4/1/2014 ICD-10 CM/PCS. Benefits to ICD-10. Fewer queries and/or requests for additional clarification. Fewer denials based on medical necessity

Transcription

1 Clinical Documentation and ICD-10 Presented by: Altegra Health 1 ICD-10 CM/PCS ICD-10 will be the official HIPAA-transaction set to communicate all patient conditions and all inpatient treatments, beginning on October 1, 2015 ICD 10 CM US clinical modification of the World Health Organization s ICD 10 Diagnostic coding system (no procedure codes) Approximately 68,000 ICD 10 CM alpha and numeric diagnosis codes Current ICD 9 CM has 14,000 numeric diagnosis codes ICD 10 PCS Developed under contract by CMS specifically to replace the ICD 9 CM procedural coding system. Approximately 70,000 ICD 10 PCS alpha and numeric codes Current ICD 9 Volume 3 has 4,000 numeric procedure codes 2 Benefits to ICD-10 Fewer queries and/or requests for additional clarification Fewer denials based on medical necessity Financial impact for VBP, ACO and other quality driven incentives Improved clinical outcomes Patient related risk factors Treatment effectiveness Quality of care rendered (metrics) Death, Complications, Readmissions, Length of Stay Predictors Resource Intensity, Severity of Illness, Risk of Mortality, Risk of Complications, Risk of Readmission 3 1

2 CDI Clinical Documentation Improvement (CDI) programs began in the late 1980s in response to the Federal Government s implementation of Diagnosis Related Groups (DRGs) in Programs started as DRG optimization are now known as CDI. The programs emphasized concurrent inpatient chart review by nurses/coders to collaborate with physicians to clarify their documentation. 4 The Importance of Documentation Coders need clear documentation to accurately tell the story of the patient s visit/admission. The story reflects the severity of illness, potential length of stay, diagnoses that were POA (present on admission) or HAC (hospital acquired condition) Queries and Clarifications Follow Trends Use consistent templates and feedback format Query the correct specialty 5 Osteoarthritis This is a 52-year-old male who presented with left knee pain and swelling for 1 to 2 months. He has a history of right total knee arthroplasty done in the past, twice; one 6 years ago and second was done recently in the beginning of History of Right total knee arthroplasty 2. Osteoarthritis (ICD-10-CM Left Osteoarthritis ) 6 2

3 Asthma ICD-9-CM Indicate Status of Disease Acute Exacerbation/Chronic/Status Asthmaticus ICD-10-CM Indicate Severity of Disease Mild Intermittent or Mild Persistent Moderate Persistent or Severe Persistent 7 Urosepsis He has been at the rehab facility and apparently at some point, he was determined to have a urinary tract infection for which he received Levaquin. At any rate, he had fevers and chills and had generalized malaise. He has been having some general decline and most recently got a little worse with altered mental status and was therefore sent to the ER. He had a high-grade fever and low blood pressure and was admitted initially into the intensive care unit with some sepsis. He was placed empirically on vancomycin and cefepime. Urine culture is growing greater than 100,000 colonies of enterococcus. IMPRESSION: 1. Urosepsis (ICD-10 Sepsis due to enterococcus ) PLAN: 1. Continue vancomycin for 7 days for urinary tract infection. 8 Respiratory Failure ICD-9-CM Status of Disease Acute/Chronic/Acute on Chronic ICD-10-CM Severity of Disease With Hypercapnia or Hypoxia 9 3

4 Pneumonia She was found to have a fever on admission as well as a large right-sided infiltrate. Also, she was noted to have elevated troponin, evidence of urinary tract infection, renal failure, anemia and hypoxemia. She was also noted on an arterial blood gas to have evidence of acute hypoxic and hypercarbic respiratory failure. She has since been placed on BiPAP with improvement of her hypercarbic and hypoxic respiratory failure, although requiring high amounts of oxygen. ASSESSMENT: The patient is a pleasant 66-year-old female who presents with healthcareassociated pneumonia (ICD-10 Suspect Gram Negative, or Resistant to Gram Positive ) RECOMMENDATIONS: 1. Continue antibiotics intravenously. 10 Hemiplegia This is a 69-year-old patient who presented with slurred speech. Went from Mesa Christian Healthcare Center, also have altered mental status. The patient was being treated for a femur fracture, status post fall. The patient was admitted and was seen by neurology, had MRI, PT, OT. The patient slowly improved. Doing better. She is back to her normal baseline. The patient will continue her PT, OT. Okay by neurology to be transferred. FINAL DIAGNOSES: 1. Cerebrovascular accident 2. Multiple sclerosis 3. Spastic hemiplegia (ICD-10-CM- Indicate affected side and dominant side) 11 Renal Failure Acute: With cortical necrosis, medullary necrosis, tubular necrosis Acute kidney injury (non-traumatic) Chronic: Stage? Due to hypertension? Due to diabetes? 12 4

5 Fractures specific area of bone laterality type of fracture severity of fracture episode of care Initial encounter Subsequent Sequela 13 Tobacco Use or Dependence ICD-9-CM Tobacco Use ICD-10-CM Tobacco Use Tobacco Dependence 14 Compliance and CDI Partnership Routine involvement in partnering committees Track Query trends and response time Coder/CDI feedback on EHR template builds Enhanced Documentation does not have to be restricted to ICD-10 implementation!! Continue our efforts 15 5

6 Thank You QUESTIONS? 16 6