Timothy N. Brundage, MD, CCDSCertified Clinical Documentation Specialist

Physician CDI Preparation for ICD-10

Clinical Documentation Integrity Program:

“We do not believe there is anything inappropriate, unethical, or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment that is supported by documentation in the medical record.”◦ CMS 2008 IPPS Final Rule, http://

www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1533-FC.pdf, page 208

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Why does CDI Matter?

Clinical Medicine

Medical Record

Utilization

Quality

Medical legal

Reimbursement

Physician Profiles

& Hospital Report CardsData

Coded

Physician documentation in the medical record is an important instrument in the economics of healthcare

Cost per patient Resource utilization Length of stay Complication Rates Morbidity Scores Mortality Scores Outcome Analysis Audits

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Why does CDI Matter?Medicine Under The Microscope

Documentation reflects severity of illness (SOI) and risk of mortality (ROM) scores.

Specificity is vital, a definitive diagnosis must be documented.

Physician profiles are developed from documented information

Golden Rule: “If it is not written in coding language, it didn’t happen”

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In this World of Documentation

ICD Versions ICD-9

◦ 1977 – Worldwide use◦ 1979 – U.S. modification

Clinical & mortality

ICD-10 ◦ 1994 – Release of full ICD-10 by WHO

Published in 42 languages

◦ 1999 – Adopted for death certificates in the United States Mortality

◦ 2014 – U.S. modification Clinical

ICD-11◦ 2015 – Tentative rollout worldwide

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Differences Between ICD-9-CM and ICD-10-CM/PCS

ICD-9-CM diagnosis◦ 3–5 characters◦ Allows for 1 letter (1st

position); otherwise numeric

ICD-9-CM procedures◦ 4 characters only◦ All characters are numeric

ICD-10-CM◦ 3 to 7 characters◦ 1st character is alpha (except U);

others are either alpha or numeric Numbers 0–9; letters A–H,

J–N, P–Z Alpha characters are not

case-sensitive

ICD-10-PCS◦ Same as ICD-10-CM except each

code must have 7 characters Letter “Z” used as a placeholder

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ICD-9-CM Structure – Format

X .X X X X5E 1 4 0 0.V

Category Etiology, anatomic site, manifestation

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Numeric or alpha (E or V) Numeric

3–5 characters8

ICD-10-CM Structure – Format

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X X X X

Category

.Etiology, anatomic

site, severity

Added code extensions (7th character) for obstetrics, injuries, and external causes of injury

X X XAMS 3 2 0. 1 0 A

Additional characters

Alpha (except U)

2–7 numeric or alpha

3–7 characters

The most challenging aspect of CDI

How do you motivate physicians to educate themselves?

Physician Buy In to CDI

• Without all diagnoses documented, profiles will inappropriately reflect higher than expected mortality

• Complete documentation, reflective of the true severity of illness of patients will justify outcomes

Profiles are used for both commercial and public useFuture reimbursement methods will likely incorporate profiles in the formula (e.g., pay for performance)

Teach Physicians about Quality Data

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Hospital Report cards Healthgrades, Delta Group, Leapfrog Medicare Physician Data (since 2007) Federal and state regulatory agencies (e.g. OIG) The Joint Commission (TJC) Centers for Medicare and Medicaid Services (CMS) Quality Improvement Organizations (QIO)

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Physician Profiling

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Healthgrades.com

Predicted Mortality Rates for some disease processes in this case:◦ Community Acquired Pneumonia = 10%◦ Sepsis = 30%◦ Septic shock = 50%

If the patient survives, quality ratings will be much higher in the public reporting data because the physician took care of a “sicker” patient.☻Expected mortality will be higher than actual mortality.

Physician Quality Ratings

Don’t need to turn doctors into coders Need good documentation habits Need specialty specific documentation

education Begin the process of education now for ICD-9

and incorporate ICD-10 issues into the education

ICD-10 Physician Education

Questions?Email

DrBrundage@Gmail.com