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1 What the Data Is Telling Us About ICD 10 Coding and Documentation Mark Morsch, MS Vice President of Technology Optum360 San Diego, CA 1 Learning Objectives At the completion of this education activity, the learner will be able to: Determine the accuracy of ICD 10 predictions Compare the general results of ICD 10 coding and documentation from organizations that prepared using dual coding or applying technology Discuss takeaways for continued clinical documentation improvement 2 Perspectives on ICD 10 Early phase Research studies on productivity, quality, and denial Forecasts based upon experience in other countries Implementation preparation Provider testing results Dual coding and new technology (i.e., CAC) Post implementation Production results and trends Documentation improvement opportunities 3

2 ICD 10 Assessing the Predictions Impact areas Productivity impact Coding results & quality DRG shifts Codes reported per case CDI opportunities Prediction 30% to 50%+ for coding Increase above 5% Minimal shifts per CMS Significant increase in certain specialties Increase in CDI queries for ICD 10 specificity 4 Coding Productivity Research Study Results Prevailing estimate: 30% to 50% loss Productivity ICD 9 ICD 10 Avg min/chart Avg charts/hr ICD-10 % coding time increase Negative correlation between productivity and accuracy Training and experience matter Avg Trainer Avg Avg Basic Consider time limits Series Source: Stanfill et al, Preparing for ICD 10 CM/PCS Implementation: Impact on Productivity and Quality. Perspectives in Health Information Management. 5 ICD 10 Early Adopters ICD 10 implementation date delay gave providers more time to assess and mitigate impact Dual coding and ICD 10 early adopters focused on staff training and system testing/validation Typical dual coding goals Mitigate productivity loss Production coding experience Augment documentation improvement efforts Mitigate avoidable DRG shifts Collect analytics to validate transition efforts 6

3 ICD 10 Early Adopter Testing Summer 2015 Acute care facility 100 cases, timed Observation and a variety of inpatient claims Coders were experienced with CAC tool and used CAC during testing Results 28% coding productivity loss Participants coded ICD 10 after ICD 9 Provider expected less impact than forecast due to use of tools such as CAC 7 ICD 10 Early Adopter Testing Summer 2015 Pediatric study 328 cases dual coded Same day surgery, obstetrics, inpatient All lengths of stay Expect less than 10% initial loss Coding time same for ICD 9 and ICD 10 Only 3% of ICD 10 flagged for review Expect return to baseline once coders Gain confidence Have an opportunity to use the classification system Are comfortable with the CAC tool 8 ICD 10 Early Adopter Coding Quality Coding systems, such as CAC, provide data to measure coding quality Database of code assignments and edits Coding variance = instances in which CAC suggested codes are deemed correct though different from coder assigned codes Addressing coding variance Coder education Review of coding procedures Documentation review 9

4 ICD 10 Early Adopter Coding Variance Significant coder variance in diagnoses and procedures Early adopter data covered 32,000 coded cases IP and OP Coder edits reviewed to determine agreement with coding guidelines and clinical documentation Coding variance 47% Coding variance 50% ICD 10 CM ICD 10 PCS Correct edit 53% Correct edit 50% 10 DRG Shift Estimates 10,759,276 claims GEMs mapped ICD 10 1,659 claims Natively coded ICD 10 Case shift: 1% Case shift: 18% 55% 45% 56% 44% Lower Higher Lower Higher Source: Estimating the Impact of the Transition to ICD 10 on Medicare Inpatient Hospital Payments (2013) Source: Early adopter provider, acute care study (2014) 11 ICD 10 Early Adopters Codes Per Case Average codes per case Inpatient Dx Observed dual-coding early adopter codes per case Acute care hospital aggregate Outpatient Dx Inpatient Px ICD 9 CM IP DX ICD 9 CM OP DX ICD 9 PCS IP PX Pediatric averages lower, but consistent between ICD-9 and ICD-10 12

5 ICD 10 Early Adopters CDI Opportunities Type and acuity of congestive heart failure Type of cerebrovascular accident Acuity of deep vein thrombosis Body region for chemotherapy Type of contrast in cardiac catheterizations Repair of OB lacerations 13 ICD 10 Early Adopters Type and Acuity of CHF Discharge summary BRIEF HISTORY AND HOSPITAL COURSE: This patient is a 79 year old white female who has had previous stroke, with severe dementia, currently in a nursing home. She does have diabetes, chronic kidney disease and chronic heart failure with an ejection fraction of 30%. She was brought to the hospital at this time with altered mental status for a couple of days since she was actually combative on admission day and even required oxygen up to 5 L, but the chest x ray showed no acute abnormality. Urinalysis was positive for UTI. After admission she also had a CT of the abdomen which reported ascites with possible rightsided heart failure. After admission, she was treated with Lasix and breathing treatment, oxygen eventually down to 2 L and she has been Type and acuity of congestive heart failure not completely documented 14 ICD 10 Early Adopters Type and Acuity of CHF Consultation IMPRESSION AND PLAN: 01. Aortic stenosis, non rheumatic: Echocardiography findings suggest severe aortic stenosis. The patient has CHF and a mildly depressed LVEF with her severe AS. I had a long discussion with the family re: symptomatic severe aortic stenosis. Over time as an outpatient, I will be able to make a better judgment of her candidacy for valvular intervention, and consider invasive treatments if appropriate. 02. Acute on chronic diastolic heart failure: She appears to be volume overloaded. She has noted improvement of her SOB with increased urine output on IV Lasix. She will require 1 2 more days of IV diuresis. 03. Chronic kidney disease, Stage III (moderate Discharge summary DISCHARGE DIAGNOSES: 1. Acute on chronic systolic congestive heart failure exacerbation with ejection fraction 45% to 50% at last echo in January Conflicting type of congestive heart failure documented in the same record 15

6 ICD 10 Early Adopters Type of CVA Patient 1 Discharge summary DISCHARGE DIAGNOSES: 1. Acute right thalamic cerebro vascular accident. 2. Left hemiplegia, dense secondary to number 1 (one). 3. Accelerated hypertension. Patient 2 Discharge summary DIAGNOSES AT THE TIME OF DISCHARGE: 1. Acute cerebro vascular accident with severe neurologic deficits. 2. Aphasia, dysphagia. 3. Altered mental status/encephalopathy. Type of cerebrovascular accident not completely documented Patient 3 Discharge summary DISCHARGE DIAGNOSES: 1. Acute ischemic stroke, left parietal location. The patient has been examined by physical therapy and no further rehabilitation or therapy is needed at this time. The patient is fully functional and 16 ICD 10 The New Y2K? Impact areas Productivity impact Coding results & quality DRG shifts Codes reported per case CDI opportunities Results 30% or less in general Big initial impact, improving Small drop in early months Increase seen in IP Early adopter areas confirmed with some new opportunities 17 Coding Productivity Impact in First Month Average across 78 organizations using CAC Nine month average for ICD 9 Jan 2015 Sep 2015 vs ICD 10 Oct 2015 IP: 18.8% AMBS: 3.25% ED: 10.6% DIAG: 6.2% ICD 9 can include time for those orgs dual coding Cases/hour ICD 9 ICD 10 18

7 Coding Productivity Impact After 4 Months Average across 78 organizations using CAC Nine month average for ICD 9 Jan 2015 Sep 2015 vs ICD 10 Jan 2016 IP: 9.2% AMBS: +13.5% ED: +1.1% DIAG: +18.1% ICD 9 can include time for those orgs dual coding Cases/Hour ICD 9 ICD Coding Productivity Trend Line IP IP Linear (IP) /4/ /11/ /18/ /25/ /1/ /8/ /15/ /22/ /29/ /6/ /13/ /20/ /27/2015 1/3/2016 1/10/2016 1/17/2016 1/24/2016 1/31/ Coding Variance Trends First Month Expected high variance due to coder learning curve Improved from early adopters but several common areas of variance Appropriate reporting of diagnoses from past medical history Nicotine use and dependence Sign and symptom coding Body character for VAD ICD 10: Oct 2015 Correct edit 76% Sample of 3356 IP and OP cases with code edits Coding variance 24% 21

8 Coding Variance Trends After 4 Months Coding variance is reduced but additional areas monitored revealing other issues Expect continued slow improvement Osteoarthritis and arthritis Psychoactive substance use Use of screening codes Tracheostomy approach Augmentation of labor ICD 10: Jan 2016 Correct edit 80% Coding variance 20% Sample of 1,249 IP and OP cases with code edits 22 DRG Shifts Short term and long term perspective Surgical categorization for minor procedures Short term Significant impact on MCC/CC capture rate for first month or two Varied by facility, but MCC/CC capture rate drop of 5% 10% was observed at certain facilities Likely tied to coding quality and learning curve Long term More data needed, but generally consistent with pre ICD 10 expectations No drop in CDI opportunities 23 Steps for Attendees to View/Answer POLLING QUESTIONS 1. Navigate to the event Agenda in the main menu 2. Tap the name of the current session to view the session details page 3. Tap Polls 4. Tap the name of the poll 5. Tap your answer choice and then tap Submit 24

9 Polling Question 1 Is Your Organization Observing MS DRG Shifts post ICD 10? None or very minimal shifts Observing shifts in expected areas Observing shifts in expected and some unexpected areas Don t know or no data 25 Is Your Organization Observing MS DRG Shifts Post ICD 10? None or very minimal shifts Observing shifts in expected areas Observing shifts in expected and some unexpected areas Don t know or no data 26 Surgical Categorization Change Some cases with minor procedures are being categorized as surgical that weren t before Examples include banding of esophagus, scout endoscopy, insertion of A line, paracentesis, FNA biopsy of lymph nodes, BAL Suspected grouping issue caused by application of GEMs when ICD 10 grouping logic was designed Confirmation of issue and resolution is still pending recommend to identify these charts for potential risk Looking for potential resolution in 2017 IPPS update 27

10 Codes Reported Per Case ICD 9 vs. ICD 10 Average codes per case Inpatient Dx One-month comparison Aug 2015 vs. Jan 2016 Outpatient Dx 3.81 Inpatient Px ICD 9 CM ICD 9 CM ICD 9 PCS Data from two early adopter organizations 28 Post Implementation CDI Opportunities ICD 10 documentation issues we continue to see from early adopters Type and acuity of congestive heart failure Type of cerebrovascular accident Repair of OB lacerations Other ICD 10 opportunities Blood loss with anemia Cemented vs. uncemented joint replacement 29 Polling Question 2 How has ICD 10 affected CDI opportunities for your organization? No changes, basically same number of opportunities as pre ICD 10 Initial increase in opportunities, but decreasing over time Sustained increase in CDI opportunities. Decrease in CDI opportunities Don t know or no data 30

11 How Has ICD 10 Affected CDI Opportunities for Your Organization? No changes, basically same number of opportunities as pre ICD 10 Initial increase in opportunities, but decreasing over time Sustained increase in CDI opportunities Decrease in CDI opportunities Don t know or no data 31 ICD 10 Post Implementation Repair of OB Lacerations Delivery record With next contraction head delivered LOA with nuchal cord x1 easily reduced over 2nd degree perineal laceration. Anterior shoulder delivered without delay. Attempted to clamp/cut cord immediately but infant with spontaneous cry. VMI, apgars 8 and 9, normal 3VC. Infant placed on maternal abdomen and assessment performed by NICU CNP. Placenta delivered intact, uterus explored, no retained POC noted. 2nd degree perineal laceration repaired with 3 0 vicryl in the usual fashion. Repair of OB lacerations documentation can lead to miscoding. Coders assigning 2nd degree OB laceration repairs using OHQNXZZ (skin repair of perineum). The correct code is OKQM0ZZ (muscle repair of perineum). Please see Coding Clinic, Fourth Quarter 2013, p ICD 10 Post Implementation Blood Loss With Anemia Consultant note: CHIEF COMPLAINT: This 66 year old female presents for f/u ileus, DM2. ILEUS: resolved, tolerating reg diet Post op anemia: hgb > 10 CBC next week as OP DM2: resume Glimepiride Cont Accu Checks Refusing Lispro ISS Hypothyroidism: On Synthroid Link between anemia and causative factor, such as postoperative blood loss, should be documented to assign most specific code, such as D62, acute posthemorrhagic anemia. Please see Coding Clinic, Third Quarter

12 ICD 10 Post Implementation Cemented vs. Uncemented Joint Replacement Procedure note Procedure: Right direct anterior hip arthroplasty. Anesthesia: General with Duramorph spinal. Estimated blood loss: 150 ml. IV Fluids: 2600 ml crystalloid. Implants: Stryker Tritanium hemispherical cluster hole shell, 48 mm outer diameter with one 6.5 x 25 mm cancellous bone screw, and a Trident X3 0 degree polyethylene insert, neutral 32 mm inner diameter with a Depuy Corail femoral stem, standard offset, size 12 with a collar and a Biolox Delta ceramic femoral head, +1, 32mm diameter. Documentation lacking mention of cementing does not necessarily indicate that the replacement was uncemented. Use of cement should be clearly documented or 7 th character of Z is used, No qualifier. 34 Conclusion ICD 10 coding productivity trends are much better than predicted across IP and OP Training, experience, and technology have mitigated the productivity loss Coding variance analysis has identified quality as a potential issue target areas for education IP having small increase in codes per case CDI opportunities continue with core challenges carrying over from ICD 9 35 Thank you. Questions? Mark.Morsch@optum360.com In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide. 36