Coding in Germany - The Use of ICD-10 for Diagnoses

Transcription

1 Coding in Germany - The Use of ICD-10 for Diagnoses Dr. Thomas Mansky, TU Berlin Th. Mansky, HIMSS DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

2 Conflict of Interest Disclosure Dr. Thomas Mansky Other: Travel expenses related to conference partially paid by 3M Health Information Systems, Germany 2012 HIMSS 2

3 Learning Objectives How ICD-10-CM increases the level of details For two examples understand what kind of details were added in ICD-10 diagnosis coding Do all details matter clinically? There is no new medicine But new information is needed for coding Translation is not enough, revision of coding strategies is needed What technical changes are there affecting IT demands? How is reimbursement affected? 3

4 Coding in Germany ICD 9 used for inpatients since 1986 ICD 10 introduced for inpatients 2000 ICPM-based procedure coding since 1995 G-DRG introduction 2003 Classifications and DRG system revised every year 4

5 Coding in Germany In Germany coding is mostly done by the doctors treating the patients They know what they treated In the USA coding is mostly done by professional coders They depend on the information they get 5

6 Level of Detail Classification # of Codes Germany # of Codes USA ICD-9-CM # of Codes USA ICD-10-CM ICD-10 13,348 13,000 68,000 Procedures 27,990 4,000 72,000 DRG (2011) 1,

7 Medical View The basic structure of ICD-10 is very similar to ICD-9 In many cases ICD-10 is medically more appropriate than ICD-9 ICD-10-CM is much more detailed For doctors who are directly involved in the treatment it might be easier to find an appropriate code 7

8 Example: Stroke ICD-9-CM / Occlusion and stenosis of precerebral arteries 0 without mention of cerebral infarction 1 with cerebral infarction Basilar artery Carotid artery Vertebral artery Multiple and bilateral Other specified precerebral artery Unspecified precerebral artery 6 possible codes for this type of cerebral infarction (with occl./stenosis of precerebral arteries) 8

9 Example: Stroke ICD-9-CM / Occlusion of cerebral arteries 0 without mention of cerebral infarction 1 with cerebral infarction.0 /.1 /.9 <affected artery> 435 Transient cerebral ischemia.0 /.1 /.2 /.3 /.8 /.9 <affected artery> 436 Acute, but ill-defined, cerebrovascular disease Apoplexy, apoplectic: NOS Attack Cerebral Seizure Cerebral seizure

10 Example: Stroke ICD-10-CM I63 Cerebral infarction I63.0 Cerebral infarction due to thrombosis of precerebral arteries I63.01 Cerebral infarction due to thrombosis of vertebral artery... I63.03 Cerebral infarction due to thrombosis of carotid artery I Cerebral infarction due to thrombosis of right carotid artery I63.1 Cerebral infarction due to embolism of precerebral arteries... I63.2 Cerebral infarction due to unspecified occlusion or stenosis of precerebral arteries I63.4 Cerebral infarction due to embolism of cerebral arteries > 70 codes 10

11 Example: Stroke The unspecific code I64 (corresponding to '436 ill-defined disease' in ICD-9) which is present in WHO ICD-10 has (intentionally) been omitted in ICD-10-CM This supports more precise coding for reimbursement (DRG) 11

12 What is different? ICD-9-CM: Occlusion (unspec.) affected artery (6) with/without infarction ICD-10-CM Infarction type of occlusion: thrombosis / embolism / unspec. // special) affected artery: unspec. precerebral / vertebral / carotid / basilar / unspec. cerebral / middle anterior posterior cerebral / cerebellar / venous thrombosis / other / unspec. (>11) side: right / left (where applicable) 12

13 ICD-10-CM Advantage The hierarchy changed, i.e. the Cerebral Infarction (major form of stroke) has become an entity of its own This is basically more appropriate with respect to the clinical view 13

14 ICD-10-CM Disadvantage The CM adds a lot of details: I Cerebral infarction due to thrombosis of right carotid artery I Cerebral infarction due to embolism of right carotid artery While this is a good nosologic view of the disease, in many patients it would require sophisticated scientific investigations to find out which it was 14

15 Medical Practice (stroke) A doctor would usually state that there was an ischemic stroke due to stenosis (or occlusion) of the right carotid artery, thus the code would be: I Cerebral infarction due to unspecified occlusion or stenosis of right carotid arteries 15

16 What Do We Learn Here? There are many details in ICD-10-CM, but in real life many may not be used as the clinical information is not present to such level of detail and sometimes not even relevant for treatment Other medically important details, which are usually known (e.g. degree of stenosis as known from Doppler- Ultrasound) are unfortunately missing 16

17 Stroke: Walk from 9 to 10 Stroke codes of ICD-9-CM did not contain many of the details required for ICD-10-CM type of occlusion (embolism etc.) and affected artery (carotid etc.) did not have to be coded or were less detailed Consequence: A simple mapping list would not help at all Moving from more detail to less is easy, moving from less to more cannot be fully automized 17

18 Stroke: From 9 to 10 Medically nothing will change: Much of the additional information needed is already there in the medical record today, but it has to be found and coded in a new way in future Remember: There are new things to look for and to understand more later 18

19 Example: Hip Fracture in ICD-9-CM 820 Fracture of neck of femur Transcervical fracture, closed Transcervical fracture, open Pertrochanteric fracture, closed Pertrochanteric fracture, open Unspecified part of neck of femur, closed Hip NOS Neck of femur NOS Unspecified part of neck of femur, open 19

20 Example: Hip Fracture in ICD-10-CM S72.0 Fracture of head and neck of femur with 36 subcodes S72.1 Pertrochanteric fracture with 27 subcodes i.e. very many details 20

21 Right / left ICD-10-CM Hip Fracture Details Part: unspecified, intracapsular, epiphysis, midcervical, head, neck... Displaced / nondisplaced Many very specific details which might be found in X-ray- or OR-report 21

22 What Do We Learn Here? Again: Medically nothing would change; information is already there, but has to be found in the record The details are again listed in a very systematic and detailed way, but probably more detailed than needed for purposes like reimbursement The choice of the major procedure would be more important 22

23 Further Remarks Time is not sufficient to go through all details It should be mentioned, in short, that external causes of morbidity (E-codes in ICD-9) have been integrated in ICD- 10 The chapter covering mental and behavioural disorders has undergone a major revision as compared to ICD-9 (this is less DRG-relevant) 23

24 What Do We Learn? Coders need to find very specific information in the medical record, which was not needed before Usually this information would often already be somewhere in the medical record In some cases physicians might have to add details which had not been previously included 24

25 Focus on What is Important Not all details in ICD-10-CM will be important for reimbursement For each major disease, find out what would probably be the details needed for DRG differentiation e.g. DX causing different ressource use many DX codes may leed to same DRG Focus on the relevant issues first 25

26 Don't Forget CCs! Analyze coding of comorbidities and complications in your hospital Check the more important codes against the new ICD-10 CC-list contained in the new DRG manual as soon as it becomes available Make sure that more specific codes are used, if appropriate, in order not to miss higher severity levels 26

27 Do Not Change Medicine Medical diagnosis and treatment must serve the patient, not the coder The issue must be to clarify what information is there as part of the medical process and where it can be found in the record Do not require information just because there are codes for it 27

28 Source of Information Coders will often have to use some information from the medical record, which they did not need previously X-ray, OR-report, ultrasound etc. This requires a lot of learning and new understanding However this should not be a fundamental problem 28

29 Affected Areas in Coding Codelists or hitlists may be present at many different sites in your hospital X-ray, OR, endoscopy, laboratory for infection codes, etc. etc. etc. All these lists have to be revised 29

30 Other Affected Areas ICD codes might be used in very different (non-medical) areas for example, contracting All these areas have to be identified The codes used must be revised according to their purpose; simple translation will often not be sufficient Teamwork between coders, physicians, administration is advisable Other areas should be updated externally for example, quality control AHRQ IQI use ICD codes, but should be updated by AHRQ 30

31 Some IT Problems ICD-10-CM is alphanumeric (ICD-9 was in some parts) with up to 7 characters If there (still) would be systems, which treat the ICD code as a numeric field or if the fields are too short, action would be needed Code reference tables have to be updated where necessary (similar to yearly ICD-9-CM updates) Statistics might have to be revised if certain aggregation levels are needed Checklist: Where is ICD used in my system? What must be done for transition? 31

32 High Importance Need to update any process that uses ICD-9 codes today before ICD-10 goes live Management process, top level involvement needed Coders may take the lead in practice Checklists should be prepared and be worked through 32

33 Relation to DRG Reimbursement In the beginning many new details will not have major effects on DRGs as cost differences are not yet known Many codes differentiating new details will end up in the same DRG, thus the risk of transition is limited (but not zero) After a few years new details might be used for more precise DRG definitions if they affect resource use 33

34 Risks for Reimbursement If appropriate care is taken in coding, the risks for reimbursement should be limited However this cannot be taken for granted good preparation is needed 34

35 Conclusions ICD-10-CM diagnosis coding will require new clinical information Simple mapping of ICD-9 to ID-10 is not enough; revision of information requirements and work flow is needed Use of ICD code lists in the hospital has to be identified and appropriately adopted A well managed revision process has to be set up There are risks to reimbursement, which should be limited if the transition process is well managed 35

36 Thank you! Prof. Dr. Thomas Mansky Technische Universität Berlin Strasse des 17. Juni 135 D Berlin GERMANY