Barbara Godbey-Miller, RHIA, CCS, CHC

1. ICD-10 Preparation: Understanding your own data to create your ICD10 Strategy for SuccessData Analytics and Audit Barbara Godbey-Miller, RHIA, CCS, CHC

2. Today’s Agenda • Step 1: Data Analytics: • Aggregate information analysis • Step 2: Audit Findings • Real results from clients • Step 3: Education • What your team needs to know

3. But First A Word About Data Governance and Clinical Documentation Integrity

4. Data Variables Clinical Documentation Program Physician Clinical Documentation Regulatory Change Managing the I-10 CDI process will require additional staff to cover increased workload. Will staffing be adequate to cover 100% of cases & what percentage of queries will go unasked or unanswered? Coding Accuracy Coding Quality Review Data Normalization Not all DRGs are created equal or have the same probability for DRG assignments errors. Data normalization without manipulation. What is your DRG risk population for change and what is the revenue impact? With increase demand for coding resources and cash flow demands, will organizations have an internal coding quality review process to identify increased coding errors? • CMS givith and take it away. Regulatory factors should be included to determine revenue impact. • Documentation & Coding Adjustment Factor • Prospective Payment System Changes • ICD-10 Oncology Grouper Changes Understanding the clinical documentation specificity of I-9, a system used for 30 years, required a CDI program to manage. What will the CDI error rate be? ICD-10 coder errors will increase with use of new system and increased requirement to interpret physician documentation requirements. What will the coding error rate be of coders and contract personnel?

5. Clinical Documentation Integrity The HIM professional’s role is to combine emerging technologies with innovative processes to meet the aims of this strategy ─ improve the quality of healthcare, improve the health of the US population, and reduce the cost of quality healthcare.

6. What is Data Governance? Making strategic and effective decisions regarding the organization’s information assets. Includes: • Defining roles and responsibilities for data • Establishing data quality policies • Creating metadata management practices • Arbitrating shared data questions • Release of Information

7. The HIM Professional’s Key to Successful Information Governance • Data or Information governance is the high-level, corporate, or enterprise policies or strategies that define the purpose for collecting data, ownership of data, and intended use of data. Accountability and responsibility flow from governance. • The Information Governance plan is the framework for the overall organizational approach to data governance.

8. Clinical Documentation Integrity The HIM professional’s role is to combine emerging technologies with innovative processes to meet the aims of this strategy ─ improve the quality of healthcare, improve the health of the US population, and reduce the cost of quality healthcare.

9. ICD-10 Analytics Approach Key activities and timing Define assessment scope Identify stakeholders Initiate ICD-10 revenue impact analysis Documentation audit Focus on high-risk MS-DRGs Assess Educational mapping Recommended remediation or mitigation of risk Recommend Put plan into action Plan

10. ICD-10 Data Analytics ICD-10 data analytics will return higher probability rates if they are fact based using a set of variables that will influence the outcomes analysis for DRG assignment predictability ICD-10 analytics are derived or analyzed using the GEMS file, which without audit is not a reliable tool to identify DRG shifts

11. Data Analytics – How its Done • 12 months of claims are processed through an analytics program for ICD-10 CM/PCS using GEMS and reimbursement maps • Data Analysts review each mapping to identify legitimate risks • Two scenarios – financial risk, operational risk • ICD-10 Auditors validate documentation on highest risk areas • Output – Physician and Coder education strategy

12. Data Analytic Analysis 2 Sites - Post Audit Results

13. Post Audit Findings

14. Scenarios Specific examples of MS-DRG changes discovered on I-10 re-code projects

15. MS-DRG SHIFT Cardiology: Patient was readmitted for treatment of post infarction angina & CAD, 1 week status post acute myocardial infarction

16. ICD-10 Re-Code: What We Discovered • MS-DRG changed due to timeframe established within ICD-10 to indicate an acute myocardial infarction • Even as a secondary diagnosis, the AMI will “drive” this MS-DRG based on grouper logic with PDX from Circulatory MDC 5 and AMI • Category I21 (AMI) is coded up to 4 weeks following the AMI regardless of reason for admission • The terminology used in ICD-9 to capture “subsequent episode of care” for AMI does not exist in ICD-10 • Subsequent AMI codes are used when a patient has a second AMI within 4 weeks of the initial AMI • NOTE: “Subsequent” refers to the MI and NOT the episode of care in ICD-10

17. Acute Myocardial Infarction • ICD-10-CM has decreased the acute phase of an acute myocardial infarction from 8 weeks or less to 4 weeks (28 days) or less. • ICD-10-CM classifies acute myocardial infarction in two separate categories. STEMI and NSTEMI • Clinical documentation will need to indicate laterality. Additional specificity is required to identify the anatomical site affected I21.02 ST elevation (STEMI) myocardial infarction involving left main coronary artery Laterality

18. Subsequent Myocardial Infarction • ICD-10-CM has added a category for subsequent myocardial infarction. • Subsequent is identified as a myocardial infarction occurring within 4 weeks (28 days) of a previous myocardial infarction. • Clinical documentation must include the type of subsequent myocardial infarction Example: A patient is admitted with a subsequent STEMI of the anterior wall 7 days after being discharged for a STEMI of left main artery, anterior wall I22.0 subsequent STEMI myocardial infarction of anterior wall I21.01 STEMI myocardial infarction involving left main coronary artery of anterior wall Code indicates this is the subsequent MI Code indicates this was the first MI

19. Potential Readmission Flag ICD-9 Acute Myocardial Infarction – 8 weeks ICD-10 Acute Myocardial Infarction – 4 weeks Readmission Risk if patient winds up back in the hospital in 30 days. Zero additional payment – potential gain may be lost in this instance

20. MS-DRG SHIFT Cardiology: Patient was admitted with AMI and had coronary intervention with four drug-eluting stents.

21. ICD-10 Re-Code: What We Discovered • MS-DRG changed due to the fact that even though patient had four drug-eluting stents inserted there were only three sites being treated • In ICD-10- PCS, the code is assigned based on number of sites being treated rather than number of stents inserted • Occasionally, this will result in lower-weighted DRG assignment in ICD-10

22. Documenting Procedures • Clinical documentation for all procedures will require documentation identifying the following: • General physiological system or anatomical region involved • What type of procedure was performed root operationadministration, dilation, drainage, biopsy, excision, resection, bypass, transplantation • The exact anatomical site of the procedure body part • Right, left, bilateral • The technique used to reach the site surgical appro achopen, closed, laparoscopic, percutaneous, endoscopic, needle • If adev ice was used, what site/area was the device placed (e.g. stent, graft, implant) • If the procedure was for diagnostic purposes Body system Root Operation Body part Laterality Surgical approach Device Qualifier

23. Documenting Procedures • When a PTCA is performed, clinical documentation by the physician must indicate how many sites were dilated and what device was utilized for “each” site. Example: OR report indicates that patient had PTCA of both the left anterior descending artery and the right coronary artery. A drug-eluting stent was placed in the right coronary artery. 02703ZZ Dilation, Artery, Coronary, One Site 027034Z Dilation, Artery, Coronary, One Site No stent inserted Two codes required to identify procedure on each artery Stent inserted

24. MS-DRG SHIFT Medicine: Patient was admitted for treatment of anemia secondary to ESRD. Patient also has hypertension.

25. ICD-10 Re-Code: What We Discovered • MS-DRG changed due to change in principal diagnosis per sequencing instructions in ICD-10-CM Official Coding Guidelines • Anemia in chronic kidney disease is a classified as a manifestation of chronic kidney disease • Manifestation codes cannot be assigned as principal diagnosis • Notes instruct to code first the underlying disease of ESRD • Under ESRD, there is another instructional to code first any hypertensive chronic kidney disease

26. Chronic Kidney Disease ICD-10-CM uses the following table to identify the stage of kidney disease

27. Hypertensive Diseases • Clinical documentation for hypertension in ICD-10-CM should be described as accelerated, benign, essential, idiopathic, malignant, and systemic I10 Essential (primary) hypertension Documentation by physician indicates Essential

28. Hypertensive Diseases • ICD-10-CM presumes a cause-and-effect relationship between hypertension and chronic kidney disease. Clinical documentation will need to include the stage of chronic kidney disease. I12 Hypertensive Kidney Disease N18.5 Chronic Kidney Disease, Stage 5 Clinical documentation indicates hypertension and chronic kidney disease Clinical documentation requires the correct staging of the chronic kidney diseases

29. Hypertensive Diseases Example: A 68-year-old gentleman is admitted with hypertension, heart disease, acute on chronic CHF, and stage 4 renal disease. The physician documents that the heart disease is associated with the hypertension. I13.10 Hypertensive heart and chronic kidney disease with heart failure, with stage I-IV CKD N18.4 Chronic Kidney Disease, Stage 4, severe I50.33 Acute on chronic diastolic heart failure Code shows hypertension, heart disease, CHF, and stage 4 renal disease all combined in one code Additional codes show stage of CKD and specificity of heart failure

30. Chronic Kidney Disease with Hypertension • ICD-10-CM presumes a relationship between chronic kidney disease and hypertension. • Clinical documentation for hypertensive kidney disease will also require identification of the stage of kidney failure I12 Hypertensive Kidney Disease N18.5 Chronic Kidney Disease, Stage 5 Disease Stage of CKD

31. Hypertensive Heart and CKD Case Study A 68-year-old gentleman is admitted with hypertension, heart disease, acute on chronic CHF, and stage 4 renal disease. The physician documents that the heart disease is associated with the hypertension. I13.10 Hypertensive heart and chronic kidney disease with heart failure, with stage I-IV CKD N18.4 Chronic Kidney Disease, Stage 4, severe I50.33 Acute on chronic diastolic heart failure Disease Stage of CKD Type of Heart Failure

32. MS-DRG SHIFT Medicine: Patient was admitted for treatment of anemia secondary to lung cancer

33. ICD-10 Re-Code: What We Discovered • MS-DRG changed due to change in principal diagnosis per sequencing instructions in ICD-10-CM Official Coding Guidelines • When the admission is for management of an anemia associated with malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis followed by code D63.0, Anemia in neoplastic disease

34. Anemia in Chronic Diseases • ICD-10-CM classifies anemia in chronic diseases into several categories. Clinical documentation will be required to identify the type of chronic anemia as well as the associated cause • Anemia in neoplastic disease • Documentation will need be required to identify associated neoplasm • Anemia in chronic kidney disease • Documentation will be required to identify the stage of chronic kidney disease • Anemia in other chronic disease

35. Acquired Aplastic Anemia • Clinical documentation for acquired aplastic anemia should indicate the cause as follows: • High-dose radiation or chemotherapy • Environmental toxins • Medications • Viral infections • Autoimmune disease • Paroxysmal nocturnal hemoglobinuria

36. MS-DRG SHIFT Surgery: Patient was admitted with rectal bleeding and peritoneal abscess. Treatment included partial resection of ileum and lysis of peritoneal adhesions.

37. ICD-10 Re-Code: What We Discovered • MS-DRG changed due to the fact that a partial small bowel resection (ileum in this case) no longer groups to major small and large bowel procedures DRG in ICD-10 • Surgical hierarchy dictates the principal procedure selection • In this case, the lysis of adhesions overrides any other procedure performed based on surgical hierarchy

38. MS-DRG SHIFT Pulmonary: Patient was admitted with exacerbation of COPD. Patient also had accelerated hypertension which was treated.

39. ICD-10 Re-Code: What We Discovered • MS-DRG changed due to the fact that a specific code for accelerated or malignant hypertension does not exist in ICD-10 thereby, eliminating the ability to capture CC • There is only one code for hypertension in ICD-10 which encompasses all types and is NOT classified as a CC

40. Diseases of the Gastroenterology System • Clinical terminology used to describe diseases of the digestive system and has been updated to reflect advances in diagnosis and procedures as well as greater specificity Example: ICD-9-CM 555.1 Regional enteritis large intestine ICD10-CM K50.10 Crohn’s disease of large intestine without complications K50.111 Crohn’s disease of large intestine with rectal bleeding K50.112 Crohn’s disease of large intestine with intestinal obstruction K50.113 Crohn’s disease of large intestine with fistula K50.114 Crohn’s disease of large intestine with abscess K50.118 Crohn’s disease of large intestine with other complication K50.119 Crohn’s disease of large intestine with unspecified complications

41. Diseases of the Digestive System • Terminology for many of the categories in gastroenterologyhave been updated to reflect current terminology. • The gastroenterology category contains specific respiratory diagnosis codes for infections, inflammations, causative organisms, and external agents • The physician will be required to document details such as • Specific forms of the disease • Site of the disease/disorder • Laterality • Causative organism • External agents • Associated conditions • Acuity

42. Additional Documentation for Gastroenterology • ICD-10-CM requires additional documentation to identify external factors attributing to diagnoses within this category. Clinical documentation will be required to show associated causes such as: • Alcohol abuse and dependence • Exposure to environmental tobacco smoke • Exposure to tobacco smoke in the perinatal period • History of tobacco use • Occupational exposure to environmental tobacco smoke • Tobacco dependence • Tobacco use

43. Regional Enteritis (Crohn’s Disease) • ICD-10-CM categorizes regional enteritis (Crohn’s Disease) by site: • Small intestine • Large intestine • Both small and large intestine • Clinical documentation will also be required to identify any associated complications such as: • Abscess • Fistula • Intestinal obstruction • Rectal bleeding • Other specified complication K50.114 Crohn’s disease of large intestine with abscess Disease Location Complication

44. Ulcerative Colitis • Clinical documentation for ulcerative colitis in ICD-10-CM will require identification of the site of ulcerative colitis or other condition within this category, such as: • Inflammatory polyps • Left sided colitis • Panocolitis (enterocolitis, ileocolitis, universal colitis) • Proctitis • Rectosigmoiditis (proctosigmoiditis) • Other specified site • Additional documentation will be required to identify any associated complication, such as: • Abscess • Fistula • Intestinal obstruction • Rectal bleeding • Other specified complication

45. Diverticulosis/Diverticulitis • Clinical documentation will be required to identify between diverticulosis and diverticulitis • Specificity will be required to identify the location of the disease as: • Small intestine • Large intestine • Both small and large intestine • Additional documentation will be required to identify any associated conditions such as: • Perforation • Abscess • Bleeding K57.32 Diverticulitis, large intestine, without perforation or abscess, without bleeding Disease No associated conditions Location

47. Documenting Procedures • Clinical documentation for all procedures will require documentation identifying the following: • General physiological system or anatomical region involved • What type of procedure was performed root operationadministration, dilation, drainage, biopsy, excision, resection, bypass, transplantation • The exact anatomical site of the procedure body part • Right, left, bilateral • The technique used to reach the site surgical a open, closed, laparoscopic, percutaneous, endoscopic, needle • If ad evicwasused, what site/area was the device placed (e.g. stent, graft, implant) • If the procedure was for diagnostic purposes Body system Root Operation Body part Laterality Surgical approach Device Qualifier

48. Partial Large Bowel Resection Operating Room Report indicates open right hemicolectomy with end-to-end anastomosis for treatment of large carcinoid tumor No Device Large Intestine, Right ODT F 0 Z Z No Device Resection Open Approach

49. Chronic Obstructive Pulmonary Disease • The following conditions are classified in this category: • Asthma with chronic obstructive pulmonary disease • Chronic asthmatic (obstructive) bronchitis • Chronic bronchitis with airways obstruction • Chronic bronchitis with emphysema • Chronic emphysematous bronchitis • Chronic obstructive asthma • Chronic obstructive tracheobronchitis • Clinical documentation of chronic obstructive pulmonary disease should identify any associated acute exacerbation or lower respiratory infection J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection J20.2 Acute bronchitis due to streptococcus Disease Associated Condition/Organism

50. Emphysema • Clinical documentation for emphysema should include a full description of the disease and document the specific types as: • Unilateral emphysema (MacLeod’s syndrome) • Centrilobular emphysema • Panlobular emphysema • Other emphysema • Unspecified emphysema • Clinical documentation should also include any associated exposures such as: • Exposure to environmental tobacco smoke • History of tobacco use • Occupational exposure to environmental tobacco smoke • Tobacco dependence • Tobacco use