2016 GHIMA Annual Meeting & Exhibit. "Charting the Course...A World of Opportunities."

Transcription

1 2016 GHIMA Annual Meeting & Exhibit "Charting the Course...A World of Opportunities."

2 ICD 10 CM/PCS Year in Review What have we learned Wendy Deaton, RHIT, CCS, CCS P AHIMA Approved ICD 10 CM/PCS Trainer

3 Overview Outcome of ICD 10 Implementation ICD 10 CM MS DRG Struggles ICD 10 PCS MS DRG Struggles FY 2017 ICD 10 CM/PCS Updates

4 Outcome of ICD 10 Implementation Relatively seamless: Claim submission Information technology ICD 10 CM/PCS Production National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) ICD 10 CM/PCS Code Difficulties

5 Claim Submission Approximatley 2% of rejected claims for Q Minor issues with interfaces between computer systems Testing of claim transmission prior to ICD 10 implementation resulted in smooth transition

6 ICD 10 CM/PCS Production 30 to 45 percent productivity decrease on the inpatient side 20 to 40 percent productivity decrease on the outpatient side Increase in quality reviews Decrease in coder accuracy

7 Claim Denials Denials were minimal months after implementation but have increased Facilities closely monitoring the denials due to changes within the NCDs and LCDs The Centers for Medicare and Medicaid (CMS) have taken steps to address these discrepancies Questions about specific NCDs and LCDs should be submitted to the appropriate Medicare Administrative Contractor (MAC)

8 ICD 10 CM Code Difficulties Excludes1 note definition and CMS clarification Assigning the 7 th character for injuries, poisoning and certain musculoskeletal disorders Coding for rehabilitation admissions Coding obstetric cases, assigning ICD 10 CM diagnosis codes for tobacco use/dependence and osteoarthritis

9 ICD 10 PCS Code Difficulties Incorrectly applying the definition of the root operation Using the wrong body system Assigning the wrong body part Inappropriate use of qualifier X diagnostic

10 Example of Incorrect Root Operation Open Aneurysmal Repair using synthetic graft Replacement Putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part PCS code 04R00JZ MS DRG: 269 R.W

11 Example of Incorrect Root Operation Supplement Putting in or on biological or synthetic material that physically reinforces and/or augments the function of a portion of a body part PCS code 04U00JZ MS DRG: 254 R.W

12 Wrong Body System Example Malignant melanoma is a cancer of the skin Excision of melanoma Body System Body System General Anatomic Subcutaneous Tissue Arm Subcutaneous Tissue of Right Lower Arm PCS code 0XBD0ZZ PCS code 0JBG0ZZ MS DRG: 578 RW MS DRG: 572 RW

13 Example of Wrong Body Part Bronchoscopy to irrigate mucous plugs in a patient admitted for pneumonia Mucous Plug Accumulation of mucus in your airways (bronchus) Extirpation Taking or cutting out solid matter from a body part 0BCJ8ZZ Body part Left Lower Lobe of Lung value (J), results in MS DRG: 165 R.W BCB8ZZ Body part Left Lower Lobe Bronchus, value (B) results in MS DRG: 195 R.W

14 Inappropriate use of Qualifier (X) Qualifier X diagnostic is to be used when documentation supports that the intent of the procedure is to determine the nature of specimen Fluid removal sent to cytology does not automatically indicate diagnostic Patient with ascites who undergoes a paracentesis and documentation does not specify that the removal of the fluid is for diagnostic purposes Alters the MS DRG from a surgical MS DRG to a nonsurgical MS DRG

15 MS DRG Struggles ICD 10 CM and ICD PCS Code errors

16 ICD 10 CM MS DRG Coding Errors Principal and secondary diagnosis code inaccuracies resulting in: MS DRG differences Case mix Reimbursement Patient care Severity of Illness Intensity of service

17 7 th Character Assignment Impacting Case Mix Assigning the 7 th character of subsequent versus initial S06.5x0D Traumatic subdural hemorrhage without loss of consciousness, subsequent encounter. MS DRG 950 R.W S06.5x0D Traumatic subdural hemorrhage without loss of consciousness, initial encounter. MS DRG 087 R.W

18 Reimbursement Difference due to Incorrect ICD 10 CM Code Incorrect ICD 10 CM code for a patient admitted to undergo hemodialysis Z49.01 Encounter for fitting and adjustment of extracorporeal dialysis catheter. MS DRG 685 R.W N18.6 End stage renal disease. MS DRG 684 R.W

19 Improper Indexing resulting in Severity of Illness Decrease Improper indexing of a condition leading to decrease in the severity of illness. Case Example: A 65 year old male presents with severe abdominal pain. Found to have biliary pancreatitis from biliary calculus status post cholecystectomy 2 weeks prior K85.1 Biliary acute pancreatitis K80.70 Calculus of gallbladder and bile duct without cholecystitis without obstruction MS DRG 440 R.W K85.1 Biliary acute pancreatitis K91.86 Retained cholelithiasis following cholecystectomy MS DRG 439 R.W

20 Incorrect Code Assignment Affecting Patient Care Assigning the incorrect complication of care code results in diagnosis code not supporting: condition being treated by the physician resources used at the facility Original Code Recommended code DRG Impact T80.219A, Unspecified infection due to CVC, initial encounter T82.119A, Breakdown (mechanical) of unspecified cardiac electronic device, initial encounter T80.211A, Bloodstream infection due to CVC, initial encounter T82.110A, Breakdown (mechanical) of cardiac electrode, initial encounter No Yes (over payment)

21 ICD 10 PCS MS DRG Coding Errors ICD 10 PCS errors resulting in: Case Mix Index Discrepancies Sub optimal MS DRG s Increase in surgical MS DRG s Rise in billed MS DRG s and

22 Case Mix Example Pregnant female admitted to deliver infant and sustained a 3 rd degree laceration which was repaired Pre implementation MS DRG: 775 Vaginal Delivery without Complication R.W ICD 10 MS DRG 989: Non Extensive O.R. Proc Unrelated to Principal Diagnosis w/o CC/MCC R.W

23 Sub Optimal DRG Example Patient admitted with a primary cancerous mass of the ileum for removal Prior to ICD 10 the ICD 9 codes for these conditions grouped to 331: Major Small & Large Bowel Procedures w/o CC/MCC R.W The same codes in ICD 10 group to MS DRG 349: Anal and Stomal Procedures w/o CC/MCC R.W

24 Surgical Increase Example Bleeding duodenal ulcer controlled with clips Acute duodenal ulcer with hemorrhage, without mention of obstruction Endoscopic control of gastric/duodenal bleeding K26.0 Acute duodenal ulcer with hemorrhage 0DQ98ZZ Repair Duodenum, Via Natural or Artificial Opening Endoscopic MS DRG: 379 G.I. Hemorrhage w/o CC/MCC MS DRG: 328 Stomach, Esophageal & Duodenal Proc w/o CC/MCC

25 Rise in DRG 981 Example Bleeding esophageal varix due to cirrhosis with banding MS DRG: 432 R.W MS DRG: 981 R.W DX with DX K74.60 with I Endoscopic excision/destruction of Lesion/tissue of esophagus 06L34CZ Occlusion Esophageal Vein with Extraluminal Device, Percutaneous Approach

26 Solutions Regular audits/quality Assurance (internal/external) Monthly meetings to provide feedback from results of coding reviews or quality assurance Hold coding luncheons on indexing new ICD 10 terms and discussion of ICD 10 PCS root operations Education is key: Anatomy and Physiology Disease Process AHA Coding Clinic advice Invite surgeons to give in service on how certain procedures are performed

27 FY 2017 ICD 10 CM/PCS Update ICD 10 CM Code Changes/ICD 10 PCS Official Coding Guidelines Changes/FY2017 MS DRG Changes

28 FY 2017 ICD 10 CM Code Changes Postprocedural and Intraoperative Hemorrhage/Hematoma categories Created a distinct sub category for postprocedural and intraoperative hematoma Complication of Care Codes Revised the term of to due to for implants and grafts Added codes to represent complications of stents for: Urinary Coronary Expansion of codes to represent erosion and exposure of specific implant and grafts

29 FY 2017 ICD 10 CM Code Changes Diabetes category changes Added the term uncontrolled to index The term Osteomyelitis is included under the concept of with in the alphabetical index Expansion of diabetic ocular diseases and disorders categories Retinal and Glaucoma Categories 84 new code additions

30 FY 2017 ICD 10 CM Code Changes Hypercholesterolemia Code added to represent familial Acute Vascular disorders of intestine Subcategory additions: Focal/diffuse Infarction/Ischemia Small/large Pancreatitis codes to include Necrosis Infection

31 FY 2017 ICD 10 CM Code Changes Creation of Category M84.75 (CC) Atypical femoral fracture Incomplete atypical femoral fracture Complete transverse atypical femoral fracture Complete oblique atypical femoral fracture Hypertension code expansion Hypertensive urgency I16.0 Hypertensive emergency I16.1 Hypertensive crisis I16.9

32 FY 2017 ICD 10 CM Code Changes Addition of Category M97. Periprosthetic fracture codes (CC) Hip joint Knee joint Ankle joint Shoulder joint Elbow joint

33 FY 2017 ICD 10 CM Code Changes Chapter 15 changes Abdominal/tubal pregnancy categories to include with or without intrauterine pregnancy New codes in categories for Gestational edema, Gestational proteinuria, preeclampsia and eclampsia to include complicating childbirth and puerperium

34 FY 2017 ICD 10 CM Code Changes Addition of NIHSS (National Institute of Health Stroke Scale) category R29.7 Glasgow coma scale score codes expanded to incorporate where the score was assessed Fracture code changes Addition of category to represent base of skull Laterality added to fractures of: Occipital condyle/occiput Orbital floor Facial Foot Concussion Deleted all codes to represent loss of consciousness greater than 31 minutes

35 ICD 10 PCS 2017 Guideline Change for Root Operation ICD 10 PCS Guideline B3.7 Control The root operation Control is defined as, Stopping, or attempting to stop, postprocedural or other acute bleeding. If an attempt to stop postprocedural or other acute bleeding is initially unsuccessful, and to stop the bleeding requires performing any of the definitive root operations Bypass, Detachment, Excision, Extraction, Reposition, Replacement, or Resection, then that root operation is coded instead of Control.

36 New 2017 PCS Root Operation Definition for Control ICD 10 PCS Value Control Definition Definition: Stopping, or attempting to stop, postprocedural or other acute bleeding Includes/Excludes: Control of post prostectomy hemorrhage, control of intracranial subdural hemorrhage, control of bleeding duodenal ulcer, control of retroperitoneal hemorrhage

37 Control used for Acute Bleeding Potential for more medical MS DRGs instead of surgical using other root operations Repair Drainage Extirpation Occlusion Possibility of grouping to the Extensive and Non Extensive OR procedure MS DRGs in 2017

38 Branches of a Body Part ICD 10 PCS Guideline B4.2 Where a specific branch of a body part does not have its own body part value in PCS, the body part is typically coded to the closest proximal branch that has a specific body part value. In the cardiovascular body systems, if a general body part is available in the correct root operation table, and coding to a proximal branch would require assigning a code in a different body system, the procedure is coded using the general body part value Examples: A procedure performed on the mandibular branch of the trigeminal nerve is coded to the trigeminal nerve body part value Occlusion of the bronchial artery is coded to the body part value Upper Artery in the body system Upper Arteries, and not to the body part value Thoracic Aorta, Descending in the body system Heart and Great Vessels

39 FISCAL YEAR 2017 MS DRG CHANGES

40 MS DRGs , and Reassignment Angioplasty of Extracranial Vessel Excision of Abdominal Arteries Excision of Retroperitoneal Tissue Occlusion of Vessels: Esophageal Varices

41 MS DRGs , and Reassignment Excision of Vulva Lymph Node Biopsy Obstetrical Laceration Repair

42 O.R. Procedures to Non O.R. Procedures Endoscopic/Transorifice Insertion Endoscopic/Transorifice Removal Tracheostomy Device Removal Endoscopic/Percutaneous Insertion Percutaneous Removal Percutaneous Drainage

43 O.R. Procedures to Non OR Procedures Percutaneous Inspection Inspection without Incision Dilation of Stomach Endoscopic/Percutaneous Occlusion Infusion Device Monitoring Device

44 Non O.R. Procedures to O.R. Procedures Drainage of Pleural Cavity Drainage of Cerebral Ventricle

45 Conclusion ICD 10 is a complex system that allows for greater detail/description of code set Patience is needed while this complex system is under intense review/revisions Growth and improvement is already underway Exciting and challenging opportunities

46 Thank You Wendy Deaton, RHIT, CCS, CCS P AHIMA Approved ICD 10 CM/PCS Trainer LexiCode, a SourceHOV Company Wdeaton@LexiCode.com