Transcript Step 1: Data Analytics

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
– Real results from clients
• Step 3: Education
– What your team needs to know
But First A Word About Data
Governance and Clinical
Documentation Integrity
Data Variables
Physician
Clinical
Clinical
Documentation
Documentation Program
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?
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
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?
Coding
Quality
Review
With increase
demand for coding
resources and
cash flow
demands, will
organizations have
an internal coding
quality review
process to identify
increased coding
errors?
Regulatory
Data
Normalization Change
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?
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
Clinical 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?
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
• 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 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.
ICD-10 Analytics Approach
Initiate
Define
assessment
scope
Identify
stakeholders
Assess
ICD-10 revenue
impact analysis
Documentation
audit
Recommend
Recommended
remediation or
mitigation of risk
Educational
mapping
Plan
Key activities and timing
Put plan into
action
Focus on highrisk MS-DRGs
ICD-10 Data Analytics
ICD-10
analytics
are
derived or analyzed using
the GEMS file, which
without audit is not a
reliable tool to identify DRG
shifts
ICD-10 Data
Analysis
Challenges
Data Variables
GEM mappings
There are defined data
provide all possible variables that when
iterations of ICD-10 applied to a set of
codes. Some are very specific assumptions,
unlikely. We’ve
will provide a more
learned from these
relevant outcomes
wild goose chases. analysis.
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
Use What We've
Learned
We’ve found common
(40 projects) coding
issues causing CC/MCC
loss or gain and DRG
shifts due to root
operations and coding
guidelines.
Next Steps
Prepare an action plan
for your hospital based
on your risks and our
experience.
Data Analytics – How its Done
• 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
Total Cases
I-9 CMI
I-10 CMI
98
1.84
1.56
CMI Increases
I-9 CMI
I-10 CMI
40
1.31
1.99
CMI Decreases
I-9 CMI
I-10 CMI
58
2.21
1.27
Post Audit Findings
Reason for
DRG Change
PDX Change
Cases
19
Add CC
6
Add MCC
3
Minus CC
15
Minus MCC
Root PX
DRG Logic
5
56
5
Scenarios
Specific examples of MS-DRG changes
discovered on I-10 re-code projects
MS-DRG SHIFT
Cardiology: Patient was readmitted
for treatment of post infarction
angina & CAD, 1 week status post
acute myocardial infarction
303 - Atherosclerosis
without MCC
RW 0.6034
282 - Acute
Myocardial
Infarction,
Discharged Alive
without CC/MCC
RW 0.7551
Relative Weight
GAIN
0.1517
ICD-10 Re-Code: What We Discovered
• MS-DRG changed due to timeframe established within ICD10 to indicate an acute myocardial infarction
– Even as a secondary diagnosis, the AMI will “drive” this MSDRG 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
• 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
•
•
•
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
Code indicates this is the subsequent MI
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 was the first MI
Potential Readmission Flag
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 SHIFT
Cardiology: Patient was admitted with
AMI and had coronary intervention with
four drug-eluting stents.
246 –
Percutaneous
Cardiovascular
Procedures with
drug-eluting stent
w/MCC OR 4+
vessels/stents RW
3.1830
247 - Percutaneous
Cardiovascular
Procedures with
drug-eluting stent
without MCC
RW 2.0408
Relative Weight
LOSS
1.1422
ICD-10 Re-Code: What We Discovered
• MS-DRG changed due to the fact that
even though patient had four drugeluting 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 lowerweighted DRG assignment in ICD-10
Documenting Procedures
• Clinical documentation for all procedures will
require documentation identifying the following:
 General physiological system or anatomical region involved
Body system
Rootoperation
Operation administration, dilation, drainage, biopsy,
 What type of procedure was performed root
excision, resection, bypass, transplantation
 The exact anatomical site of the procedure body partBody part

Right, left, bilateral
Laterality
 The technique used to reach the site surgical
Surgical appro
approachach open, closed, laparoscopic, percutaneous,
endoscopic, needle
 If a devDevice
ice was used, what site/area was the device placed (e.g. stent, graft, implant)
 If the procedure was for diagnostic purposes
Qualifier
Documenting Procedures
•
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.
No stent inserted
02703ZZ Dilation, Artery, Coronary, One Site
027034Z Dilation, Artery, Coronary, One Site
Stent inserted
Two codes
required to
identify procedure
on each artery
MS-DRG SHIFT
Medicine: Patient was admitted for
treatment of anemia secondary to
ESRD. Patient also has hypertension.
811 - Red Blood
Cell Disorders with
MCC
RW 1.2488
682 – Renal Failure
with MCC
Relative Weight
GAIN
RW 1.5401
0.2913
ICD-10 Re-Code: What We Discovered
• MS-DRG changed due to change in principal
diagnosis per sequencing instructions in ICD-10CM 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
ICD-10-CM uses the following table to identify
the stage of kidney disease
Chronic Kidney Disease Severity Stages
Stage 1
Stage 2 (mild)
Stage 3 (moderate)
Stage 4 (severe)
Stage 5
End stage renal disease
Chronic kidney disease, unspecified
Hypertensive Diseases
• Clinical documentation for hypertension in ICD-10CM should be described as accelerated, benign,
essential, idiopathic, malignant, and systemic
Documentation by physician indicates Essential
I10Essential (primary) hypertension
Hypertensive Diseases
• 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.
Clinical documentation indicates
hypertension and chronic kidney
disease
I12
N18.5
Hypertensive Kidney Disease
Chronic Kidney Disease, Stage 5
Clinical documentation requires the
correct staging of the chronic
kidney diseases
Hypertensive Diseases
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.
Code shows hypertension, heart disease, CHF, and stage 4
renal disease all combined in one code
I13.10
N18.4
I50.33
Hypertensive heart and chronic kidney disease with heart failure,
with stage I-IV CKD
Additional codes show stage of
Chronic Kidney Disease, Stage 4, severe
Acute on chronic diastolic heart failure
CKD and specificity of heart
failure
Chronic Kidney Disease with Hypertension
• ICD-10-CM presumes a relationship
between chronic kidney disease and
hypertension.
Disease
• Clinical documentation for
hypertensive kidney disease will also
require identification of the stage of
Stage of CKD
kidney failure
I12 Hypertensive Kidney Disease
N18.5 Chronic Kidney Disease, Stage 5
Hypertensive Heart and CKD Case Study
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.
Disease
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
Stage of CKD
Type of Heart Failure
MS-DRG SHIFT
Medicine: Patient was admitted
for treatment of anemia
secondary to lung cancer
812 - Red Blood
Cell Disorders
without MCC
182 – Respiratory
Neoplasms
without CC/MCC
RW 0.7985
RW 0.8275
Relative Weight
GAIN
0.029
ICD-10 Re-Code: What We Discovered
• 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
• 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
Acquired Aplastic Anemia
• 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 SHIFT
Surgery: Patient was admitted with
rectal bleeding and peritoneal abscess.
Treatment included partial resection of
ileum and lysis of peritoneal
adhesions.
329 – Major small
and large bowel
procedures with
MCC RW 5.1272
335 – Peritoneal
adhesiolysis with
MCC
RW 4.1615
Relative Weight
LOSS
0.9657
ICD-10 Re-Code: What We Discovered
• 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 SHIFT
Pulmonary: Patient was admitted with
exacerbation of COPD. Patient also had
accelerated hypertension which was
treated.
191 – COPD with CC
RW 0.9343
192 – COPD without
CC/MCC
Relative Weight
LOSS
RW 0.7120
0.2223
ICD-10 Re-Code: What We Discovered
• 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
•
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
• Terminology for many of the categories in gastroenterology have
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
• 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)
• 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
•
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
• 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
Disease
Location
No associated conditions
K57.32 Diverticulitis, large intestine, without perforation or abscess, without bleeding
Diagnosis
Quick Tip
Barrett’s Esophagus
With dysplasia
- Low grade
- High grade
Without dysplasia
Gastritis
Acute, alcoholic, chronic superficial, chronic
atrophic, associated hemorrhage
Gastroenteritis
Salmonella, viral, infectious, toxic, allergic, causative
agents, causative organism
Alcoholic liver disease
Alcoholic fatty liver, alcoholic hepatitis, alcoholic
fibrosis and sclerosis of liver, alcoholic cirrhosis liver,
alcoholic hepatic failure, associated ascites,
associated coma
Acute Pancreatitis
Alcohol-induced, biliary (gallstone), drug induced,
idiopathic
Documenting Procedures
• Clinical documentation for all procedures will
require documentation identifying the
following:
 General physiological system or anatomical region involved
Body system
Root
Operation administration, dilation, drainage,
 What type of procedure was performed root
operation
biopsy, excision, resection, bypass, transplantation
Body part
 The exact anatomical site of the procedure body part

Right, left, bilateral
Laterality
 The technique used to reach the site surgical
a
open, closed, laparoscopic,
Surgical approach
percutaneous, endoscopic, needle
 If a d
Deviceevicwas used, what site/area was the device placed (e.g. stent, graft, implant)
 If the procedure was for diagnostic purposes
Qualifier
Partial Large Bowel Resection
Operating Room Report indicates open right
hemicolectomy with end-to-end anastomosis
for treatment of large carcinoid tumor
Large Intestine, Right
No Device
ODT F 0 Z Z
Resection
Open Approach
No Device
Chronic Obstructive Pulmonary Disease
• 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
Disease
J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection
J20.2 Acute bronchitis due to streptococcus
Associated Condition/Organism
Emphysema
• 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
• 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
Asthma
• 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
Asthma
• Clinical documentation should identify
Asthma
of Daytime Symptoms
theSeverity
severity of Frequency
asthma
Intermittent
Less than or equal to 2 times per week
Mild Persistent
More than 2 times per week
Moderate Persistent
Daily. May restrict physical activity
Severe Persistent
Throughout the day. Frequent severe attacks limiting
ability to breathe.
Asthma Case Study
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.
Severity
J45.41
Acuity
Moderate persistent asthma with (acute) exacerbation
Z79.51 Long term (current) use of inhaled steroids
Use of Steroids
Respiratory System Documentation
Diagnosis
Quick Tip
Pneumonia
Causative Organism, manifestation of other
condition, lobar, multilobar
COPD
Associated acute respiratory infection, acute
exacerbation, Causative agents, long term use
steroids
Influenza
Type, causative organism, manifestations
Asthma
Type, intermittent, persistent, mild, moderate,
severe, causative irritant, exacerbation, associated
conditions, status asthmaticus
Respiratory Failure
Acute, chronic, with hypoxia, with hypercapnia,
Associated conditions, causative irritants
In Summary:
Clinical 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
– 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
– 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