Planning for ICD-10-/PCS: Clinical Documentation, Training, and Data Quality

Transcription

1 Planning for ICD-10-/PCS: Clinical Documentation, Training, and Data Quality Prepared by: Luisa DiIeso, RHIA, MS, CCS October 26, 2010 Agenda History and Benefits of Coding Classification Upgrade Key Categories of Changes and Clinical Service Considerations Documentation : Impact on Data Quality and Analysis Training Plans and Time Line Considerations Resources 1 2 History and Benefits of Upgrade to ICD-10: Basic Overview 30 Years Old Structural Limitations: Technology and Medical Treatment Quality of Care; Value Based Purchasing; Public Health; Research Benefits of ICD-10 Improved Measures Quality, Safety, Efficacy of Rx. Health Policy/Health Care Delivery Clinical Research Monitoring Resource Utilization 14,000 Diagnoses Codes Numeric Codes: Max. of 5 Digits 4,000 Procedure Codes Numeric Codes: Max. of 4 69,000 Diagnoses Codes Alphanumeric Codes: Always Start with a Letter (Exc. U) Max. of 7 Procedure Codes (ICD-10-PCS) Alpha/Numeric Codes: Start with a Number or Letter (Exc. O or I to avoid confusion with 0/1) Public Health/Risk 3 4

2 Key Categories of Changes: - Overview Key Categories of Changes: Basic Overview Combination Codes E11.21 Type II Diabetes with Diabetic Neuropathy I ASHD of Native Coronary Artery with Unstable Angina Extensions Encounter Episode Extensions: A Initial D Subsequent S - Sequelae Fracture Care Extensions (A, B, D, G, K, P, S) 5 J14 H. Flu Pneumonia L23.2 Allergic Contact Dermatitis, Cosmetics K11.20 Sialoadenitis, Unspecified L Cellulitis, Right Lower Limb S01.01xA Laceration Scalp, w/o FB, Initial Encounter Instructional Notes: Excludes 1: Not Coded Here Can t Use Both Together Excludes 2: Two Codes May Be Used Together 6 Key Categories of Changes: Diabetes Clinical Service Considerations Diabetes Clinical Service Examples Combination Codes Focus: Diabetic Complications Documentation Requirements: Type, Body System Affected, Complication Elimination: Dual Diagnoses Coding Controlled vs. Uncontrolled: No Longer Captured in Diabetic Retinopathy (Type II-Controlled) , Diabetic Ulcer L. Foot (Type I Diabetic- Uncontrolled) ; (laterality and severity of ulcer not captured in I-9) Diabetic Retinopathy (Type II) E11.21 Diabetic Ulcer L. Foot (Type I Diabetic- Uncontrolled) E10.621; L (laterality and severity of ulcer if documented/ specified) 7 8

3 Key Categories of Changes: Injuries, Poisonings, Other Categories of Changes: Injuries, Poisonings, Other Injuries Grouped by Body Part Extensions (A, D, S) Fractures Greater Anatomic Specificity; Laterality; Displaced/Non- Displaced Extensions: A, B, D, G, K, P, S Extension: Gustilo Classification Glasgow Coma Scale Codes: Traumatic Brain Injuries, CVA Extensions (0-4) 9 Poisonings, Adverse Effects, Underdosing Sequencing Changes for Adverse Effects Underdosing: Additional Code Required for Intent (Noncompliance; Dosage Failure During Medical/Surgical Care Extension (A, D, S) Initial, Subsequent, Sequelae Encounters 10 Adverse Effect/Underdosing: Diabetic Clinical Service Examples Underdosing Example I-9 Adverse Effect I-10 Adverse Effect I-9 Underdosing I-10 Underdosing Initial Admission for Steroid Induced Diabetes Uncontrolled = 1 st Listed Dx. 5 th Digit = Uncontrolled E932.0 Adverse Effect of Steroids Initial Admission for Steroid Induced Diabetes Uncontrolled T38.0x5A = 1 st Listed Dx. is Adv. Effect Drug - Initial E09.9 Drug Induced Diabetes (code does not reflect control) Admit for DKA (Type I) Secondary to Medication Noncompliance (pt. could not afford Insulin) DKA-Type I Uncontrolled; w/o Coma V15.81 Noncompliance with Medical Treatment Admit for DKA (Type I) Secondary to Medication Noncompliance (pt. could not afford Insulin) E10.10 DKA-Type I w/o Coma T38.3x6A Underdosing Insulin Initial Encounter Extension Initial Encounter 11 Z Intentional Underdosing d/t Financial Hardship 12

4 Service Specific Documentation Considerations: Injuries, Orthopedics Categories of Changes: Pregnancy, OB, Postpartum Data Capture/Forms Re-Design: ED; Cast Room; Orthopedic Clinic Areas; PT/OT; Character Extensions and Episodes of Care Medical Staff Communication/Mutual Training; Input Documentation Templates: Glasgow Coma Scale; Gustilo Open Fx. Classification; PCS Root Operations and Specific A&P Requirements Radiology Service Awareness (Degree Anatomic Specificity and Classification) Data Comparisons/Analysis: Adverse Effects 13 Trimester Designations 1 st =Less than 14 wks, 0 Days 2 nd = 14 wks, 0 Days to Less than 28 weeks 3 rd = 28 wks, 0 Days to Delivery Elimination of Episodes of Care for Most Categories of Codes Time Frame Changes Abortion/Fetal Death From 22 to 20 Weeks Early/Late Vomiting in Pregnancy From 22 to 20 Weeks Postpartum Period = 6 Weeks 14 Categories of Changes: Pregnancy, OB, Postpartum Pregnancy Example Extensions: Multiple Gestations 0 (unspecified) to 9 (other fetus) Specifically identifies Fetus Affected or Causing Condition (i.e. IUGR) Prenatal Forms Revisions OB Service Documentation Updates Comparative Data Analysis and Reporting Pre-Existing Diabetes vs. Gestational Diabetes 15 I-9 Gestational Diabetes Prenatal Encounter (18 weeks) for Gestational Diabetes and UTI, Pt. on Insulin Gestational Diabetes, Antepartum (episode of care) ; UTI in Pregnancy, Antepartum V58.67 Insulin I-10 Gestational Diabetes Prenatal Encounter (18 weeks) for Gestational Diabetes, Pt. on Insulin Gestational Diabetes in Pregnancy, Insulin Control (*) UTI in Pregnancy, 2 nd Trimester 16

5 Service Specific Documentation Considerations: OB/GYN ICD-10-PCS/Overview Prenatal Data Capture/Forms Revisions and Considerations: Consistent Documentation of Pertinent Conditions OB Service: Clinical Documentation Updates: Status of Current, Chronic, Historic Conditions Documentation Templates: Code Specific Requirements Comparative Data Analysis and Reporting Distinctions (Episode of Care vs. Trimester) Seven Character Alphanumeric Code Structure (Letters O, I Not Used) Section,Body System,Root Op.,Body Part, Approach, Device, Qualifier Example: Excisional Debridement Diabetic Skin Ulcer Left Foot (0HBNXZZ) Index = Tables/Grids of Options ICD-10-PCS/Example Project Management: Training Considerations Example: 0HBNXZZ Alpha Index: Excision 0 Medical and Surgical (Section Character 1) H Skin/Breast (Body System Character 2) B Excision (Root Operation- Character 3) Body Part Character 4 * Approach - Character 5 Device- Character 6 Qualifier- Character 7 Technical Training Coders Physicians Clinicians/Research/ CDI Audience Specific Overview Training Data Quality/Risk Management IS Compliance Ancillary Services K-Skin RLL L-Skin LLL M-Skin R. Foot N- Skin L. Foot X External Z No Device X Diagnostic Z No Qualifier 19 Training Budget Physician Practice Staff Other: Finance, Registration 20

6 Project Management: Technical Training Assessments Project Management: Flow Process Inpatient: /PCS Outpatient: /CPT Flow Process Productivity Considerations Recruitment; Retention; Future Staffing Projections Coding Workflow Process Coding Abstracting: Additional Data End-User Considerations Productivity Considerations: Consults/Data Quality DNR/DNI/CMO Discharge Disposition Specialty Data Ancillary Service Data: (Example: Radiology Exams CT/MRIs) IS/Order Entry Overlap 21 Tools 22 Project Management:Casemix and Productivity Project Management: Recruitment; Retention; Staffing Casemix and Productivity High Volume/High Dollar Services Categories of Documentation Challenges Current Revenue Cycle/AR Post-Review/Denials Mgt: Tracking Considerations: Streamlining Efforts Forms/Template Design and Re-Design IT Options (Clinical; CAC; Front End Charge Capture) Coordinated CDI Contract Management Payer/Provider Relations 23 Recruitment/ Retention: Staff Assessment Evaluations Future Shifts in Services and Work Types Point of Service Coding Individual Preferences Contract Services Considerations: Shortages Budget: FTE Additions; Flex Staffing; Contract Staffing Transition Recruitment: Behavioral Skill Sets Retention: Support 24

7 Training Plans: Activities Training Plans: Time Line Considerations I-10/PCS/AHIMA Recommendations (50 Hours) 16 Hours I-10-CM 24 Hours I-10-PCS 10 Hours Practice Application (Source: American Health Info. Mgt. Association Jan.,2010) AAPC Recommendations No Standardized Training Time to Date Credential Maintenance Required 2 Years (10/1/12-9/30/14) 75 Question I-10 Assessment (AAPC) /2011 Training Needs/Staff Assessments ID Training/Data Resource Individual(s) Staged Exposure to /PCS Root Operations: A&P Reinforcement Based on Key Services and Staff Composition Inpatient vs.outpatient Work Types Core Foundations Identify Current and Future Documentation Challenges Inpatient and Outpatient IS Considerations and Cautions: Electronic Health Record Templates and Design 26 Training Plans: Time Line Considerations Training Plans: Time Line Considerations 2011/2012 Plan Training Programs based on Audiences (Technical vs. Overview) Technical: Continued Exposure to Coding Fundamentals PCS Root Operations; Official Guideline Companion Review Coordinated Clinical Documentation Improvement Program Considerations; Clinical Service Specific Changes Overview: Data Quality Parallel Systems Planning; Vendor and Payer Considerations /2013 Intensive Technical Training (3-5 Day) Casemix/Service Specific Practice Examples (Potential Expansion Hours: Based on High Volume/High Dollar Services; Data Quality Testing/Partnerships: External Vendors, Internal Data Users; Payers 28

8 Data Quality/Analysis: Hospital Acquired Conditions (HACs) Data Quality/Analysis: HACs FB Retained After Surgery (998.4; E Code(s) ) 2 Codes General Classification External Cause of Injury Category of Procedure FB Retained After Surgery (T81.500A- T81.599A; T81.600A- T81.69xA) 53+ Codes Specific Codes as to Type or Category of Procedure Specific Encounter (Initial, Subsequent, Sequelae) Stage III/IV Pressure Ulcers (707.23/ Secondary Dx. Codes + Anatomic Site(s)) 2 Codes Two Separate Codes Secondary Diagnosis Code Reflects the Stage of Ulcer Laterality Not Captured (i.e. left/right hip, buttock, heels) Stage III/IV Pressure Ulcers (Example: L89.003/L89.004) 1 Code Combined Codes for Site and Stage of Ulcer(s) Laterality Captured if Specified (i.e. left/right hip, buttocks, heels) Data Analysis Categories of Changes: Data Quality/HACs Vascular/Central Line Associated Infections ( E Code(s)) 2 Codes Classification External Cause of Injury Vascular/Central Line Associated Infections (T80.21xA) 1 Code More Specific Character Extension Considerations: Initial (A), Subsequent (D), Sequelae (S) Sources and Resources /PCS AHIMA Newsletters: January, 2010, March,