Value Based Purchasing, Changes for ICD-10 and the Future of Neurology Robert S. Gold, MD

1. Value Based Purchasing, Changes for ICD-10 and the Future of NeurologyRobert S. Gold, MD

2. Medicine Under the Microscope Morbidity Mortality Cost per patient Resource utilization Length of stay Complications Outcomes ARE YOU SAFE – avoiding harm, avoidable readmissions?

3. Value-Based Purchasing Program • Beginning in FY 2013 and continuing annually, CMS will adjust hospital payments under the VBP program based on how well hospitals perform or improve their performance on a set of quality measures. The initial set of 13 measures includes three mortality measures, two AHRQ composite measures, and eight hospital-acquired condition (HAC) measures. The FY 2012 IPPS final rule (available at http://tinyurl.com/6nccdoc) includes a complete list of the 13 measures.

4. Where Does This Data Come From? • Documentation leads to identification of diagnoses and procedures • Recognition of diagnoses and procedures lead to ICD codes – THE TRUE KEY • ICD codes lead to APR-DRG assignment • APR-DRG assignment massaged to “Severity Adjustments • Severity adjusted data leads to morbidity and mortality rates

5. Semantics Coding guidelines and conventions Use of signs, symbols, arrows Accuracy and specificity Relationship between accuracy and specificity of code assignment and Complexity of Medical Decision Making World Health Organization and ICD Codes

7. Is There a Diagnosis? 82 yo WF altered mental status, shaking chills, fevers, decr UO, T = 103, P = 124, R = 34, BP = 70/40 persistent despite 1 L NS, on Dopamine, pO2 = 78 on non-rebreather, pH = 7.18, pCO2 = 105, WBC = 17,500, left shift, BUN = 78, Cr = 5.4, CXR – Right UL infiltrates, start Cefipime, Clinda, Tx to ICU. May have to intubate – full resusc.

8. Is There a Diagnosis? Assessment/Plan 82 YO F patient presented to ER with: 1. Sepsis, 2. Septic Shock, 3. Acute Hypercapnic Respiratory Failure, 4. Acute Renal Failure due to #2, (don’t forget CKD and stage, if present) 5. Aspiration Pneumonia, 6. Metabolic Encephalopathy Will transfer to ICU, continue Dopamine and monitor respiratory status for possible ARDS, renal status with hydration and initiate Cefapime/clindamycin for possible aspiration pneumonia CC time 1hr 45 minutes John Smith MD

9. So What’s the Difference?

10. What Is An Index?

11. Mortality index Complication index Length of stay index Cost per patient index What Is An Index? Observed Rate of Some Thing Severity Adjusted Expected Rate of That Thing =1

12. Profiles Come from Severity Adjusted Statistics <1; preferred provider –  significantly better Observed mortality Expected mortality From severity adjusted DRGs =1; as good as the next guy >1; excessive mortality; find another provider - 

14. Patient Safety

15. Surgery Bundling Test Model • Disclosed May 16, 2008 • ACE (Acute Care Episode) project • Combine Part B payments with Part A • “Value Based Centers” started with Texas, Oklahoma, New Mexico and Colorado • Value based purchasing • 28 cardiac and 9 orthopedic inpatient surgical services • Gainsharing also permitted here • Based on severity adjusted financial outcomes

16. Florida Blue and Mayo Clinic Introduce Knee Replacement Bundled Payment Program Friday, December 14, 2012 JACKSONVILLE, Fla. — Florida Blue and Mayo Clinic jointly announce a new collaboration aimed at providing the utmost in quality care for knee replacement patients in Florida. The two Florida health care leaders are teaming up to create a bundled payment agreement specific to the treatment of knee replacement surgery. Knee replacement surgery is the most common joint replacement procedure. According to the Agency for Healthcare Research and Quality, health care professionals perform more than 600,000 knee replacements annually in the United States.

17. Florida Blue and Holy Cross Create Accountable Care Arrangement Jacksonville and Fort Lauderdale, Fla. – Florida Blue, Florida’s Blue Cross and Blue Shield Company, and Holy Cross Physician Partners are pleased to announce that effective January 1, 2013, Holy Cross Physician Partners will participate in the Florida Blue Accountable Care Program. “Florida Blue is excited to expand our relationship with Holy Cross surrounding this exciting new partnership,” said Dr. Jonathan Gavras, chief medical officer and senior vice president for Florida Blue. “In the age of reform, both organizations realize the importance of moving away from the fee-for-service model to one that focuses on quality outcomes that will benefit our members in South Florida.”

18. Aetna, Baptist Memorial Health Care Announce Collaborative Care Agreement Thursday, April 25, 2013 4:11 pm EDT MEMPHIS, Tenn.--(BUSINESS WIRE)--Aetna (NYSE: AET) and Baptist Memorial Health Care today announced a collaborative care agreement to bring a new health care model to Aetna members and introduce Aetna Whole HealthSM, a commercial health care product. This collaboration will give employers and their workers access to highly coordinated care from physicians and facilities in the Baptist Select Health Alliance. The Baptist Select Health Alliance is a clinically integrated group of physicians focused on tracking outcomes, sharing data and measuring clinical standards to improve quality and efficiency. In collaborative care models, a group of health care providers delivers more coordinated care for patients to drive better quality and lower overall costs. Through Baptist Memorial Health Care, Aetna members will receive an enhanced level of coordinated care in addition to the member benefits of their current Aetna plan.

19. Getting Studies Paid ForLaboratory/Radiographic • Bundled payment modes rely on payment being made for lab or x-ray studies • Validation of reason for performing any procedure or test depends on Medical Necessity • Local Medical Review Policies (LMRPs), Local or National Coverage Determinations (LCDs, NCDs) • Not giving a reason for a test you order (symptom or diagnosis) could result in: • Advance Beneficiary Notification (ABN) saying patient may have to pay for the test • Somebody bugging you for a reason for the test

20. Banner Announces Joint Venture with Blue Cross Blue Shield of Arizona Banner Health and Blue Cross Blue Shield of Arizona have entered into a new joint venture, Blue Cross Blue Shield of Arizona Advantage, which will bring enhanced Medicare services to Arizonans. This collaboration brings together two premier organizations with the common goal of improving the quality of patient care, enhancing wellness and assuring affordability. "The activities of this joint venture will be a further demonstration of how Banner is rapidly transitioning to population health management models to enhance care and control costs through an emphasis on wellness and care coordination," said Banner Health President and CEO Peter S. Fine. "This and our other partnerships with Aetna,  HealthNet and United Healthcare in Arizona and Kaiser Permanente in Colorado, as well as our selection as a Medicare Pioneer ACO organization, are helping to position Banner for continued success in a challenging and transformational health care environment."

21. Readmissions Initiative Identify hospitals with excess readmissions for certain selected conditions beginning in FY 2013 for discharges on or after October 1, 2012. Acute myocardial infarction (i.e., heart attack) Heart failure Pneumonia Definition of readmission: “occurring when a patient is discharged from the applicable hospital and then is admitted to the same or another acute care hospital within a specified time period from the time of discharge from the index hospitalization.” The specified time period would be 30 days. 21

22. Clinical Integration • CMS proposes to pay separately for complex chronic care management services starting in 2015.  • "Specifically, we proposed to pay for non-face-to-face complex chronic care management services for Medicare beneficiaries who have multiple, significant, chronic conditions (two or more)."  Rather than paying based on face-to-face visits, CMS would use "G-codes" to pay for revision of care plans, communication with other treating professionals, and medication management over 90-day periods. • These code payments would require that beneficiaries have an annual wellness visit, that a single practitioner furnish these services, and that the beneficiary consent to this arrangement over a one-year period.

23. Goals of Implementation – Prove You Are Value Based • Low incidence of HACs • Reasonable occurrence of PSIs • Lower than average Readmissions for Pneumonia, Heart Failure, AMI • Cooperation with quality initiatives • Decent responses to a new questionnaire on discharge

24. Change in the Entire System ICD-9 ICD-10

25. Notable Changes ICD-9 has maximum of 5 digits with rare alphanumeric codes (V-, E-) limiting breakdown for specificity or addition of categories; ICD-10 has three to seven alphanumeric places ICD-9: 14,000 codes; ICD-10: 73,000 codes ICD-9 has no specificity as to which side of the body (e.g., percent burn on right or left arm or leg, side of paralysis after stroke)

26. Don’t Wait Till Tomorrow for ICD-10

27. How Ready Are We?

28. Example - Integration ICD-9 – Multiple codes 707.03 – Chronic skin ulcer, lower back 707.21 – Pressure ulcer, stage I No code for which side ICD-10 – Single code L89.131 – Pressure ulcer right lower back, stage I (stages II, III, IV, unspecified have 6th digits 2, 3, 4, 9)

29. Example Specificity - Location M67.4 Ganglion M67.41 shoulder M67.411, right M67.412, left M67.419, unspecified M67.42 elbow M67.43 wrist M67.44 hand M67.45 hip M67.46 knee M67.47 ankle and foot Sixth digits 1 – right 2 – left 9 - unspecified

30. 430 Subarachnoid hemorrhage 431 Intracerebral hemorrhage Hemorrhage (of) Basilar, bulbar, cerebellar, cerebral, etc. 432 Other and unspecified intracranial hemorrhage 432.0 Nontraumatic extra(epi)dural hemorrhage 432.1 Subdural hemorrhage 432.9 Unspecified intracranial hemorrhage 433 Occlusion and stenosis of precerebral arteries 433.01 Basilar artery with cerebral infarction 433.11 Carotid artery with cerebral infarction 433.21 Vertebral artery with cerebral infarction 433.31 Multiple and bilateral with cerebral infarction 433.81 Other specified precerebral artery with cerebral infarction 433.91 Unspecified precerebral artery with cerebral infarction 434 Occlusion of cerebral arteries 434.01 Cerebral thrombosis with cerebral infarction 434.11 Cerebral embolism with cerebral infarction 434.91 Cerebral artery occlusion, unspecified with cerebral infarction Overall Stroke ICD-9

31. Intracerebral Bleed Specify if traumatic or nontraumatic Specify by location in brain (cortical, subcortical, brainstem, intraventricular)

32. Intracerebral Bleed I-9 431 Intracerebral hemorrhage (nontraumatic) Hemorrhage (of): basilar bulbar cerebellar cerebral cerebromeningeal cortical internal capsule intrapontine pontine subcortical ventricular

33. Intracerebral Bleed I-10 I61.0Nontraumatic intracerebral hemorrhage in hemisphere, subcortical Deep intracerebral hemorrhage (nontraumatic) I61.1Nontraumatic intracerebral hemorrhage in hemisphere, cortical Cerebral lobe hemorrhage (nontraumatic) Superficial intracerebral hemorrhage (nontraumatic) I61.2Nontraumatic intracerebral hemorrhage in hemisphere, unspecified I61.3Nontraumatic intracerebral hemorrhage in brain stem I61.4Nontraumatic intracerebral hemorrhage in cerebellum I61.5Nontraumatic intracerebral hemorrhage, intraventricular I61.6Nontraumatic intracerebral hemorrhage, multiple localized I61.8Other nontraumatic intracerebral hemorrhage I61.9Nontraumatic intracerebral hemorrhage, unspecified

34. Subdural Bleed Specify traumatic or nontraumatic Specify acute, subacute or chronic Specify laterality

35. Cerebral Infarct Specify artery involved Specify precerebral vessel and which one Specify when embolic and origin (ulcerated plaque, heart) Specify right vs left side of brain (and patient’s handedness)

36. Glasgow Coma Scale The coma scale codes (R40.2-) can be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease or sequelae of cerebrovascular disease codes. These codes are primarily for use by trauma registries, but they may be used in any setting where this information is collected. The coma scale codes should be sequenced after the diagnosis code(s). These codes, one from each subcategory, are needed to complete the scale. The 7th character indicates when the scale was recorded. The 7th character should match for all three codes. At a minimum, report the initial score documented on presentation at your facility. This may be a score from the emergency medicine technician (EMT) or in the emergency department. If desired, a facility may choose to capture multiple coma scale scores. Assign code R40.24, Glasgow coma scale, total score, when only the total score is documented in the medical record and not the individual score(s).

38. 7th digit – when analyzed 0 – unspecified time 1 – in the field (EMT or ambulance 2 – at arrival in ED 3 – at hospital admission 4 – 24 hours or more after admission R40.20Unspecified coma Coma NOS Unconsciousness NOS R40.21 Coma scale, eyes open (4 levels) R40.211 Coma scale, eyes open, never R40.212 Coma scale, eyes open, to pain R40.213 Coma scale, eyes open, to sound R40.214 Coma scale, eyes open, spontaneous R40.22 Coma scale, best verbal response (5 levels) R40.221 Coma scale, best verbal response, none R40.222 Coma scale, best verbal response, incomprehensible words R40.223 Coma scale, best verbal response, inappropriate words R40.224 Coma scale, best verbal response, confused conversation R40.225 Coma scale, best verbal response, oriented R40.23 Coma scale, best motor response (6 levels) R40.231 Coma scale, best motor response, none R40.232 Coma scale, best motor response, extension R40.233 Coma scale, best motor response, abnormal R40.234 Coma scale, best motor response, flexion withdrawal R40.235 Coma scale, best motor response, localizes pain R40.236 Coma scale, best motor response, obeys commands R40.24 Glasgow coma scale, total score Use codes R40.21 - through R40.23 - only when the individual score(s) are documented R40.241Glasgow coma scale score 13-15 R40.242Glasgow coma scale score 9-12 R40.243Glasgow coma scale score 3-8 R40.244 Other coma, without documented Glasgow coma scale score, or with partial score reported

39. Late Effect Issues • Deficits on this admission are coded as new • Deficits that were from a previous admission or are used to admit to post-acute care are late effects • Note dominant side or handedness in hemiparesis • Late effects designate as DUE TO: • Old stroke • Old CNS infection • Old trauma • Old CNS surgery

40. Severity of Intracranial Bleed • Unconscious • Glasgow Coma Scale determinations at site, in ED, after 24 hours, etc. • Spastic or flaccid paralysis • Quadriplegic • Cerebral edema • Brain herniation • Brain dead

41. Hypertension – ICD-10 Essential hypertension (I10) – includes high blood pressure, hypertension, malignant hypertension, accelerated hypertension, benign hypertension Secondary hypertension (I15) I15.0 – renovascular I15.1 – hypertension secondary to other renal disorders I15.2 – hypertension secondary to endocrine disorders (carcinoid, pheochromocytoma, etc.) I15.8 – other secondary hypertension I15.9 – secondary hypertension, unspecified

42. Hypertensive Emergency?Out the Window I67.4 – Hypertensive encephalopathy (benign, malignant, accelerated, essential, systemic, idiopathic) Hypertensive acute kidney injury? Hypertensive acute diastolic heart failure? With ICD-9, identify accelerated or malignant hypertension (401.0) and the stroke (434.91), or acute heart failure (428.21), or acute renal failure (584.9)

43. Hypertension – ICD-10 Hypertensive heart disease - I11 I11.0 - with heart failure I11.9 - without heart failure Hypertensive kidney disease - I12 I12.0 - with stage 5 CKD or ESRD I12.9 - with CKD stages 1–4 N18.1, 2, 3, 4, 5, 6, 9 for CKD stages 1, 2, 3, 4, 5, ESRD, unspecified

44. Respiratory Failure in ICD-10 Document acute or chronic or both Specify if hypoxemic or hypercapnic respiratory failure for either acute or chronic Without specificity, defaults to unspecified, with least severity

45. NOT Acute Respiratory Failure • Patients being purposely maintained on the ventilator after heart surgery or any surgery because of weakness, chronic lung disease, massive trauma are NOT in acute respiratory failure • Prevention of acute respiratory failure from angioedema, stroke, trauma when patient does NOT HAVE acute respiratory failure when intubated for airway protection

46. Hydrocephalus • Be as specific as possible • Default 331.4 – acquired, noncommunicating, obstructive, etc. • Due to stricture of aqueduct 742.3 • With spina bifida 741.0 • Normal pressure 331.3

47. Hydrocephalus ICD-9 742.3 Congenital hydrocephalus – ONE CODE Aqueduct of Sylvius: anomaly obstruction, congenital stenosis Atresia of foramina of Magendie and Luschka Hydrocephalus in newborn 331.3 Communicating (secondary NP hydrocephalus) 331.4 Obstructive acquired hydrocephalus 331.5 Idiopathic normal pressure hydrocephalus Excludes: due to congenital toxoplasmosis (771.2) with any condition classifiable to 741.9 (741.0)

48. Congenital Hydrocephalus – ICD-10 Q03.9 Congenital (external) (internal) Q05.0Cervical spina bifida with hydrocephalus Q05.1Thoracic (dorsal/thoracolumbar) spina bifida with hydrocephalus Q05.2Lumbar (LS) spina bifida with hydrocephalus Q05.3Sacral spina bifida with hydrocephalus Q05.4Unspecified spina bifida with hydrocephalus Q05.5 Cervical spina bifida without hydrocephalus Q05.6 Thoracic (dorsal/thoracolumbar) spina bifida without hydrocephalus Q05.7Lumbar (LS) spina bifida without hydrocephalus Q05.8Sacral spina bifida without hydrocephalus

49. Acquired Hydrocephalus ICD-10 G91.0Communicating hydrocephalus Secondary normal pressure hydrocephalus G91.1Obstructive acquired hydrocephalus G91.2(Idiopathic) normal pressure hydrocephalus Normal pressure hydrocephalus NOS G91.3Post-traumatic hydrocephalus, unspecified G91.4 Hydrocephalus in diseases classified elsewhere Code first underlying condition, such as: congenital syphilis (A50.4-) neoplasm (C00-D49) due to congenital toxoplasmosis (P37.1)

50. Encephalopathies Metabolic encephalopathy G93.41 Includes due to sepsis, hyper and hyponatremia, diabetic encephalopathy Hepatic encephalopathy K72 Toxic encephalopathy G92 Lead encephalopathy, bromidism Polypharmacy over prolonged periods leading to CNS damage