Medicine Under the Microscope

1. Value Based Purchasing, Changes for ICD-10 and the Future of Physical Medicine and RehabRobert 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. 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.

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. 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 Object accidentally left in patient Air embolism Reaction from blood incompatibility

23. Participation and Success in Reporting of Core Measures • Acute MI • Heart failure • Pneumonia • Postoperative wound infections • Venous thromboembolism • Stroke • Asthma in children’s hospitals

24. 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

25. Inpatient Rehab Coding Coding Clinic, Third Quarter 2006 Page 3: The Central Office on ICD-9-CM has continued to receive questions regarding the coding and sequencing of diagnoses in inpatient rehabilitation facilities (IRF). These facilities are required to complete a data collection instrument called Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI), as well as a claim form. The IRF-PAI requires the assignment of ICD-9-CM diagnosis codes for the etiologic diagnosis to indicate the condition for which the patient is receiving rehabilitation, as well as other comorbid conditions. As stated in Coding Clinic, First Quarter 2002, pages 18-19, a different set of instructions/rules apply to the IRF-PAI. Hospitals should be guided by the Medicare IRF-PAI Manual for the coding and reporting of the etiologic diagnosis and comorbidities for the IRF-PAI. A code from category V57, Care involving use of rehabilitation procedures, should be assigned as the principal diagnosis on the claim form when the patient is admitted for rehabilitative services. The following questions and answers apply to the coding and reporting of secondary diagnoses on the claim form for IRF patients. This information is being published in order to clarify some of the confusion that has resulted from dual reporting requirements.

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

27. 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)

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

29. Rehab ICD-9 V57Care involving use of rehabilitation procedures Use additional code to identify underlying condition V57.0 Breathing exercises V57.1 Other physical therapy Therapeutic and remedial exercises, except breathing V57.2 Occupational therapy and vocational rehabilitation V57.21 Encounter for occupational therapy V57.22 Encounter for vocational therapy V57.3 Speech-language therapy V57.4 Orthoptic training V57.8 Other specified rehabilitation procedure V57.81 Orthotic training Gait training in the use of artificial limbs V57.89 Other Multiple training or therapy V57.9 Unspecified rehabilitation procedure

30. Rehab ICD-10 Z51.89 Encounter for other specified aftercare PLUS . . .

31. Subarachnoid Bleed Specify when traumatic Specify vessel of origin - aneurysm Specify right or left side of the brain If hemiparesis, specify dominant or nondominant side

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

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

34. 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

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

36. 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

37. 433.0 Basilar artery 433.00 without mention of cerebral infarction 433.01 with cerebral infarction 433.1 Carotid artery 433.10 without mention of cerebral infarction 433.11 with cerebral infarction 433.2 Vertebral artery 433.20 without mention of cerebral infarction 433.21 with cerebral infarction 433.3 Multiple and bilateral 433.30 without mention of cerebral infarction 433.31 with cerebral infarction 433.8 Other specified precerebral artery 433.80 without mention of cerebral infarction 433.81 with cerebral infarction 433.9 Unspecified precerebral artery 433.90 without mention of cerebral infarction 433.91 with cerebral infarction Stroke ICD-9Caused by Occlusion Precerebral Artery

38. Stroke ICD-9Cerebral Artery 434.0 Cerebral thrombosis 434.00 without mention of cerebral infarction 434.01with cerebral infarction 434.1 Cerebral embolism 434.10 without mention of cerebral infarction 434.11with cerebral infarction 434.9 Cerebral artery occlusion, unspecified 434.90 without mention of cerebral infarction 434.91with cerebral infarction

39. Stroke ICD-10 I63.0 Cerebral infarction due to thrombosis of precerebral arteries I63.00 Cerebral infarction due to thrombosis of unspecified precerebral artery I63.01 Cerebral infarction due to thrombosis of vertebral artery I63.011 Cerebral infarction due to thrombosis of right vertebral artery I63.012 Cerebral infarction due to thrombosis of left vertebral artery I63.02 Cerebral infarction due to thrombosis of basilar artery I63.03 Cerebral infarction due to thrombosis of carotid artery I63.031 Cerebral infarction due to thrombosis of right carotid artery I63.032 Cerebral infarction due to thrombosis of left carotid artery I63.09 Cerebral infarction due to thrombosis of other precerebral artery

40. Stroke ICD-10 I63.10 Cerebral infarction due to embolism of unspecified precerebral artery I63.11Cerebral infarction due to embolism of vertebral artery I63.111 Cerebral infarction due to embolism of right vertebral artery I63.112 Cerebral infarction due to embolism of left vertebral artery I63.12 Cerebral infarction due to embolism of basilar artery I63.13Cerebral infarction due to embolism of carotid artery I63.131 Cerebral infarction due to embolism of right carotid artery I63.132 Cerebral infarction due to embolism of left carotid artery

41. Stroke I-10 I63.30 Cerebral infarction due to thrombosis of unspecified cerebral artery I63.31 Cerebral infarction due to thrombosis of middle cerebral artery I63.311 Cerebral infarction due to thrombosis of right middle cerebral artery I63.312 Cerebral infarction due to thrombosis of left middle cerebral artery I63.32 Cerebral infarction due to thrombosis of anterior cerebral artery I63.321 Cerebral infarction due to thrombosis of right anterior cerebral artery I63.322 Cerebral infarction due to thrombosis of left anterior cerebral artery

42. Stroke I-10 I63.33 Cerebral infarction due to thrombosis of posterior cerebral artery I63.331 Cerebral infarction due to thrombosis of right posterior cerebral artery I63.332 Cerebral infarction due to thrombosis of left posterior cerebral artery I63.34 Cerebral infarction due to thrombosis of cerebellar artery I63.341 Cerebral infarction due to thrombosis of right cerebellar artery I63.342 Cerebral infarction due to thrombosis of left cerebellar artery I63.349 Cerebral infarction due to thrombosis of unspecified cerebellar artery

43. 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).

45. 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

46. Late Effects Identify specific late effects Aphasia, dysphagia, neglect, hemiparesis (dominant or nondominant), etc. Identify specific insult Late effect SAH, SDH, ICH Late effect embolic stroke or localized occlusive stroke Identify when monoplegia, hemiplegia

47. Late Effects ICD-9 438.0 Cognitive deficits 438.1 Speech and language deficits 438.10 Speech and language deficit, unspecified 438.11 Aphasia 438.12 Dysphasia 438.13 Dysarthria 438.14 Fluency disorder 438.19 Other speech and language deficits 438.2 Hemiplegia/hemiparesis 438.20Hemiplegia affecting unspecified side 438.21Hemiplegia affecting dominant side 438.22Hemiplegia affecting nondominant side 438.3 Monoplegia of upper limb 438.30 Monoplegia of upper limb affecting unspecified side 438.31 Monoplegia of upper limb affecting dominant side 438.32 Monoplegia of upper limb affecting nondominant side 438.4 Monoplegia of lower limb 438.40 Monoplegia of lower limb affecting unspecified side 438.41 Monoplegia of lower limb affecting dominant side 438.42 Monoplegia of lower limb affecting nondominant side

48. 438.5 Other paralytic syndrome Use additional code to identify type of paralytic syndrome, such as: locked-in state (344.81) quadriplegia (344.00-344.09) 438.50 Other paralytic syndrome affecting unspecified side 438.51 Other paralytic syndrome affecting dominant side 438.52 Other paralytic syndrome affecting nondominant side 438.53 Other paralytic syndrome, bilateral 438.6 Alterations of sensations Use additional code to identify the altered sensation 438.7 Disturbances of vision Use additional code to identify the visual disturbance 438.8 Other late effects of cerebrovascular disease 438.81 Apraxia 438.82 Dysphagia Use additional code to identify the type of dysphagia, if known (787.20-787.29) 438.83 Facial weakness 438.84 Ataxia 438.85 Vertigo 438.89 Other late effects of cerebrovascular disease Use additional code to identify the late effect 438.9 Unspecified late effects of cerebrovascular disease

49. 1 = right dominant side 2 = left dominant side 3 = right nondominant side 4 = left nondominant side 9 - unspecified Sequelae ICD-10 4th digits: 0 = nontraumatic subarachnoid hemorrhage, 1 = nontraumatic intracerebral hemorrhage, 2 = nontraumatic intracranial hemorrhage, 3 = cerebral infarction I69.x0 Unspecified sequelae of specific type of stroke I69.x1 Cognitive deficits following specific type of stroke I69.x2 Speech and language deficits following specific type of stroke I69.x20 Aphasia following specific type of stroke I69.x21 Dysphasia following specific type of stroke I69.x22 Dysarthria following specific type of stroke I69.x23 Fluency disorder following specific type of stroke I69.x28 Other speech and language deficits following specific type of stroke I69.x3 Monoplegia of upper limb following specific type of stroke plus 6th digit for side I69.x4 Monoplegia of lower limb following specific type of stroke plus 6th digit for side

50. 1 = right dominant side 2 = left dominant side 3 = right nondominant side 4 = left nondominant side 9 - unspecified 4th digits: 0 = nontraumatic subarachnoid hemorrhage, 1 = nontraumatic intracerebral hemorrhage, 2 = nontraumatic intracranial hemorrhage, 3 = cerebral infarction I69.x5 Hemiplegia and hemiparesis following specific type of stroke plus 6th digit for laterality I69.x6 Other paralytic syndrome following specific type of stroke plus 6th digit for laterality I69.x9 Other sequelae of specific type of stroke I69.x90 Apraxia following specific type of stroke I69.x91 Dysphagia following specific type of stroke Use additional code to identify the type of dysphagia, if known (R13.1-) I69.x92 Facial weakness following specific type of stroke Facial droop following specific type of stroke I69.x93 Ataxia following specific type of stroke I69.x98 Other sequelae of specific type of stroke