is an obligation of HIM

    • HIM professionals must assume a leadership role in transforming these functions

    • Now is the time to analyze and visualize documented and undocumented intra and interdepartmental HIM functions to understand the current and future state of the HIM department while ensuring HIM best practices and standards are consistently maintained


    Action items as you prepare for icd10 implementation
    Action Items as you prepare for ICD10 Implementation Governance

    • Identify risks and opportunities for your hospital

    • Use examples in this presentation to identify the same issues in your facility

      • DRG Shifts

        • Positive

          • Principal Diagnosis

          • Principal Procedure (root operation)

          • CC/MCC

        • Negative

          • Principal Diagnosis

          • Principal Procedure (root operation)

          • CC/MCC

    • Educate Physicians, CDI Team and Coding Professionals

    • Compare I-9 to I-10 DRG assignment if dual coding


    Action items post implementation
    Action Items post - Implementation Governance

    • Prepare a DRG report by month for beginning the go live date

      • List of cases by individual DRG

    • Compare by month DRGs year to year

      • Identify total numbers for pre-I-10 and post I-10 by DRG for each month

      • Work the list of DRG shifts

        • Print out I-9 DX and PX with descriptions

        • Compare to I-10 DX and PX with descriptions

        • Identify PDX, PPX and CC/MCC changes