Real World Experience In Recoding Charts In ICD-10

Transcription

1 Real World Experience In Recoding Charts In ICD-10 By Karen G. Youmans, MPA, RHIA, CCS President, YES HIM Consulting, Inc. YES HIM Consulting, Inc.

2 OVERVIEW AND BACKGROUND INFORMATION During April-May 2013, YES HIM Consulting, Inc. consultants recoded 2720 inpatient encounters from 4 th Qtr 2012 from one healthcare system. The healthcare system consists of 9 hospitals including small acute care facilities, Children s and Women s hospitals and large acute care facilities. The encounters were selected by the healthcare system to represent their various patient populations and MS-DRGs. The inpatient encounters encompassed all 989 MS-DRGs for both Medicare and Managed care payers. The main purpose and scope of the recoding project was originally to provide coded data to the healthcare system for them to compare the ICD-9 MS-DRG assignment to the ICD-10 MS-DRG assignment and develop a financial impact. However, the experience of the YES consultants was priceless. Eight (8) YES HIM Consulting, Inc. consultants recoded the encounters. The YES consultants all have years of ICD-9 coding experience along with ICD-10 training including possessing the AHIMA-approved ICD-10-CM/PCS Trainer status. Also, all eight consultants have worked with YES for no less than four (4) years on ICD-10 documentation gap analysis reviews. The objective was to recode all inpatient encounters in ICD-10 and calculate the MS-DRG. The goal was to code 3.25 charts an hour and to complete the assignment within six weeks. RECODING PROCESS The healthcare system provided to YES all the patient demographics along with the ICD-9 codes and MS-DRG assignment for the 2720 inpatient encounters in MS Excel format. The YES project manager assigned each consultant a data file consisting of a specific hospital with various MS-DRGs to total 100 encounters at a time. The consultants then uploaded the data into the TruCode encoder into the ICD-9 tab. The example below displays the TruCode ICD-9 tab for a patient encounter coded for diverticulitis of the colon with an abscess and an abdominal paracentesis grouped to MS-DRG 391: YES HIM Consulting, Inc. 2

3 The YES consultants then reviewed the specific patient medical record source documents within the healthcare system s EHR to assign the ICD-10 codes via TruCode. TruCode provided the consultants with the ICD- 10 encoder, ICD-10 references, and ICD-10 MS-DRG assignments. The image below displays the TruCode ICD-10 tab for the same patient encounter recoded for diverticulitis of the colon with an abscess along with the abdominal paracentesis which grouped to MS-DRG 392. The YES consultants could click on the TruCode ICD-9 tab to review the healthcare system s code and MS-DRG assignments for comparative analysis. The YES consultants utilized TruCode s custom field 1 to indicate the finalization of the ICD-10 code and MS-DRG assignments for each of the 2720 recoded inpatient encounters. In this example, the consultant would select ID #2 Dx code not CC/MCC in ICD-10 as the abscess is no longer a separate code and not an MCC. YES HIM Consulting, Inc. 3

4 Additionally, all ICD-10 code and MS-DRG assignments were uploaded into the CMS pilot grouper for comparison to the TruCode ICD-10 grouper. All ICD-10 MS-DRG assignments grouped the same in the Tru- Code ICD-10 grouper and the CMS pilot grouper. If the MS-DRG assignment was not the same as the original ICD-9 MS-DRG recoded to ICD-10, another consultant reviewed the inpatient encounter to ensure that the original consultant recoded the encounter accurately. If the second consultant agreed with the original consultant, the encounter was assigned for a third and final review by a YES manager. The consultant also wrote a brief description of the recoding specifics such as image below ICD-10-CM has a combination code for diverticulitis with abscess. ICD-9 had abscess as an MCC. Changes the DRG from 391 to 392. The custom field 1 selections for when the ICD-9 and ICD-10 MS-DRGs did not match included: 2. Dx code not CC/MCC in ICD Dx code is CC/MCC in ICD Pr code more specific in ICD ICD-10 guideline/sequencing change 8. Pilot grouper error (potential) 9. Coding summary doesn t agree with UB codes Other custom field 1 selections when the MS-DRGs matched included the following: 1. MS-DRG same 5. Auditor disagrees w ICD-9 code/ms-drg NO MS-DRG change but notation made (listed suggested codes and changed MS-DRG both ICD-9 and ICD-10 - in notes YES to discuss these with healthcare system s management team for them to review YES assumption was if the coder coded it a certain way in ICD-9, then they would code it the same in ICD-10) 6. Cannot code ICD-10 documentation gap NO MS-DRG change but notation made (YES to add these to healthcare system s documentation issues to discuss at the ICD-10 HIM and CDI teams YES had to make some body part and/or approach assumptions to assign a code for this financial audit -- note that these documentation gaps would not affect the MS-DRG assignment) Each inpatient encounter was assigned a reason code from the drop-down menu within the custom field 1. Once the YES consultants completed their 100 encounter files, they exported the data from TruCode. All of the files were then compiled by the YES project manager and submitted back to the healthcare system for their financial analysis. For the financial analysis, the ICD-10 recoding of 2720 inpatient encounters produced a 96% MS-DRG YES HIM Consulting, Inc. 4

5 STATISTICS match. The following statistics represent the data submitted: Audit Outcome - All Facilities Audit Outcome Charts MSDRG Same 2514 Auditor disagrees w ICD-9 code/msdrg 64 Pr code more specific in ICD-10* 45 Cannot code ICD-10 - documentation gap 38 ICD-10 guideline/sequencing change* 24 Dx code not CC/MCC in ICD-10* 18 Dx code is CC/MCC in ICD-10* 8 Pilot grouper error * 7 Coding summary doesn t agree with UB codes* 2 TOTAL 2720 *4 % MS-DRG change 96% MS-DRGs remained the same The 4% MS-DRG changes represented both some positive and negative dollar amounts with an overall positive dollar amount. The healthcare system calculated their own internal MS-DRG calculations and trending. However, the basic calculations from TruCode presented the following baseline numbers: Facility ICD-9 Reimbursement ICD-10 Reimbursement Difference 1 756, , , ,228, ,326, , ,391, ,496, , ,611, ,617, , ,409, ,507, , ,309, ,314, , ,560, ,641, , ,253, ,365, , ,976, ,042, , TOTAL 25,498, ,078, , The first week of the recoding project presented some challenges for the YES consultants. Even with all of PRODUCTIVITY their coding experience, the pressure to be productive (goal was 3.25 charts coded per hour) displayed some anxieties among the group. With all of the complexities of ICD-10 code assignments, most of the consultants were only averaging coding charts per hour. Many of the inpatient encounters had up to 30 diagnoses coded in ICD-9. During the second week of the project, YES approached the healthcare system with a YES HIM Consulting, Inc. 5

6 proposal to only code the significant ICD-10 diagnoses codes. Therefore, YES would not code status post codes, external cause codes, or history codes. The healthcare system approved this process. The surgical procedures were the most difficult and time-consuming to assign ICD-10 codes. Due to the lack of PCSrequired specifics in the brief procedure statements on the operative reports, the consultants had to read the full operative report text to assign an accurate ICD-10-PCS code. Example: Procedure performed: Debridement of burn with autograft, thigh donor site (can code in ICD-9-CM from this statement) Full text: the burn on the left lower leg was debrided through the skin and subcutaneous layer down to the fascia. Split-thickness skin graft from the left thigh was used to (terms in bold are necessary for PCS) By the end of the six weeks, each of the consultants was meeting and/or exceeding the goal of 3.25 charts coded per hour. The chart below displays the average coding time per chart for each consultant for the entire six week project. Coding Time by Coder Consultant Charts Coded Avg Coding time TOTAL Note that we began the project by assigning all diagnostic codes (some encounters up to 30) but then reduced our coding during the third week to exclude external cause codes, status post codes and history codes. We averaged 9 diagnostic codes per encounter. YES HIM Consulting, Inc. 6

7 MS-DRG CHANGES AND ICD-10 CODING SPECIFICS The following paragraphs encompass our reason codes for the MS-DRGs not matching between ICD-9 and ICD-10 along with specific examples: Dx code not CC/MCC in ICD-10 the ICD-10 codes that did not display their CC/MCC status included the following diagnoses: Accelerated hypertension (note: accelerated / malignant hypertension is not separately designated within ICD-10-CM) Gestation hypertension Depression Type II diabetic ketoacidosis (note: E13.10, Other specified diabetes mellitus with ketoacidosis without coma is assigned for a patient with type 2 diabetes with ketoacidosis) Diverticulitis with abscess is a combination code Hepatic encephalopathy (chronic without coma) Dx code is CC/MCC in ICD-10 the ICD-10 codes that did display their CC/MCC status which were not CC/MCCs within ICD-9 included the following diagnoses: Previous myocardial infarction within 4 weeks Opioid dependency Dilated cardiomyopathy Pr code more specific in ICD-10 the procedures assigned a more specific code in ICD-10-PCS which subsequently changed the MS-DRG included: Colostomy take-down Insertion PEG tube Revision hip replacement (removal and replacement) Revision of shoulder replacement (removal and replacement) Revision of knee replacement (removal and replacement) Replacement pacemaker device (removal and insertion) Spinal tap Revision A-V fistula Percutaneous drainage of gallbladder Bronchoscopy with lung biopsy Thrombectomy (specific veins) Debridement (fascia or bone level) Angioplasty (specific arteries) Dilations (i.e. veins, pylorus) Drainage abscess (i.e. rectal, neck, pelvic) Insertion stent (specific arteries) YES HIM Consulting, Inc. 7

8 ICD-10 guideline/sequencing change the following guideline and/or sequencing changes included: Osteoporotic pathological fractures Admission for rehab Underlying chronic kidney disease Maxillary sinus fracture (note: ICD-10 code for maxillary sinus fracture is included in maxillary fracture; and ICD-9 assigns maxillary sinus fracture to base of skull fx) Previous myocardial infarction (note: change from 8 weeks within ICD-9 and 4 weeks within ICD-10) Potential Pilot grouper error we did encounter a few potential pilot grouper errors which we reported to CMS. The potential pilot grouper errors included: Revision of knee replacement: In ICD-10-PCS, revision of knee replacement, code both the removal of old and replacement with new which should group to MS-DRG 467 (as in ICD-9); For revision of knee arthroplasty, when the removal of the prosthesis is added to the replacement, the MS-DRG is 467 (just as in ICD-9 MS-DRGs) with 7 th character Z. However, when the 7 th character is 9 or A for cemented or uncemented, then the DRG changes to 464 (as reported to CMS on 3/28/12) Radiculopathy included in ICD-9 code and ICD-10 code for displacement vertebral disc with radiculopathy; procedure is a fusion, so should group to the fusion MS-DRG 473 but is grouping to MS-DRG 030 spinal procedures. However if I choose the displacement code without radiculopathy, groups to same MS-DRG as the ICD-9 (473) (as reported to CMS on 3/28/12) DOCUMENTATION GAPS YES HIM Consulting, Inc. has been assisting this facility with ICD-10 documentation gap analyses for three years so the documentation gaps within this project were minimal 38 encounters. It should be noted that this recoding project did not attempt to gain specificity in diagnoses nor improve clinical documentation for additional CC/MCCs. The purpose and scope was to recode the 2720 inpatient encounters. The documentation gaps were from the procedures and included: Location of amputations (body part) Transfusion specificities (body system and qualifier) tpa injections (body system and qualifier) PICC line insertions (ending body part) Lysis of abdominal adhesions (body part) Declotting of A-V fistula (body part) Portion of esophagus dilated (body part) Medical induction of labor (body system) Angiography (fluoroscopy or plain) ICD-10-PCS Transfusion see 302 table below: YES HIM Consulting, Inc. 8

9 EXAMPLES OF ICD-10-PCS SPECIFICITIES NEEDED see 02H table: ICD-10-PCS - Insertion of PICC line The main pur- YES HIM Consulting, Inc. 9

10 SUMMARY AND LESSONS LEARNED pose and scope of the recoding project was originally to provide coded data to the healthcare system for them to compare the ICD-9 MS-DRG assignment to the ICD-10 MS-DRG assignment and develop a financial impact. There was a 4% MS-DRG change with a minimal overall increase in revenue predicted. However, the experience of the YES consultants was priceless. As previously noted, all of the eight YES consultants were very experienced coders and auditors, but when they were put under pressure to be productive in coding ICD-10, it was initially a stressful situation. Remember that change is hard for each and every one of us. There are numerous changes due to combination codes and specificity in ICD-10-CM and everything changes in ICD-10-PCS. In order to assign the correct ICD-10-PCS code, we needed to read the detailed operative reports. Each consultant was very glad that we had previously taken the YES Coding Clinical Concept Courses to review Medical Terminology, Anatomy, Pathophysiology and Pharmacology with ICD-10 concepts. An area of concern regarding productivity were the numerous ICD-9 diagnoses codes currently assigned such as non-specific status codes, family history codes with no connection to the current episode of care, non-treated secondary diagnoses codes, etc. In addition, procedures such as blood transfusion, therapeutic injections and radiology procedures are being coded in ICD-9-CM. While the coding of some of these additional secondary diagnoses and procedures are for quality measures and/or severity and mortality groupings, it is our recommendation that each facility review their policy regarding secondary diagnoses and noninvasive procedure codes. There is a lack of detailed references and guidance for ICD-10 to date. For the recoding project, there were only two published Coding Clinics for ICD-10. Additional references are needed for us to assign ICD-10 codes accurately and consistently across the U.S. We could not have performed our scope of work without the usage of the TruCode encoder system. We imported the data, utilized the ICD-9 and ICD-10 tabs, and utilized the supplementary tab with the custom field for reporting. The TruCode encoder system permitted us to review the ICD-9 code and MS-DRG assignment against our ICD-10 code and MS-DRG assignment. The export feature was essential to report our data back to the healthcare system. We highly recommend that the coders (especially the inpatient coders needing to assign ICD-10-PCS codes) take clinical courses/training prior to their ICD-10 in-depth training. The in-depth ICD-10 training needs to focus on the differences between ICD-9 coding and ICD-10 coding with various scenarios and exercises. We then encourage all healthcare facilities to allow their coders time to practice coding in ICD-10 prior to the go-live date of Dual coding will provide the inpatient coders the experience in comparing the ICD-9 MS-DRG to the ICD-10 MS-DRG and analyzing the variations. Note that when coding ICD-10, productivity will be decreased in the first few weeks, so plan accordingly. However, with coding practice (and more practice), the productivity will stabilize. YES HIM Consulting, Inc. 10

11 ABOUT THE AUTHOR Karen G. Youmans, MPA, RHIA, CCS, is the President of YES HIM Consulting, Inc. based in Largo, Florida. Ms. Youmans has over 25 years of experience in the healthcare industry and the HIM and coding professions. She was previously the Executive Vice President for a national healthcare consulting firm. Ms. Youmans has also held positions as an Instructor/Assistant Professor in the university of Central Florida s RHIA program, the Program Director for the RHIT program at St. Petersburg Junior College, and the Practice Manager of coding products and services with AHIMA. Over the years, Ms. Youmans has also been an HIM and coding consultant in various capacities, including all aspects of HIM operations and revenue cycle improvement projects as well as ICD-9-CM and CPT-4 coding education. She has given numerous presentations at local, state and national levels on a variety of topics including ICD-10 implementation. Her clients include hospitals of all sizes, healthcare systems and encoding vendors. Ms. Youmans is a past president of the Florida Health Information Management Association and has served on the AHIMA Board of Directors. Ms. Youmans obtained her Master of Public Administration degree in Healthcare Administration from Golden Gate University and a Bachelor of Arts degree in Health Information Administration from the College of St. Scholastica. She attended the October 2009 AHIMA Academy for ICD-10 and is an AHIMA-approved ICD-10-CM/PCS trainer. ABOUT YES HIM CONSUTING, INC. YES HIM Consulting, Inc. is a health information management consulting firm that provides extensive ICD- 10 coder education, training and assessments. We offer ICD-10 implementation plans, project management and ICD-10 clinical documentation reviews. Our training program is based on AHIMA and CMS recommendations and includes online seminars, online HIM coder clinical assessments and training, and ICD- 10-CM and ICD-10-PCS code training offering AHIMA and AAPC approved CEUs. ABOUT TRUCODE TruCode is a company focused solely on medical coding. We empower medical coders with a streamlined coding experience and the intuitive guidance and support of our intelligent Research Pane. The result is a balance of power, flexibility and support that allow medical coders to work faster and more efficiently to deliver accurate results throughout the coding process. Our philosophy is simple: design specifically for the way coders think and work and empower them to do everything better. This means intuitive function, clean presentation and the continuous guidance of on-screen medical coding reference support whenever it s needed. The results are immediate and far-reaching and include: Optimal insurance, Medicare and Medicaid reimbursement through increased coding accuracy Reduced A/R days through increased medical coder productivity Increased healthcare regulatory compliance by providing official medical coding guidance during the coding process YES HIM Consulting, Inc. 11