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

1. Value Based Purchasing, Changes for ICD-10 and the Future of DermatologyRobert 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. 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."

20. 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

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. Patient Safety Indicators Hospital acquired preventable diagnoses Hospital falls that lead to patient damage (fractures, etc.) Mediastinitis post-CABG Catheter-associated UTIs Vascular catheter associated infections Pressure ulcers Iatrogenic pneumothorax following central line insertion Object accidentally left in patient Air embolism Reaction from blood incompatibility

24. What Does This Mean? • Properly identify complication of care when complication – specify when due to a disease • We don’t want to assign complication codes when not complication • If event due to disease, not a complication • If even doesn’t exist, not a complication • Don’t use the word “post-op” in the post-op period!

25. Is an Adverse Event Always a Complication? • Not at all. • Stuff happens. • Diseases cause adverse effects • Anemia due to blood loss is usually due to the disease and not to the surgery State so: anemia of chronic blood loss due to 40% second degree body burns; anemia of acute blood loss due to complex scalp laceration • Adverse effects are easily explained and defended in a patient with more risk factors. If you didn’t name these, you lose.

26. Goals of Implementation – Prove You Are Value Based • Competitive severity adjusted mortality and morbidity statistics • 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

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

28. 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)

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

30. 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)

31. 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

32. How Close Are We?

33. Specificity is NOT Always Possible Sign/Symptom/Unspecified Codes In both ICD-9-CM and ICD-10-CM, sign/symptom and “unspecified” codes have acceptable, even necessary, uses. While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter. Each healthcare encounter should be coded to the level of certainty known for that encounter. If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis. When sufficient clinical information isn’t known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate “unspecified” code (e.g., a diagnosis of pneumonia has been determined, but not the specific type). In fact, unspecified codes should be reported when they are the codes that most accurately reflects what is known about the patient’s condition at the time of that particular encounter. It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code. Source: Cooperating Parties for ICD-10-CM/PCS and ICD-9-CM Coding, May 2013.

34. Documentation Needs:What’s The Surgery For? • Provide the diagnosis for which the surgery is being performed • Tell why it’s necessary for that diagnosis • DON’T just say that the patient is being admitted for the surgery • DON’T just provide signs and symptoms

35. Documentation Needs:Complexity of Patient • Name other diseases patient has coming through the door – chronic, stable conditions • Avoid “Resume home meds” unless you identify each disease being treated • Permit other physicians to follow serious co-morbidities, but name each at least ONCE

36. ACS NSQIP Data Collection Overview The ACS NSQIP collects data on 136 variables, including preoperative risk factors, intraoperative variables, and 30-day postoperative mortality and morbidity outcomes for patients undergoing major surgical procedures in both the inpatient and outpatient setting.

37. Surgical Risk Stratification • NSQIP databases depend on identification of risk factors

38. Risk Stratification for Pulmonary Complications

39. Modified NSQIP Data Sheet

40. Was It Present on Admission? Patient safety indicators may give us a black eye if it’s not documented! • Ileus from perforated bowel or from peritonitis – was it present on admission? • DVT in patient from nursing home – was it present on admission? • Pressure ulcer – is it an ulcer? – is it a pressure ulcer? - was it present on admission? • Atelectasis in a morbidly obese patient – was it present on admission? If we don’t document it, we get charged with causing it!

41. 176 Kaposi's sarcoma 176.0 Skin 176.1 Soft tissue 176.2 Palate 176.3 Gastrointestinal sites 176.4 Lung 176.5 Lymph nodes 176.8 Other specified sites Oral cavity NEC 176.9 Unspecified C46 Kaposi's sarcoma C46.0 Kaposi's sarcoma of skin C46.1 Kaposi's sarcoma of soft tissue C46.2 Kaposi's sarcoma of palate C46.3 Kaposi's sarcoma of lymph nodes C46.4 Kaposi's sarcoma of gastrointestinal sites C46.5 Kaposi's sarcoma of lung C46.50 Kaposi's sarcoma of unspecified lung C46.51 Kaposi's sarcoma of right lung C46.52 Kaposi's sarcoma of left lung C46.7 Kaposi's sarcoma of other sites C46.9 Kaposi's sarcoma, unspecified Kaposi’s Sarcoma

42. Malignant Melanoma – ICD-9 172 Malignant melanoma of skin 172.1 Eyelid, including canthus 172.2 Ear and external auditory canal 172.3 Other and unspecified parts of face 172.4 Scalp and neck 172.5 Trunk, except scrotum 172.6 Upper limb, including shoulder 172.7 Lower limb, including hip 172.8 Other specified sites of skin 172.9 Melanoma of skin, site unspecified

43. Malignant Melanoma ICD-10 C43 Malignant melanoma of skin C43.0 Malignant melanoma of lip C43.1 Malignant melanoma of eyelid, including canthus ** C43.2 Malignant melanoma of ear and external auricular canal ** C43.3 Malignant melanoma of other and unspecified parts of face C43.30 Malignant melanoma of unspecified part of face C43.31 Malignant melanoma of nose C43.39 Malignant melanoma of other parts of face C43.4 Malignant melanoma of scalp and neck C43.5 Malignant melanoma of trunk C43.51 Malignant melanoma of anal skin C43.52 Malignant melanoma of skin of breast C43.59 Malignant melanoma of other part of trunk C43.6 Malignant melanoma of upper limb, including shoulder C43.7 Malignant melanoma of lower limb, including hip ** C43.8 Malignant melanoma of overlapping sites of skin C43.9 Malignant melanoma of skin, unspecified ** 0=unspecified 1=right 2=left

44. Other Skin Malignancies ICD-9 Add 5th digit 0 – unspecified 1 – basal cell 2 – squamous cell 9 - other 173.0 Skin of lip 173.1 Eyelid incl canthus 173.2 Ear and ext aud canal 173.3 Other parts of face 173.4 Scalp and neck 173.5 Trunk except scrotum 173.6 Upper limb incl shoulder 173.7 Lower limb incl hip 173.8 Other specified sites 173.9 Unspecified

45. Other Skin Malignancies ICD-10 Add 5th digit 0 – unspecified 1 – basal cell 2 – squamous cell 9 - other C44.0 Skin of lip C44.1 Eyelid incl canthus C44.2 Ear and ext aud canal C44.3 Other parts of face C44.4 Scalp and neck C44.5 Trunk except scrotum C44.6 Upper limb incl shoulder C44.7 Lower limb incl hip C44.8 Other specified sites C44.9 Unspecified

46. Merkel Cell Cancers ICD-10 Add 5th digit Specific areas of basic grouping (eg, left and right eyelid) C4A.0 Skin of lip C4A.1 Eyelid incl canthus C4A.2 Ear and ext aud canal C4A.3 Other parts of face C4A.4 Scalp and neck C4A.5 Trunk except scrotum C4A.6 Upper limb incl shoulder C4A.7 Lower limb incl hip C4A.8 Other specified sites C4A.9 Unspecified

47. 695.1 Erythema multiforme 695.10 Erythema multiforme, unspecified 695.11 Erythema multiforme minor 695.12Erythema multiforme major 695.13Stevens-Johnson syndrome 695.14Stevens-Johnson syndrome-toxic epidermal necrolysis overlap syndrome SJS-TEN overlap syndrome 695.15Toxic epidermal necrolysis Lyell's syndrome 695.19Other erythema multiforme Use additional code to identify associated manifestations, such as: arthropathy associated with dermatological disorders (713.3) conjunctival edema (372.73) conjunctivitis (372.04, 372.33) corneal scars and opacities (371.00-371.05) corneal ulcer (370.00-370.07) edema of eyelid (374.82) inflammation of eyelid (373.8) keratoconjunctivitis sicca (370.33) mechanical lagophthalmos (374.22) mucositis (478.11, 528.00, 538, 616.81) stomatitis (528.00) symblepharon (372.63) Use additional E-code to identify drug, if drug-induced Use additional code to identify percentage of skin exfoliation (695.50-695.59) Erythema Multiforme ICD-9

48. L51 Erythema multiforme L51.0 Nonbullous erythema multiforme L51.1 Stevens-Johnson syndrome L51.2 Toxic epidermal necrolysis [Lyell] L51.3 Stevens-Johnson syndrome-toxic epidermal necrolysis overlap syndrome SJS-TEN overlap syndrome L51.8 Other erythema multiforme L51.9 Erythema multiforme, unspecified Use additional code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5) Use additional code to identify associated manifestations, such as: arthropathy associated with dermatological disorders (M14.8-) conjunctival edema (H11.42) conjunctivitis (H10.22-) corneal scars and opacities (H17.-) corneal ulcer (H16.0-) edema of eyelid (H02.84) inflammation of eyelid (H01.8) keratoconjunctivitis sicca (H16.22-) mechanical lagophthalmos (H02.22-) stomatitis (K12.-) symblepharon (H11.23-) Use additional code to identify percentage of skin exfoliation (L49-) Erythema Multiforme ICD-10

49. Skin Abscesses, furuncles, lymphangitis, cellulitis Acute when appropriate Laterality (R/L) Location Erythema multiforme Identify, when appropriate, Stevens-Johnson, Toxic Epidermal Necrolysis, overlap between these two Identify percent of body surface involved

50. Pressure Ulcers Precise location laterality for limbs upper, middle, lower back, presacral Stage or tissues involved (skin, skin and subq, involving muscle, involving bone) – or unstageable. If it can be staged after treatment, revise staging