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

1. Value Based Purchasing, Changes for ICD-10 and the Future of UrologyRobert 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. 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. 20

21. 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.

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

23. 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!

24. 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 right renal cell carcinoma; anemia of acute blood loss due to femur fracture • Adverse effects are easily explained and defended in a patient with more risk factors. If you didn’t name these, you lose.

25. NOT Acute Respiratory Failure • Patients being purposely maintained on the ventilator after surgery because of weakness, chronic lung disease, massive trauma are NOT in acute respiratory failure – unless they are • Patients being purposely maintained on the ventilator after extensive surgery in the face of morbid obesity or COPD are NOT in acute respiratory failure – unless they are. • Prevention of acute respiratory failure from angioedema, stroke, trauma when patient does NOT HAVE acute respiratory failure when intubated for airway protection

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. 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 (Admitted for radical suprapubic prostatectomy) • DON’T just provide signs and symptoms • Tell the story of the workup that led to the diagnosis

28. 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, especially in discharge summary

29. 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.

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

31. Risk Stratification for Pulmonary Complications

32. Modified NSQIP Data Sheet

33. The Mayo Model ofPreOperative Medical Evaluation • Initial medical evaluation for risk stratification – fill out POME • Lab and radiographic studies as indicated – fill out POME • Consultative visits and tests as needed – fill out POME • Visit to Anesthesiology with recommendations and results – fill out preop anesthesia forms • Visit to surgeon with all needed risk factors complete – complete H&P • Eliminate cancelled surgeries, delays

34. 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? • Decubitus ulcer – is it an 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 it!

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

36. 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)

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

38. 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)

39. 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

40. How Close Are We?

41. 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.

42. Renal Malignancies ICD-9 189.0 Kidney, except pelvis (Includes Wilms tumor, renal cell carcinoma, urothelial cell ca) 189.1 Renal pelvis 189.2 Ureter 189.3 Urethra 189.4 Paraurethral glands 189.8 Other specified sites of urinary organs Malignant neoplasm of contiguous or overlapping sites of kidney and other urinary organs whose point of origin cannot be determined 189.9 Urinary organ, site unspecified

43. Renal Malignancies ICD-10 C64.1 Malignant neoplasm of right kidney, except renal pelvis (includes all cell types) C64.2 Malignant neoplasm of left kidney, except renal pelvis (includes all cell types) C64.9 Malignant neoplasm of unspecified kidney, except renal pelvis (includes all cell types) C65 Malignant neoplasm of renal pelvis C65.1 Malignant neoplasm of right renal pelvis C65.2 Malignant neoplasm of left renal pelvis C65.9 Malignant neoplasm of unspecified renal pelvis C66Malignant neoplasm of ureter C66.1 Malignant neoplasm of right ureter C66.2 Malignant neoplasm of left ureter C66.9 Malignant neoplasm of unspecified

44. Similarities and Differences • Now identify right or left kidney, pelvis, ureter • Same differentiation by part of renal system • No breakdown as to cell types • Do we need this? • Wilms tumor (nephroblastoma) • Renal cell carcinoma • Urothelial cell carcinoma

45. ICD-9 198.5Bone and bone marrow ICD-10 C79.51 Bone C79.52 Bone marrow Mets to Bone

46. 592.0 Calculus of kidney Nephrolithiasis NOS Renal calculus or stone Staghorn calculus Stone in kidney Excludes: uric acid nephrolithiasis (274.11) 592.1Calculus of ureter Ureteric stone Ureterolithiasis 592.9 Urinary calculus, unspecified N20.0 Calculus of kidney Nephrolithiasis NOS Renal calculus Renal stone Staghorn calculus Stone in kidney N20.1Calculus of ureter Ureteric stone N20.2 Calculus of kidney with calculus of ureter N20.9 Urinary calculus, unspecified Stones in 9 and 10

47. Benign Prostatic Disease – ICD-9 600.0 Hypertrophy (benign) of prostate 600.00 Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptoms (LUTS) 600.01 Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS) 600.1 Nodular prostate 600.10 Nodular prostate without obstruction 600.11 Nodular prostate with urinary obstruction 600.2 Benign localized hyperplasia prostate 600.20 Benign localized hyperplasia of prostate without urinary obstruction and other lower urinary tract symptoms (LUTS) 600.21 Benign localized hyperplasia of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS) 600.3 Cyst of prostate Use additional code to identify symptoms: incomplete bladder emptying (788.21) nocturia (788.43) straining on urination (788.65) urinary frequency (788.41) urinary hesitancy (788.64) urinary incontinence (788.30-788.39) urinary obstruction (599.69) urinary retention (788.20) urinary urgency (788.63) weak urinary stream (788.62)

48. Benign Prostatic Disease ICD-10 N40.0 Enlarged prostate without lower urinary tract symptoms N40.1 Enlarged prostate with lower urinary tract symptoms N40.2 Nodular prostate without lower urinary tract symptoms N40.3 Nodular prostate with lower urinary tract symptoms No code for benign localized hyperplasia prostate N42.83 Cyst of prostate Use additional code forassociatedsymptoms, when specified: incomplete bladder emptying (R39.14) nocturia (R35.1) straining on urination (R39.16) urinary frequency (R35.0) urinary hesitancy (R39.11) urinary incontinence (N39.4-) urinary obstruction (N13.8) urinary retention (R33.8) urinary urgency (R39.15) weak urinary stream (R39.12)

49. Adhesions Specify in females if due to pelvic inflammatory diseases or post uterine or adnexal surgery General adhesions, male or female, due to other than diseases of the female pelvic organs are assigned the same code Distinguish with or without obstruction

50. Endocrine Complications or Metabolic Disorders After Endocrine Surgery or Other Surgery Postop hypoadrenalism, hypothyroidism, hypoparathyroidism, hypopituitrism, ovarian failure (symptomatic or asymptomatic) Specify when these are desired outcomes of (integral to) the surgery performed Identify accidental puncture or laceration and hematoma or hemorrhage in renal, adrenal surgeries