Transcript Dreyer Medical Group

3M Health Information Systems, Inc.
Dryer Medical Group
Thomas C Kravis MD
Innovating
the
Innovating
Language
the
of Health
Language
of Health
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3M Health Information Systems
Impact of Accurate Complete Documentation
Profiling
Core
Measures
ICD-9-CM
ICD-10
RAC Audits
Quality
Management
Medicare
Advantage
Present-onAdmission
Indicators
2 Midnight
(CQI, TQM)
Regulatory
Compliance
Case
Management
Accountable
Care
Validating
LOS
Risk
Management
Critical
Pathways
2
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Reimbursement
3M Health Information Systems
Dryer documentation: All Payers Across the Continuum of Care
Out of Hospital
Hospital
Ambulatory
Outpatie
nt
Post Acute Care
Inpatient
Med/Surger
y
ASC
Skilled Nursing Facility
Psych
Plan
Payer
Population at Risk
Urgent Care
•
•
•
•
•
Physician
Office
Clinic
Hospital Outpatient
Home
Hospice
Day Surgeries
Emergency
Clinic visits
Observation
Aancillary services
Home
Healthcare
Rehab
Hospic
e
Physician
Office
Clinic
Physician E&M Documentation and Coding FFS>>RISK
3
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Dryer impact on services of All Payers Across the Continuum of Care
Dryer
Dryer
Dryer
Out of Hospital
Dryer
Hospital
Ambulatory
Outpatie
nt
Post Acute Care
Inpatient
Med/Surger
y
ASC
Skilled Nursing Facility
Psych
Plan
Payer
Population at Risk
Urgent Care
•
•
•
•
•
Physician
Office
Clinic
Hospital Outpatient
Home
Hospice
Day Surgeries
Emergency
Clinic visits
Observation
Aancillary services
Home
Healthcare
Rehab
Hospic
e
Physician
Office
Clinic
Physician E&M Documentation and Coding FFS>>RISK
4
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3M Health Information Systems
Total Financial Opportunity
Financial Opportunity by Payer
$2,100,000
$3,210,367
$2,800,450
MedPAR (2013)
Medicaid (3M Compare)
All Payer (3M Compare)
Payer
MedPAR (2013)
Medicaid (3M Compare)
All Payer (3M Compare)
Payer Financial
Opportunity
Financial
Opportunity @
75% Realization
$3,210,367
$2,800,450
$2,100,000
$8,110,817
SOI
variance
-5.80%
14%
-10%
ROM
variance
19.40%
-24%
-14%
ROI Type
Reduced Cost of Readmissions
Reduced Cost of HACs
Increased revenue due to better PSI scores
Increased revenue due to better SOI/ROM
Quality Indicators Financial Opportunity
$
$
$
$
$
ROI Amount
23,564
1,390,269
1,374,080
785,469
3,573,382
Total Opportunity: $14,697,083
5
5
Issue
Medical Necessity Edits
IP Only Procedure Edits
CCI Edits
Medically Unlikely Edits
Edit Financial Opp
Ineffective Modifiers
(no change in outcome)
Inappropriate Modifiers
Possible Missing
Modifiers
Modifier Financial Opp
Observation to IP Opp
Outpatient Financial
Opp
Number
11.026
6
984
1,077
Financial
Opportunity
$268,871
$123,190
$91.088
$2,128,644
$2,611,793
76
3223
4897
$193,720
$207,371
29
$3,012,884
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3M Health Information Systems
Physician Driven Solutions
 Assess
 Engage Stakeholders
 Strategy: Goals Metrics Quality
Measures
 Target service lines ICD 9/10
 High volum
 Physician profiles:
in patient & out patient
Assess
 Training: specialties
midlevel, house staff
 Physician Champion / Advisor
 Identify barriers to Physician
workflow
 Reassess
 Modify to meet goals
6
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Engage
Strategy
-
Goals
Metrics
Reports
Reengage
Retrain
3M Health Information Systems
3M™ Clinical Documentation Improvement
Assure all conditions are documented in the medical record
 To promote the appropriate assignment of
 Severity Of Illness (SOI) & Risk Of Mortality (ROM)
 Based on CMS’s rules
 Documentation Specialists
 “Real Time”
 Continuum of care
360
Physicians
7
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Unable to Code
Able to Code
Clinical Statement
8
Diagnostic Term
Multi-system organ failure
Liver failure, renal failure, resp failure
Severe respiratory distress
Respiratory failure : “Acute, due to……”
Hemodynamically unstable
Hypotension, “Shock, septic due to…..”
Will rehydrate
Dehydration, hypovolemia
Rhythm stable today
Ventricular tachycardia
“Urosepsis”
Simple UTI
↓ K = 2.0, will give KCL
Hypokalemia
LLL infiltrate
LLL pneumonia
↓ HgB 5.2, Transfuse
Acute or Chronic Blood Loss Anemia
Altered Mental Status
Dementia, Coma, Encephalopathy
Emaciated, weight loss,↓ Albumin ↓BMI
Protein Calorie Malnutrition
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General and Internal Medicine
9
1
Clinical Terms
Diagnostic Statement
(Documentation needs clarification)
(Accurate code may be assigned)
Continue home medications such as furosemide, HCTZ,
ACE inhibitor
Document specific diagnosis such as chronic
systolic/diastolic heart failure, CAD, atrial fibrillation,
angina, HTN
History of CHF, will continue home meds
Specify acuity (chronic, acute, acute on chronic); specify type
(systolic, diastolic, combined systolic and diastolic)
Cardiac enzymes elevated, elevated troponin, EKG
positive
Acute myocardial infarction (specify type such as STEMI or
NSTEMI; document specific artery involved such as LAD, left
circumflex; exact date of any recent AMI)
Acute coronary syndrome (ACS)
Clearly document intended diagnosis such as
intermediate/insufficiency syndrome, unstable angina,
coronary slow flow syndrome, myocardial infarction
Cardiac history
Clearly document specific diagnoses such as CAD, angina,
old MI (document date when MI occurred)
Atrial fibrillation
Specify type such as paroxysmal, persistent, chronic
Atrial flutter
Specify type such as typical (type I) or atypical (type II)
BP 70/40, ordered norepinephrine or dopamine for
support
Shock (specify type such as cardiogenic septic, hypovolemic)
A code may not be assigned based on abnormal laboratory results or diagnostic report findings alone. The physician
must document the corresponding diagnosis in the body of the medical record.
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Specificity and Severity of Illness
Diagnosis
Acute systolic and/or diastolic heart failure
Extreme
Moderate
X
Congestive heart failure
Decubitus ulcer Stage III or IV
X
X
Decubitus ulcer (site not specified)
X
COPD with acute exacerbation
X
COPD
Acute renal failure secondary to ATN or ESRD
X
X
Acute renal insufficiency
X
Acute blood loss anemia
X
Chronic blood loss anemia
Severe protein-calorie malnutrition
Malnutrition
10
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Minor
X
X
X
3M Health Information Systems
When do I document “other” diagnoses
…………. in the inpatient setting?
“additional conditions that affect patient care in terms
of requiring at least one of the following”:
― Clinical evaluation
― Therapeutic treatment
― Diagnostic procedures
― Extended length of hospital stay
― Increased nursing care and/or monitoring
11
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APR DRG : All Patient Refined DRGs
Severity of Illness (SOI) and Risk of Mortality (ROM)
3M™
MDC/APR MDC
316 APR DRGs
Subdivide each APR DRG
into subclasses
Severity of Illness Subclasses
Risk of Mortality Subclasses
1.
Minor
1.
Minor
2.
Moderate
2.
Moderate
3.
Major
3.
Major
4.
Extreme
4.
Extreme
1,258 Subclass Cells
12
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1,258 Subclass Cells
3M Health Information Systems
SOI and ROM are Independent
The 4 severity of illness and risk of mortality subclass are
calculated separately and may be different from each other.
Acute
Cholecystitis
SOI = 3
Major severity
of illness
ROM = 1
Low risk of
mortality
13
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Underlying Principle of 3M™ APR DRGs
Severity Of Illness (SOI) and Risk Of
Mortality (ROM) are dependent on the
patient’s underlying problems.
High SOI and ROM are characterized by:
(a) multiple serious diseases and
(b) the interaction among those diseases.
14
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Principal Diagnosis : "XYZ"
Impact of Secondary Diagnosis
example illustration only
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1
2
3
4
Severity of Illness
Minor
Moderate
Major
Extreme
1
2
3
4
Risk of Mortality
Minor
Moderate
Major
Extreme
Secondary Diagnosis-Diabetes Mellitus
Uncomplicated Diabetes
Diabetes w Peripheral Neuropathy
Diabetes w Ketoacidosis
Diabetes w Hyperosmolar Coma
Secondary Diagnosis-Cardiac Dysrhythmias
Premature Beats
Sinoatrial Node Dysfunction
Paroxysmal Ventricular Tachycardia
Ventricular Fibrillation
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Diabetic Neuropathy ICD-10
 “Diabetic neuropathy” = nonspecific code
― If known or suspected, document :
• Diabetic mononeuropathy
• Diabetic polyneuropathy
• Diabetic autonomic neuropathy
• Diabetic amyotrophy
― Type of diabetes as Type 1 or Type 2
― control status
Document :
• “inadequately controlled,”
• “out-of-control,” or
• “poorly controlled” and
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• Type with hyperglycemia.
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Medicare Severity Index Comparisons
System Hospitals
Advocate Christ MC
23.1%
Advocate Good Samaritan
2.5%
Advocate Lutheran General
8.8%
Advocate Trinity
-11.1%
Advocate South Suburban
-10.6%
Sherman Hosp.
-0.1%
-9.8%
Advocate Illinois Masonic MC
5.6%
Advocate Good Shepherd
-4.7%
Advocate Condell MC
-7.3%
-30%
-20%
Lower Than Expected
(Unfavorable)
-10%
0%
BroMenn RMC
10%
State Average
20%
30%
Higher Than Expected
(Favorable)
Source: 3MTM APR DRG Classification System and MEDPAR 2012
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Medicare Risk-Adjusted Mortality Analysis
System Hospitals
Advocate Christ MC
-24.8%
Advocate Good Samaritan
-8.7%
Advocate Lutheran General
-6.6%
Advocate Trinity
0.6%
-35.7%
Advocate South Suburban
-13.3%
Sherman Hosp.
29.6%
Advocate Illinois Masonic MC
-20.1%
Advocate Good Shepherd
-25.4%
Advocate Condell MC
72.7%
-90%
-60%
Lower Than Expected
(Favorable)
-30%
0%
30%
State Average
60%
BroMenn RMC
90%
Higher Than Expected
(Unfavorable)
Source: Risk Adjustment – by the 3MTM APR DRG Classification System and MEDPAR 2012;
Expected deaths are based on the State of Illinois’s average death rate, risk adjusted by the 3M APR DRG Classification System.
Data based on all cases using selection criteria. No inference is made or conclusion can be drawn about the significance of actual to expected mortality variance without further study.
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review only.
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Confidential
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Customer's
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3M Health Information Systems
Target Variances in ROM By Service Line Analysis: Example Cardiac
Medical Specialty
Behavioral
Cardiology
CT Surgery
Medicine
Neonatology
Neurology
Neurosurgery
Ophthalmology
Orthopedics
Pulmonary
Renal
Surgery
Transplant
Vascular
Women's Health
Total
Medicare
Volume
9
763
87
1,770
0
331
96
7
991
779
343
383
0
49
25
5,633
Actual
Deaths
0
40
6
75
0
5
0
0
7
19
5
10
0
0
1
168
Actual
Death
Rate
0.00%
5.24%
6.90%
4.24%
0.00%
1.51%
0.00%
0.00%
0.71%
2.44%
1.46%
2.61%
0.00%
0.00%
4.00%
2.98%
Expected
Deaths
0.3
32.8
3.5
92.7
0.0
12.6
2.9
0.0
14.2
54.3
12.6
18.2
0.0
1.7
0.9
246.7
Expected
Variance,
Death
In
Rate
Deaths
3.33%
-0.3
4.30%
7.2
4.02%
2.5
5.24%
-17.7
0.00%
0.0
3.81%
-7.6
3.02%
-2.9
0.00%
0.0
1.43%
-7.2
6.97%
-35.3
3.67%
-7.6
4.75%
-8.2
0.00%
0.0
3.47%
-1.7
3.60%
0.1
4.38%
-78.7
Variance,
As A %
Of Expected
-100.0%
22.0%
71.4%
-19.1%
0.0%
-60.3%
-100.0%
0.0%
-50.7%
-65.0%
-60.3%
-45.1%
0.0%
-100.0%
11.1%
-31.9%
Data based on all cases using selection criteria. No inference is made or conclusion can be drawn about the significance of actual to expected mortality variance without further study.
19
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RISK OF MORTALITY
APR DRG 194, HEART FAILURE
State Average
APR DRG
Subclass
1
2
3
4
Total
Cases
2,268
15,761
13,606
5,300
36,935
Actual
Deaths Mortality Rate
4
0.2%
101
0.6%
402
3.0%
758
14.3%
1,265
3.4%
Example Hospital
Actual
Cases
9
100
83
32
224
Actual
Expected Actual Mortality
Deaths Deaths
Rate
0.0
0
0.0%
0.6
1
1.0%
2.5
2
2.4%
4.6
8
25.0%
7.7
11
4.9%
Quality
Documentation or
Coding
20
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Mortality
Rate %
Variance
0%
67%
-20%
74%
43%
3M Health Information Systems
Heart Failure
Common
Impacts all specialties
Driver of SOI ROM
Quality (PPR)

Acuity
Acute, chronic, acute on chronic/exacerbation

Type
Systolic and/or diastolic heart failure

Etiology If known or suspected:

Collaboration and clinically effective: Core measure ;Potential Preventable Readmission (PPR);continuum
― Ischemia
― Anemia
― Kidney failure
― Hypertension
― Myocarditis
― Structural heart disease
― Supraventricular tachycardia
― Cardiomyopathy : Alcoholic congenital, congestive, constrictive, dilated, endomyocardial,
idiopathic hypertrophic sub aortic stenosis ,nonobstructive hypertrophic, obstructive hypertrophic, restrictive
21
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Acute Kidney Failure Documentation
Impact of Appropriate Documentation on SOI and ROM and Physician Scorecard
― Acute renal “insufficiency”
SOI 1; ROM 1
― Acute kidney injury (AKI)
SOI 3; ROM 3
― Acute kidney failure
SOI 3; ROM 3
Versus
― Acute kidney failure “ due to”
22
• Acute tubular necrosis
SOI 4; ROM 4
• Cortical necrosis
SOI 4; ROM 3
• Medullary (papillary) necrosis
SOI 4; ROM 3
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Learning objective:
Heart Failure
 Sample Physician: SOI less than Peers
 Respond to request for clarification
 Target for Training/guidance
 Document the drivers of SOI
 Treat underlying cause: clinical effectiveness
Top 10 secondary diagnoses from National Norms driving SOI subclass 3 and 4
194 - Heart Failure
SOI
Subclass
1
2
3
4
Overall
Cases
Actual Days
1
10
3
0
14
1
40
19
0
60
ALOS
1.0
4.0
6.3
0.0
4.29
Peer Comparison
Sample Physician
Peer Group 1 - Cardiology
Peer Group 2 - Physician Practice Group
Peer Group 3 -National
Distribution
7%
71%
21%
0%
100%
Actual
Weight
0.4868
Total
Weight
0.4868
0.6127
0.9591
2.0096
6.1270
2.8773
0.0000
9.4911
Severity
Index
0.6779
Variance
0.7311
0.7982
0.8695
--7.3%
-15.1%
-22.0%
Lower SOI
23
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Subclass 3
Dx Code

5849
486
42833
42823
4271
5119
42831
42821
2639
51883
Subclass 4
Description
Dx Code
Description
Acute Kidney Failure Nos
Pneumonia, Organism Nos
Ac On Chr Diast Hrt Fail
Ac On Chr Syst Hrt Fail
Parox Ventric Tachycard
Pleural Effusion Nos
Ac Diastolic Hrt Failure
Ac Systolic Hrt Failure
Protein-cal Malnutr Nos
Chronic Respiratory Fail
51881
41071
5070
51884
5845
4275
78551
262
99592
570
Acute Respiratry Failure
Subendo Infarct, Initial
Food/vomit Pneumonitis
Acute & Chronc Resp Fail
Ac Kidny Fail, Tubr Necr
Cardiac Arrest
Cardiogenic Shock
Oth Severe Malnutrition
Severe Sepsis
Acute Necrosis Of Liver
3M Health Information Systems
"Probable" "Possible" "Suspected"
"Unable to Rule Out"
 Inpatient application:
― Code these conditions as though they exist – applies to
hospital setting only
― If condition is ruled out, it may not be coded
 Dryer Outpatient application:
― Must code signs/symptoms, not the suspected
condition
24
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Chest Pain Alternatives
Aortic
Stenosis
MS-DRG
306/307
RW = 1.3659
Biliary Colic
MS-DRGs
444/445/446
RW = 1.6060
Cardiac Cath
MS-DRGs
286/287
RW = 2.1058
GERD
Gastritis
MS-DRGs
391/392
RW = 1.1903
Anxiety
MS-DRG 880
RW = 0.6388
Psychogenic
Angina or
Pericarditis
MS-DRGs
314/315/316
RW = 1.8941
Chest Pain
MS-DRG 313
RW = 0.5992
Costochondritis
Tietze’s Disease
MS-DRGs
205/206
RW = 1.3935
Pulmonary
Embolism
MS-DRGs
175/176
RW = 1.5346
Pleurisy
MS-DRGs
193/194/195
RW = 1.4550
Shingles
MS-DRGs
595/596
RW = 1.5958
25
Anterior CP
Pleuritic CP
Chest Wall Pain
MS-DRG 204
RW = 0.6780
CAD
MS-DRGs
302/303
RW = 1.0287
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Angina
MS-DRG 311
RW = 0.5649
Cardiac
Arrhythmia
MS-DRGs
308/309/310
RW = 1.2088
3M Health Information Systems
Documentation for Pulmonary Embolism

Document acuity:
―
―
―

Specify meaning of “history of PE”
―
―
―

Chronic PE continuing to be treated, is
being prophylactically treated
or patient no longer has the condition
“chronic pulmonary embolism” vs.
“healed PE” or “old PE”
Specify type:
―
―
―
26
Acute
Chronic
Healed/old
Saddle
Septic
Postprocedural or due to a vascular
device
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
Specify if related to any other
condition such as:
―
―
―
―
―
―

Atrial fibrillation
DVT (specify site and laterality)
Hypercoagulable state
Malignancy/Orthopedic
surgery/Sepsis/Trauma
Not POA and after an operative
episode is considered a patient
safety indicator (PSI 12)
A hospital acquired condition
(HAC) when following certain
orthopedic procedures
Document presence of cor
pulmonale (acute /chronic)
3M Health Information Systems
Acute Coronary Syndrome (ACS) – A Nonspecific Code in ICD-10
 ACS or “acute ischemic heart disease” translates in ICD-10-CM
to a nonspecific code
 Document a diagnosis which may more accurately describe the
patient's condition:
 Intermediate or insufficiency coronary syndrome
 Unstable angina
 Coronary slow flow syndrome
 Myocardial infarction
 Other condition?
27
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Myocardial Infarction
Myocardial infarction documentation and coding
will need to include:
 Type of infarction
 STEMI
ICD-10-CM
Myocardial Infarction
9 codes for initial (I21) and
5 codes for subsequent (I22)
 NSTEMI
 Age of infarction
 If within 4 weeks coded as initial
 If older than 4 weeks coded as “old”
 Specific site of myocardium involved
 Anterior wall
 Inferior wall
 Coronary artery involved
28
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Drug Underdosing
 New clinical terminology in ICD-10
 Identifies intentionally or unintentionally taking less of a
medication than prescribed
 Document intentional versus unintentional or accidental
― Intentional
• For example, due to financial hardship
― Unintentional or accidental
• For example, due to age related disability
– Age-related dementia
– Rheumatoid arthritis of hands
29
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Clarification impact
Query:
“Patient had a magnesium level of 1.6 and received magnesium sulfate.
Please provide a corresponding diagnosis for the treatment provided.”
** CDI seeks documentation of “ hypomagnesemia “
Cardiac Procedure
30
Impact w/o Response to Query
Impact w/ Response to Query
 RW = 2.9797
 RW = 2.9797
 GLOS = 8.98
 GLOS = 8.98
 SOI = 2 Moderate
 SOI = 3 Major
 ROM = 2 Moderate
 ROM = 2 Moderate
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Definitions
 Bacteremia – nonspecific laboratory finding of bacteria in the blood
with no signs of illness
 Septicemia – systemic disease associated with the presence of
pathogenic microorganisms in the blood*
 Sepsis – SIRS due to an infection.* An infection-induced syndrome
in the presence of two or more manifestations of SIRS without
organ dysfunction. Septicemia that has advanced to involve two or
more manifestations of SIRS.
 Severe sepsis – sepsis with associated acute organ dysfunction*
 Septic shock – severe sepsis in which the cardiovascular system
begins to fail, blood pressure drops, and vital organs are deprived
of adequate blood supply*
*Definitions per NCHS/CDC
31
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Sepsis Continuum
 Sepsis is classified in ICD-10 as:
― Streptococcal Sepsis (group A, group B,
Streptococcus pneumoniae, other
streptococcal) or
― Other Sepsis (e.g., MRSA,
Pseudomonas)
 Severe sepsis
― Document any associated organ
dysfunction and
― Document presence of septic shock
32
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3M Health Information Systems
3M APR DRG Classification System
Risk-Adjusted Mortality Example
APR-DRG 139 - OTHER PNEUMONIA
Illinois
APR DRG
Subclass
1
2
3
4
Total
Cases
3,549
11,118
8,186
2,123
24,976
XYZ
Actual
Deaths Mortality Rate
0
0.0%
98
0.9%
297
3.6%
352
16.6%
747
3.0%
Actual
Cases
22
84
78
23
207
Actual
Expected Actual Mortality
Deaths Deaths Rate
0.0
0
0.0%
0.8
0
0.0%
2.8
4
5.1%
3.8
6
26.1%
7.4
10
4.8%
Mortality
Rate %
Variance
0%
-100%
43%
58%
37%
Improved documentation may have increased the ROM to a higher level
Data Source: 3M APR DRG Classification System utilizing MEDPAR 2012 data
Data based on all cases using selection criteria. No inference is made or conclusion can be drawn about the significance of
actual to expected mortality variance without further study.
33
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3M Health Information Systems
Pneumonia: Complex vs. Simple
 Complex Pneumonia
Higher SOI; consume more resources
RW = 1.9934
― Anaerobic pneumonia
― Aspiration pneumonia
― Gram-negative pneumonia, which includes:
• E. coli pneumonia
• Hemophilus parainfluenzae pneumonia
• Legionnaires’ disease
• Moraxella catarrhalis
• Proteus pneumonia
• Serratia marcescens pneumonia
• Xanthomonas pneumonia
― Klebsiella pneumonia
― Pseudomonas pneumonia
― Staphylococcus pneumonia
MRSA
• MSSA
•
34
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 Simple Pneumonia
Lower SOI weight; consume less
resources
RW = 1.4550
―
―
―
―
―
―
―
―
―
Chlamydia
Gram-positive pneumonia
Hemophilus influenzae pneumonia
Mixed bacterial pneumonia
Mycoplasma pneumonia
Pneumococcal pneumonia
RSV Pneumonia
Streptococcus pneumonia
Vancomycin resistant Enterococcus
(VRE)
― Viral pneumonia
― Unspecified pneumonia, CAP, HAP
3M Health Information Systems
Neoplasms
Admit for Chemotherapy vs. Malignancy
 Document all reasons for admission:
― Chemotherapy/radiotherapy/immunotherapy
― Pain control/management
― Symptoms/conditions related to malignancy (e.g.,
weakness, ascites, cachexia, malnutrition, anemia [specify
type], dehydration)
― Staging
35
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3M Health Information Systems
Syncope Alternatives
Arrhythmia
MS-DRGs
308/309/310
Heart Failure
MS-DRGs
291/292/293
RW = 1.4609
Alcohol Abuse
MS-DRGs
896/897
RW = 1.4155
Hypotension
MS-DRGs
314/315/316
RW = 1.7589
36
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Rights Reserved.Reference
3M Confidential – for customer's
internal review only.
Note:
InAllQuick
Guide
Further use or disclosure requires prior approval from 3M.
RW = 1.2188
Syncope
MS-DRG 312
RW = .7215
Anemia
MS-DRGs 811/812
RW = 1.2431
Dig Poisoning
MS-DRGs
917/918
RW = 1.4449
Dehydration
MS-DRGs 640/641
RW = 1.0896
Stroke or CVA
MS-DRGs 64/65/66
RW = 1.8258
3M Health Information Systems
Documentation Opportunities ICD-10 for TIA
Document specific known or suspected cause:
•
Vertebro-basilar artery syndrome
― Carotid artery syndrome
― Precerebral artery syndrome
― Amaurosis fugax
― Transient global amnesia
― Other cerebral ischemic attacks and syndromes
 Document the cause and effect
― Link the patient’s TIA to a specific precerebral artery disease (e.g., occlusion, stenosis)
― Document possible probable or suspected ( if diagnosis TIA or CVA/cerebral
infarction)
37
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ICD-10 Cerebral Infarction
 What remains the same ICD-9 ? Etiology = thrombosis or embolism
 What’s new
― Site = precerebral, cerebral, or cerebellar arteries
If precerebral:

Vertebral, basilar, carotid, or other
If cerebral:

Middle, anterior, or posterior
― Laterality = right or left, when applicable
― Intraoperative or
― post procedural cerebral infarction occurring
― during cardiac surgery or
― another type of surgery
38
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ICD-9 vs. ICD-10 Structural Changes
 ICD-9 (Diagnoses)
#
#
#
#
#
3-5 characterst
Category
etiology, site,
manifestation
 ICD-10 (Diagnoses)
a
#
a/#
a/#
a/#
a/#
a/#
3-7 characters
Category
39
etiology, site,
manifestation
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extension
3M Health Information Systems
Potentially Preventable Events
3M TM Potentially Preventable
Readmissions (PPRs)
3M TM Potentially Preventable
Complications (PPCs)
3M TM Potentially Preventable
Visits (PPVs)
3M TM Potentially Preventable
Initial Admissions (PPAs)
3M TM Potentially Preventable
Services (PPSs)
40
4
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Population
Focused
Preventable
Events
3M Health Information Systems
MD Statewide Experience: PPC Cost Savings
Source: Health Affairs December 2012
Health Affairs, December 2012 31:12; doi: 10.1377/hlthaff.2012.0357
41 Source:
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3M Health Information Systems
Potentially Preventable Emergency Department Visits
(PPVs) by Enhanced Ambulatory Patient Group (EAPG)
42
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3M Health Information Systems
Manage Potentially Preventable Admissions (PPAs)
by APR-DRG
43
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3M Health Information Systems
Example: post acute care coordination
Recommendations for Dryer Outpatient Care: PPRs
44
17
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3M Health Information Systems
Reduce Potentially preventable costs
$3,500
$3,000
$2,500
$2,000
$1,500
$1,000
$500
$0
Northwestern
Potentially preventable
ICU Days/Costs
Loyola
St. Mary's
Med/Surg
ICU/CCU
Pharm
Radio
Lab
St. Joseph
St. Elizabeth
Benchmark
$400
45
$600
$800
$1,000
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$1,200
$1,400
$1,600
St. Mary's Welborn
3M Health Information Systems
3M 360 Encompass Natural Language Processing (NLP)
Inpatient > Outpatient
Physician Workflows
Tests
Labs
Interfaces
3M 360 Encompass processes EHR
for codes, documentation improvement
and
Quality metrics.
Scanned
Physician
EHR Workflow
Integration
Documentation
and Data
Quality
Extracted and
Codified Data
Compliance and
Quality
Analytics
Daily Hospital Workflows
CDI Reviewer
Workflow Application
46
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Coder CAC
Workflow Application
3M Health Information Systems
Case Study: Specificity Query Impact
Patient Overview
Improved Specificity
Acute Kidney Failure
Acute Kidney Failure
Urosepsis (UTI)
Sepsis
Heart Failure
Acute systolic heart failure
Chronic Kidney Disease
Chronic Kidney Disease, Stage IV
Old myocardial infarction
Old myocardial infarction
MS DRG
683: Renal Failure with CC
682: Renal failure with MCC
APR DRG
460: Renal Failure
460: Renal Failure
Severity of Illness
3: Major
3: Major
Risk of Mortality
2: Moderate
3 Major
National Mortality Rate
0.7%
3.9%
Principal Diagnosis
Secondary Diagnoses
Unspecified Diagnoses
47
Original Summary
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Improved
Specificity and
Quality report
3M Health Information Systems
Case Study: Specificity Query Impact
Patient Overview
Principal Diagnosis
Original Summary
Sepsis fever dx infiltrate RR
access muscles pO2 60
Acute Respiratory Failure
Secondary Diagnoses
Unspecified Diagnoses
MS DRG
Weight
APR DRG
Weight
871: Septicemia
1.8803
720: Septicemia
1.3272
3: Major
Risk of Mortality
3: Major
National Mortality Rate
7.9%
Severe sepsis
Acute Respiratory Failure
Influenza with Pneumonia
Acute on Chronic, Diastolic CHF
CHF
Severity of Illness
Patient Outcome
49
Influenza with Pneumonia
Improved Specificity
Patient expired in hospital
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871: Septicemia
1.8803
720: Septicemia
3.0499
4: Extreme
4: Extreme
30%
Patient expired in hospital
Accurate capture
SOI and ROM
More appropriate
Reflects clinical
condition
Improves hospital
and physician
quality and
outcomes
reporting
3M Health Information Systems
Care is Delivered to the Member
(face-to-face encounter)
Medicare Advantage HCCs
Care and Diagnoses are Documented
in the Chart / Progress Notes
ICD-9 CM codes are submitted on
Claims based on the face-to-face
encounter clinical findings
Plan & Providers can Deliver
better care
And reimbursement is received
Claims data diagnosis codes are
converted to HCC codes
CMS Calculates MA Risk
Adjustment
HCC codes data is submitted to CMS
50
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50
3M Health Information Systems
Medicare Advantage and HCCs
.
 A member is “flagged” with an HCC if an ICD-9 diagnosis code has
been submitted to CMS for the prior year that maps to the HCC.
 For example, ICD-9 code 250.00 (diabetes mellitus without mention of
complication) maps to HCC 19. commercial??
 If a member has this ICD-9 code submitted (and has no other diabetesrelated ICD-9 code), then that member’s risk score would increase by
0.162.
 This would result in an additional payment to a typical MA plan of about
$100 per member per month (PMPM).
51
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Analytics
52
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From Value Based Purchasing to Accountable Care-
The PPR Roadmap
Prospective
Payment
Risk Adjustment for
IP and OP
Retrospective PPR
Complete and
Accurate coding
Pay for
Performance
Process Improvement
PPR Integration of
Clinical and Data
Quality
Quantifying PPR
costs
Pay for
Outcomes
Risk Sharing
Contracts
Quality Outcome
Measurement
Improve efficiencies
Concurrent PPR
Predictive PPR
PPR Benchmark
Improvement and
Analytics
Integrated Alerts
Predicting Costs
PPR in Patient
Focused Episodes (
Population Risk)
Preventable Events
53
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Bundled
payments/ACO
s
Cost efficiency
across the continuum
or care
Predicting Bundle
risks
Preventables have
full integration in
Physician/EHR
workflow
Automate data
quality