1. Game of Documentation:Winter is Coming Surviving ICD-10Nick van Terheyden, MD (aka @drnic1)Chief Medical Information OfficerNuance Communications, Inc.

2. Harrison Ford Injury and ICD-10 Injured by the Hydraulic Door of theMillennium Falcon 2014 ICD-10-CM Diagnosis CodeV95.40XA Unspecified Spacecraft Accident InjuringOccupant, Initial Encounter 3. Changes in the Healthcare Systemand What it Means to You Entire healthcare system in transition Meaningful use in full swing EHR adoption is mandatory Entire IT infrastructures are being replaced Transition to pay-for-performance and value-basedmodels Hospitals and Healthcare facilities have to do more with less Fair reimbursement in a tighter regulatory environment 4. Survey QuestionWhere are you on the continuum of preparingyour office for ICD-10?A. Were readyB. We have a plan and are onour way to being readyC. We might be ready becauseD. Weve talked about itE. Uh, when do we have to start?F. No need to prepare.. it will be delayed again 5. ICD-10 History ICD-10 adopted by the World Health Organization in 1990 Implemented in the United Kingdom in 1995 Australian modification released in 1998 Canadian version 2001 US development US evaluation by the National Center for Health Statistics began 1994 Numerous subsequent versions Final implementation date 10/01/14 The official documents International Classification of Diseases, Tenth Revision, ClinicalModification [ICD-10-CM] International Classification of Diseases, Tenth Revision, ProcedureCoding System [ICD-10-PCS] 6. Some ICD-10 New Features Combination codes (etiology and manifestation) Type 1 diabetes with diabetic nephropathy Laterality Left, right, bilateral, unspecified (4) Episode of care Initial (open, closed), subsequent (routine, delayed,nonunion, malunion), treatment of sequela Trimesters for obstetrical care Clinical changes Time frames for acute myocardial infarctions 7. The Coder / Physician DichotomyCoders Physicians ICD-9 is 35 years old with outdatedterminology Coders must learn current anatomy,pathophysiology, terminology, etc. Coders must understand the entireICD-10 system Coders must think expansively of allpossible code options The burden on coders is tremendous ICD-10 includes modern terminology Physician practice has evolved eventhough the coding system wasstagnant Physicians need to learn what isapplicable to their specialty Physicians tend to be linear andhierarchical The burden on physicians ismanageable 8. Acute Myocardial InfarctionICD-9-CM ICD-10-CM Acute Myocardial Infarction (30 codes) Primary axis: Site involved (10) Anterolateral, other anterior wall,inferior wall, inferoposterior wall,other inferior, other lateral, trueposterior, subendocardial, other,unspecified) Secondary axis: episode of care (3) initial, subsequent, unspecified Acute Myocardial Infarction (14 codes) Axes of classification: Initial MI (9) STEMI (8) (by site) Anterior (3) L main, L anterior descending, other coronary artery Inferior (2) Right coronary artery, other Other (2) Left circumflex, other sites Unspecified (1) NSTEMI (1) Subsequent MI (5) Anterior wall Inferior wall Non-STEMI Other sites UnspecifiedSubsequent AMIAMI occurring within 4 weeks ofprevious AMI, regardless of site 9. Why Physicians Are Liking ICD-10 Codes are more specific They link etiology to disease (staph pneumonia) They link manifestation to etiology (hypertensive heart disease) They make more clinical sense Injuries grouped by anatomical site rather than type of injury Laterality has been added to relevant codes They are up to date Code titles reflect new technology & recent terminology Codes have been added to describe postoperative or post-proceduralconditions ICD-10 is essential for clinical research and epidemiology 10. High Level Message ICD-10 implementation will improve patient care ICD-10 is not being imposed on physicians by thehospital The hospital is collaborating to reduce impact onphysicians by building knowledgeable infrastructure Independent physicians need to focus now on theirpractice, specifically their systems and staff Further education will be coming at the appropriatetime for every specialty and subspecialty. 11. The Risk to Providers The only way your clinical performance is adjudicated by thoseoutside of your medical staff is through Billing Data If you do not get the billing data correct then your performancewill be adjudicated incorrectly This will be vital in the changing healthcare environment My patients are sicker is no longer an acceptable excuse forless than expected performance because severity adjustment isbuilt into the coding system But only if you get it right In a population based payment system those that have less thanexpected performance in quality and cost will be marginalized It would be a shame for your hospital and clinicians were to beaffected just because you didnt understand the Documentation,Regulatory, and Compliance environment we live in today 12. Feds to Allow Use of Medicare DataTo Rate Doctors USA Today 12/5/11The federal government announcedthat Medicare will now allow use of itsextensive medical claims database byemployers, insurance companies and consumer groups toproduce report cards on local doctors and hospitals.By analyzing masses of billing records, experts can glean such criticalinformation as how often a doctor has performed a particular procedure andget a general sense of problems such as preventable complications.Compiled in an easily understood format and released to the public,medical report cards could become a very powerful tool for promotingquality care and reducing wasteAnnounced by Marilyn Tavenner Acting Administrator of CMS 13. Sebelius and Holder specificallywarned hospitals and doctorsagainst cloning patients, orsimply copying one patientsinformation into multiple patientsrecords, a practice that is far easierusing electronic records than usinga pen and paperWheres the narrative?Wheres the physicians clinicalimpression? 14. Unfair Advantage? United Healthcare BootsThousands of MDs From Its Part C Medicare Plans"Our decisions are based on providing a network of physicianswhom we can collaborate with to help enhance health planquality, improve healthcare outcomes, and curb the growth inhealthcare costs," he wrote. "Factors include geography andensuring ready access to care, the relative performance ofproviders on a range of industry quality metrics, and a provider'sability to deliver high-quality care for the most members in themost cost-efficient manner.Medscape/Heartwireauth. Steve Stiles; October 28, 2013 15. The Healthcare Environmenthas ChangedThe Hospital Chart Has changed from an accounting of the care we were providing with limitedinformation that could be put into a written record to an expansive record fullof data and information that no one can know every data point in it Yet Physicians are responsible for every data pointThe Environment With all the information available in the record others have the ability to cometo conclusions about the care you provided based on that information. If you let the record tell the story with just its information and Physiciansare not discussing their judgment in that record then their decisions willmore likely be questioned by outsider reviewer Fraud Enforcement Malpractice Denial 16. CodingSystemsUnderstanding The System The MS-DRG system Medicare Severity-Adjusted DiagnosisRelated Groups 17. MS DRGs:DRG Assignment Based Upon Medicare Severity Diagnosis Related Groups (MS-DRGs) The Principle Diagnosis or Procedure; plus Severity (Acuity) - CC or MCCs DRG Assignment DRGs are groups of diagnoses determined by Medicare to berelated clinically and have similar resource consumption Many different diagnoses exist within one DRG One DRG per hospitalization, assigned at discharge Each DRG is assigned a Relative Weight (RW) Average of 1.00 Originally designed for hospital payment The RW has become the proxy for severity of illness 18. Co-Morbidities Drive Severity Typical Minor Comorbidities Most Infections Hypoglycemia Transient Visual Loss Chronic Kidney Disease Chronic Heart Failure Unstable AnginaTypically add complexity to thecare of the patient but not highdegree of severity Typical Major Comorbidities Septicemia Meningitis DKA Acute Heart Failure Acute Kidney Failure Acute MITypically add significant complexity tothe care and add significant severityand Risk of Mortality.Can be a main driver of care withPrinciple Dx. 19. General Diagnosis that are NoLonger Codeable CHF COPD Renal Insufficiency Since 2007 they must be defined to end up as eithera minor or major CC. If they are not clarified theycan not be used and you do not get credit for thecomplexity. But clinicians should not stop using them because theywill prompt someone to ask so you receive credit 20. The Importance of What We WriteNo Dx Vital Sign Lab Value Symptom 75y/o chronic lung disease w fever, leukocytosis, SOB with hypoxia andaltered mental status. 75 y/o with Exacerbation of COPD and chronic respiratory failure; nowcomplicated by acute pneumonia, probably Gram negative in view of age,underlying disease and recent hospitalization. Now presents with probablesepsis, with acute septic encephalopathy as well.MCC21Clinical FindingPrincipal DxCCCCMCCLab Value204 RESPIRATORY SIGNS & SYMPTOMS 0.67871SEPTICEMIA OR SEVERE SEPSIS W/O MV 96+HOURS W MCC1.91 21. THE QUALITY PERSPECTIVETHE EFFECT OFDOCUMENTATION ONOUTCOME PERFORMANCEWhat Happens if youdont get it right 22. What is a Severity AdjustedOutcome Measure Severity adjusted outcomes are usually expressedas an Index Expected outcome, such as mortality, is determined bylooking at similar MS-DRGs with the same level ofcomplexity and determining the performance across alarge database Level of Complexity within a MS-DRG is determinedby vendors using APR-DRG or 4 levels of severity foreach DRG or Statistical Regression 23. What is a Severity AdjustedOutcome Measure? Once you have established the expected outcome of a MS-DRGat similar level of complexity then your observedoutcome can be compared as a ratio Observed Outcomes/Expected Outcome = Severity AdjustedOutcome Index Determining your performance just becomes simple math If your Index is less than 1 meaning your expected outcome wasgreater than your observed then your performance is better thanexpected If your index is greater than 1 meaning your observed outcome isgreater than expected then your performance is worse than expected 24. Effect of Accurate Documentation331 Major Small and LargeBowel Procedure WOCC/MCCon OutcomesSecondary DX CHF 1.64 0.13% 5.67329 Major Small and Large BowelProcedure W MCCRel Wt ExpMortRel Wt ExpMortExpLOSExpLOSSecondary DX Acute SystolicFailure5.26 9.51% 13.59330 Major Small and Large BowelProcedure W CCRel Wt ExpMortExpLOSSecondary DX Chronic SystolicFailure2.57 0.73% 7.79*Exp Outcome Values based on specific Population with Proprietary analysis of Severity May vary with different population andassessment Methods For illustrative purposes only based on real data 25. Effect of Accurate Documentation331 Major Small and LargeBowel Procedure WOCC/MCCon OutcomesSecondary DX CHF 1.64 0.13% 5.67 $12851 8.93% $10,824329 Major Small and Large BowelProcedure W MCCRel Wt ExpMortRel Wt ExpMortExpLOSExpLOSExpCostExpCostExpReadmitExpReadmitExpPaymentExpPaymentSecondary DX Acute SystolicFailure5.26 9.51% 13.59 $30,302 18.69% $34,716330 Major Small and Large BowelProcedure W CCRel Wt ExpMortExpLOSExpCostExpReadmitExpPaymentSecondary DX Chronic SystolicFailure2.57 0.73% 7.79 $1668112.25% $16,962*Exp Outcome Values based on specific Population with Proprietary analysis of Severity May vary with different population andassessment Methods For illustrative purposes only based on real data 26. The Denial IndustryIt is being ramped up dramaticallyTywin Lannistercould learn a thingor to from theDenial Industry 27. Medical Necessity Social Security Act 1862(a)(1)(A) Requires CMS to deny payment for a particular itemor service that is not reasonable and necessary How is this determined? Contemporaneous Documentation Therefore If we fail to document the medical necessity for anygood or service, CMS is required to take backpayment28 28. Why Physicians Should Care CMS' Recovery Audit Contractor (RAC) in Region C has beeninstructed to commence audits on high level evaluation andmanagement (E/M) codes. The auditing contractor will focuson physicians' use of higher-level E/M codes, including CPTcodes 99214 and 99215. RACs in the other three regions of the country will followsuit, with similar audits in the near future. Bulk of auditswill focus on IM, FP, ED doctors use of codes.http://www.aafp.org/news-now/practice-professional-issues/20120918racaudits.html29 29. Why Physicians Should Care If the RAC denies an admission as lacking medicalnecessity, are the associated physician services (H&P, dailyvisits denied as well)? CMS: If the RAC denies an inpatient admission, it is in thediscretion of the RAC auditor whether to recover paymentsto physicians Places discretion in the hands of the RAC auditors whoget 10% of every dollar recovered30 30. Getting It RightThe Legal & Regulatory EnvironmentAccurate CompliantDocumentationMisleadingDocumentationUnderpaymentPoor ProfilesErrorRecoveryIncompleteDocumentationFraud- CivilWhat Are The Rules? - Criminal 31. CLINICAL DOCUMENTATIONIMPROVEMENTTaming the DragonYou too can tame theCDI Dragon likeDaenerys Targaryen 32. HospitalInpatient CarePhysicianDocumentationImpact of Documentation Improvement ComplianceCoding ProcessGap Assures compliant coding by supporting accurate physician documentation Decreases hospital fraud risk Revenue Cycle Assures appropriate payment based on actual patient acuity Protects against recoveries for erroneous payments (RAC) QualityTraditionalRevenue CycleQuality /OutcomeMeasurement More accurate capture of core measures, patient safety indicators, medical necessity, etc. Improves hospital / department / individual clinical profilesEvolvingQuality BasedPaymentClinicalDocumentationImprovementProcessThe medical record is the most important source of information within a healthcare organization.It is used not only for providing patient care but also for assessing the effectiveness and quality of thatcare, as well as for billing and reimbursement, research and to set healthcare policies as needed. 33. Philosophy Physicians do not need to learn coding Physicians need to work in a collaborativeprocess to achieve accurate documentation onevery patient The process must increase efficiency The CDMP implementation should beowned by physicians 34. Physician Engagement The GameTypical CDI Programs Success MetricsChanger Compliance CMI viewed as a revenue cycle metric Typical hospital revenue cycle impact 2-4% A Revenue Cycle Initiative Managed by HIM under a strong codinginfluence Little communication with qualityPhysician-Engaged CDI Success Metrics Greater compliance CMI improvement a metric of qualityand revenue Typical CMI improvement 4-8% A Clinical Initiative Integrated with clinical quality Clinical management, CMOaccountability 35. Physician Engagement The GameChangerTypical CDI Programs Focus: DRG optimization Specific focus only on those areas ofdocumentation impacting hospitalreimbursement Result Cynicism from medical leadership/staff No fit with other physician/clinicalinitiatives 1-2 year success cycle Documentation specialists progressivelydisappeared into cubiclesPhysician-Engaged CDI Focus: Clinical accuracy Accurate severity capture for everyadmission impacting reimbursement,clinical care, and quality metrics Result Ownership by the medical staff Response rates approaching 100% Integrated with other physician/clinicalinitiatives Sustained results CDSs part of the clinical team 36. How Do You Leverage PhysicianEngagement? Involve physician leadership in planning,execution, and ongoing performance of CDI Integrate physician / CDS / coder into acollaborative group Measure, But measure no need and for measureWildFire Show resultsMuch like Tyrion Lannister marshalingresources and involving everyone as hedid at the Battle of Blackwater 37. The Mortality Index:Ratio of Observed to Expected Mortality0.790.860.80.75 0.76 0.780.72University Medical CenterCompared to UHCUHC Top 10Med Center0.68 0.68 0.680.641.37 1.361.151.10.99 0.990.830.710.830.770.71.601.401.201.000.800.600.40Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4FY2008 FY2009 FY2010 38. Current Clinical Documentationand Coding ProcessesLittle operational integration of workflowQualityEHR AnalyticsDocumentation Coding Compliance ReportingPatientEncounterThe Physician World The HIM / Revenue / Compliance WorldPhysician Impact Frustration with coding Inaccurate quality reporting Query fatigueOperational Impact Frustration with physicians Inaccurate quality reporting for hospital Compliance risk 39. Leveraging the EHR for ValueCLUEHRCAPD /CA CDIAnalyticsQualityReportingDocumentation Coding CompliancePatientEncounterCodingKnowledgeCAComplianceCA QualityReportingCA DataAnalyticsCACVoice /Direct textentry 40. HOW DOES CODING IMPACT ALL OF THIS?A LOOK AT CURRENT CDI PROGRAMS 41. Uninformed Physician CodingInaccuratePhysicianDocumentationDocumentationCodingProcessRevenueCycleCDIProgramsCACComplianceInaccurateMedicalRecordQualityReworkReworkRework 42. Basic Concepts Inadequate physician documentation has been achallenge for accurate coding under ICD-9 If uncorrected, that challenge continues to increase Coding solutions, alone, cannot resolve the issue ofinadequate physician documentation Physician leaders must be able to engage theircolleagues in a proactive manner, establishing theappropriate motivation and sharing necessaryknowledge to achieve success under Coding and CDIPrograms 43. Leveraging TechnologyLeveraging TechnologyApplying a little magic like Arya Stark and her unusalfriend Jaqen H'ghar 44. Clinical Documentation isEverything 45. 46 46. Supporting the Clinician in the Avalanche of Increasing DemandsPOA/HACMedicalNecessityCoreMeasuresMUPatientSafetyOutcomeMeasuresCMISeverity ofIllness 47. CHIEF COMPLAINTPAST MEDICAL HISTORY 48. PAST MEDICAL HISTORYCHIEF COMPLAINT 49. Bringing the Power to HealthcareFrom Clinical Narrative toActionable FactsCLINICAL LANGUAGE UNDERSTANDING is Nuances NLU Specific to Healthcare63 %93%86 %Oct 10 Feb 12Rules: explicit linguistic modelsMachine learning: discovery of new patternsSyntactic parsing & Statistical semantic processingLinKBase ontology 50. Moving from the CurrentFragmented ClinicalDocumentation ProcessEHR Compliance Clinical documentation, coding and qualityreporting are loosely coupled processes Opportunities for real-time physicianengagement are limitedQualityCoding reporting Analytics Computer-assisted coding solutionsperform sub-optimally due to lack ofhigh quality and complete electronicphysician documentation andsophisticated CLU technology Value-based reimbursement modelswill make these challenges evengreater 51. To: Utilizing Intelligent Systems toBridge the GapCA-compliance CA-qualityEHR ComplianceEHR CodiCnAg-coding reporting Analytics Integrates the entire value chain startingwith increased electronic documentation Supports physicians within their EHR-centricdocumentation workflows driving enhancedutilization and documentation quality Leverages superior and common CLUtechnology across all of the key process stepsQualityreporting CA-analytics Relies on a technology enabledCDI approach that drives superiorphysician acceptance and CDIteam efficiencies Drives superior computer-assistedcoding process and resultsClinically drivenCA-CAPD-CDICLU 52. Key Challenges with Current ProcessDISRUPTIVE CDI QUERIESCDI SPECIALIST The patient hasrespiratory failureWhat is the acuity? 53. Computer Assisted PhysicianDocumentationVoice input:The patient hasacute respiratoryfailurePhysician reviews anddocumentsAcute on chronicrespiratory failureCAPD response: Multiplecorrelates of acute on chronicrespiratory failure identifiedwithin narrative documentsConcurrent medical record corrected:Acute on Chronic Respiratory Failure 54. End-to-End Clinical Documentation ProcessDriving superior outcomesMeaningful useQuality reportingDecision supportValue-based purchasingCoding / CMIPOA / HACMedical necessityCodingDocumentation integrityCLU EHROn a PCIn EHRself-editingIn EHRMT-editingOn the goPatient careFinancial integrityComplianceOn an MFPAt a dictationWith aRIS/PACSstationCapture anywhere Understand everything Use it for good 55. Where You Can Find MeNick van Terheyden, MD CMIO, Nuance CommunicationsAboutMe http://about.me/obiwanTwitter http://twitter.com/drnic1LinkedIn http://www.linkedin.com/in/nickvtVoice of the Doctor http://drvoice.blogspot.com/FaceBook http://profile.to/drnickE-Mail drnick@nuance.com, drnic1@gmail.comGoogle Voice (301) 355-0877 56. Thank YouNick van Terheyden, MD (Aka @DrNic1)Chief Medical Information Office CLUNuance Communications, Inc.