Medicine Under the Microscope

1. Value Based Purchasing, Changes for ICD-10 and the Future of Radiology/Medical ImagingRobert 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 Observed Rate of Some Thing Severity Adjusted Expected Rate of That Thing =1 What Is An Index?

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. 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 Vascular catheter associated infections Pressure ulcers Iatrogenic pneumothorax following central line insertion Object accidentally left in patient Air embolism Reaction from blood incompatibility

23. Complication? • Access site injury • Pseudoaneurysm or significant hematoma? • Incidental, insignificant ecchymosis? • Hepatic artery injury • Specific obstruction, perforation, dissection • Infection • Distinguish hepatic abscess from procedure or was it already there, procedural blood stream infection vs incidental bacteremia • Nontarget embolization • Pulmonary embolism/air embolism • Iatrogenic pneumothorax – clinically significant or just minimal apical cap?

24. Goals of Implementation – Prove You Are Value Based • Competitive severity adjusted mortality and complication data • Reasonable occurrence of HACs/PSIs • Lower than average Readmissions for Pneumonia, Heart Failure, AMI • Cooperation with quality initiatives • Patient satisfaction

25. Use of X-Ray Reports for Coding ED coding using the radiological findings; Coding Clinic, 2Q2002 Page: 3 Question: A patient comes into the emergency department after he injured his ankle while running. An x-ray of the ankle was taken and read by the emergency department physician. The patient was discharged home with the diagnosis of ankle sprain, rule out ankle fracture. Upon review of the x-rays the next morning, the radiologist documents "hairline fracture of the lateral malleolus." What code should the hospital emergency department assign? Answer If the radiology report is available when the encounter is being coded and reported by the hospital, assign code 824.2, Fracture of ankle, Lateral malleolus, closed. It is appropriate to code what is known at the time of code assignment. When available, coders may use the x-ray results to provide greater specificity. When the physician has interpreted diagnostic tests, the diagnosis may be modified based on physician interpretation. If the x-ray findings were not available, at the time the hospital coded and reported the encounter, assign code 845.00, Sprains and strains of ankle and foot, Ankle, Unspecified site. The diagnosis made in the emergency department at discharge is the clinical diagnosis using clinical data available at the time of the visit.

26. Use of X-Ray Reports for Coding Clarification - Abnormal findings on radiology reports, inpatient Coding Clinic, Second Quarter 2002 Page: 17 Abnormal Findings on Radiology Reports for Inpatient Coding and Reporting Question: Our coders have reviewed with interest the advice published in the First Quarter 2000 issue regarding the coding of outpatient diagnostic testing. We are seeking clarification whether the advice regarding the coding of the abdominal x-ray diagnosis of bilateral nephrolithiasis would be applicable if the x-ray had been performed during an inpatient hospitalization, but there was no attending physician confirmation. Answer: No, the advice published in Coding Clinic, First Quarter 2000, was intended for outpatient coding and reporting. It does not apply to inpatient coding. When the attending physician does not confirm the results of the radiology report for inpatient coding, query the attending physician regarding the clinical significance of the findings and request that appropriate documentation be provided. The attending physician is responsible for coordinating all of the information from the various testing.

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. Example - Specificity Category 1–3 Etiology, anatomic site, severity, other detail 4–6 Extension 7 S52: Fracture of forearm S52.5: Fracture of lower end of radius S52.52: Torus fracture of lower end of radius S52.521: Torus fracture of lower end of right radius S52.521A: Torus fracture of lower end of right radius, initial encounter for closed fracture

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. Example - Specificity S5: trauma to forearm S52: Fracture of forearm S52.5: Fracture of lower end of radius S52.52: Torus fracture of lower end of radius S52.521: Torus fracture of lower end of right radius S52.521A: Torus fracture of lower end of right radius, initial encounter for closed fracture Category 1–3 Etiology, anatomic site, severity, other detail 4–6 Extension 7

33. Be Acquainted with Second Digit http://www.ncbi.nlm.nih.gov 0 Head • Neck • Thorax • Abd/low back/pelv • Shoulder/upper arm • Elbow/forearm • Wrist/hand • Hip/thighs • Knee/lower leg • Ankle/foot/toes

34. 0 Contusion Open wound Fracture Dislocation Injury nerves Injury vessels Muscle/fascia/tendon Crush injury Traumatic amputation Unspecified Proximal or distal Displaced or nondisplaced Eponyms of specific fracture types (Colles, Barton’s, etc.) Third Digit 4/5 Greater SpecificityGeneral type of injury of location of injury

35. Be Acquainted with Sixth Digit

36. And Then There Were Seven (Digits) … for Injuries

37. Seventh Digit - Code extension Type of Encounter for Injuries – Chapter 19 Initial Encounter Active treatment Surgery ED E/M by new phys Subsequent Encounter Routine care Healing or recovery phase Sequelae Complications or conditions that arise as a direct result of the injury Identifies injury responsible for sequelae

38. Named Fractures are Different S52.51 Fracture of radial styloid S52.511 Displaced fracture of right radial styloid S52.512 Displaced fracture of left radial styloid S52.513 Displaced fracture of unspecified radial styloid S52.514 Nondisplaced fracture of right radial styloid S52.515 Nondisplaced fracture of left radial styloid S52.516 Nondisplaced fracture of unspecified radial styloid S52.52 Torus fracture of lower end of radius S52.53 Colles' fracture S52.54 Smith's fracture Sixth digits 1 – right 2 – left 9 - unspecified

39. Femoral Shaft Fractures ICD-9 821.0 Shaft or unspecified part, closed 821.00 Unspecified part of femur 821.01 Shaft 821.1 Shaft or unspecified part, open 821.10 Unspecified part of femur 821.11 Shaft 821.2 Lower end, closed 821.3 Lower end, open Fifth digit specificity 0 - unspecified part 1 - Condyle 2 - Epiphysis, lower (separation) 3 - Supracondylar 9 - Other

40. Femoral Shaft Fractures ICD-10 S72.30 Unspecified fracture of shaft of femur S72.301 Unspecified fracture of shaft of right femur S72.302 Unspecified fracture of shaft of left femur S72.309 Unspecified fracture of shaft of unspecified femur S72.32 Transverse fracture of shaft of femur S72.33 Oblique fracture of shaft of femur S72.34 Spiral fracture of shaft of femur S72.35 Comminuted fracture of shaft of femur S72.36 Segmental fracture of shaft of femur S72.39 Other fracture of shaft of femur Sixth digit specificity 1 Displaced, right 2 Displaced left 3 Displaced unspecified 4 Nondisplaced right 5 Nondisplaced left 6 Nondisplaced unspecified

41. 820.0 Transcervical fracture, closed 820.00 Intracapsular section, unspec. 820.01 Epiphysis (separation) (upper) 820.02 Midcervical section 820.03 Base of neck 820.09 Other (head, subcapital) 820.1 Transcervical fracture, open 820.10 Intracapsular section, unspec. 820.11 Epiphysis (separation) (upper) 820.12 Midcervical section 820.13 Base of neck 820.19 Other 820.2 Pertrochanteric fracture, closed 820.20 Trochanteric section, unspecified (greater, lesser, etc.) 820.21 Intertrochanteric section 820.22 Subtrochanteric section 820.3 Pertrochanteric fracture, open 820.30 Trochanteric section, unspec. 820.31 Intertrochanteric section 820.32 Subtrochanteric section S72.00 Fracture unspec part neck of femur S72.01 Unspecified intracapsular fracture R/L S72.02 Fracture (separation) epiphysis femur (displaced, nondisplaced digits, R/L) S72.03 Midcervical fracture (d, nonD, R/L) S72.04 Base of neck fracture (d, nonD, R/L) S72.05 Unspecified fracture head R/L S72.06 Articular fracture head of femur (d, nonD, R/L) S72.09 Other fx head and neck of femur R/L S72.10 Unspec trochanteric fracture R/L S72.11 Fracture greater trochanter (d, nonD, R/L) S72.12 Fracture lesser trochanter (d, nonD, R/L) S72.13 Apophyseal fracture (d, nonD, R/L) S72.14 Intertrochanteric fracture (d, nonD, R/L) S72.2 Subtrochanteric fracture (d, nonD, R/L) Femoral Neck Fractures – 9 vs 10

42. Femoral Neck Fractures • Name the part of the neck as usual • Identify if it’s nondisplaced or displaced • State which side of the body • It just makes sense

43. NonTraumatic Fractures • M84.3 Stress fracture • M84.4 Pathologic fracture NEC • M84.5 Pathologic fracture in neoplastic disease • M84.6 Pathologic fracture in other specified disease – name the disease, too (eg., osteoporosis M80.x)

44. Bone Now the Fifth Digit http://www.ncbi.nlm.nih.gov 0 Head • Neck • Thorax • Abd/low back/pelv • Shoulder/upper arm • Elbow/forearm • Wrist/hand • Hip/thighs • Knee/lower leg • Ankle/foot/toes

45. 7th Digit Understanding • Care of complications of fractures, such as malunion and nonunion, should be reported with the appropriate 7th character for subsequent care with nonunion (K, M, N,) or subsequent care with malunion (P, Q, R). • Closed fracture code • Open fracture with Gustilo classification designation

46. A  Initial encounter for closed fracture B  Initial encounter for open fracture type I or II C  Initial encounter for open fracture type IIIA, IIIB, or IIIC D  Subsequent encounter for closed fracture with routine healing E  Subsequent encounter for open fracture type I or II with routine healing F  Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing G  Subsequent encounter for closed fracture with delayed healing H  Subsequent encounter for open fracture type I or II with delayed healing

47. J  Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing K Subsequent encounter for closed fracture with nonunion M Subsequent encounter for open fracture type I or II with nonunion N Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion P Subsequent encounter for closed fracture with malunion Q Subsequent encounter for open fracture type I or II with malunion R Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion S  Sequela

48. Allay the Fears • Think about the fracture and how you would describe it to an internist • Name the bone • Name the part of the bone involved • Name the kind of fracture (Colles, Barton’s) if there is a common name • Identify if it’s displaced or not, open or closed • If open, describe how extensive is the local damage • Choose the code that has those words in it

49. Clavicle Fractures • According to the American Academy of Family Physicians (AAFP), the anatomic site of the clavicle fracture is typically described using the Allman classification, which divides the clavicle into thirds. • Group I (midshaft) fractures occur on the middle third of the clavicle; • Group II fractures on the lateral (distal) third; and • Group III fractures on the medial (proximal) third.

50. Coding Clavicles S42.0       Fracture of clavicle S42.01     Fracture of sternal end of clavicle S42.011 anterior displaced right – 5th digits S42.012 anterior displaced left S42.014 posterior displaced right S42.015 posterior displaced left S42.017 nondisplaced right S42.018 nondisplaced left S42.02     Fracture of shaft of clavicle S42.03     Fracture of lateral end of clavicle Should never use 4th digit of 0 for unspecified part of clavicle nor 5th digit of 3, 6 or 9 for not knowing if right or left clavicle