Value Based Purchasing, Changes for ICD-10 and the Future of Hematology Robert S. Gold, MD

1. Value Based Purchasing, Changes for ICD-10 and the Future of HematologyRobert 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. Goals of Implementation – Prove You Are Value Based • Excellence in severity adjusted data • Reasonable occurrence of PSIs • Lower than average Readmissions for Pneumonia, Heart Failure, AMI • Cooperation with quality initiatives • Patient satisfaction

5. 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

6. 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

8. 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.

9. 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

10. So What’s the Difference?

11. What Is An Index?

12. Mortality index Complication index Length of stay index Cost per patient index What Is An Index? Observed Rate of Some Thing Severity Adjusted Expected Rate of That Thing =1

13. 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 - 

15. Clinical Documentation Improvement What is this all for?

16. Goals of Implementation – Prove You Are Value Based • Excellence in severity adjusted data • Reasonable occurrence of PSIs • Lower than average Readmissions for Pneumonia, Heart Failure, AMI • Cooperation with quality initiatives • Patient satisfaction

17. Patient Safety

18. 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.

19. Change in the Entire System ICD-9 ICD-10

20. 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)

21. 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

22. 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)

23. 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

24. Specificity is NOT Always Possible Sign/Symptom/Unspecified Codes In both ICD-9-CM and ICD-10-CM, sign/symptom and “unspecified” codes have acceptable, even necessary, uses. While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter. Each healthcare encounter should be coded to the level of certainty known for that encounter. If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis. When sufficient clinical information isn’t known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate “unspecified” code (e.g., a diagnosis of pneumonia has been determined, but not the specific type). In fact, unspecified codes should be reported when they are the codes that most accurately reflects what is known about the patient’s condition at the time of that particular encounter. It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code. Source: Cooperating Parties for ICD-10-CM/PCS and ICD-9-CM Coding, May 2013.

25. Don’t Wait Till Tomorrow for ICD-10

26. How Close Are We?

27. Anemia Designations D62 D50.0 D63.1 D63.0 D63.8 285.1 – anemia due to acute blood loss FROM … name it 280.0 – anemia due to chronic blood loss FROM … name it 285.21 – anemia due to chronic renal failure and what caused the renal failure? 285.22 – anemia due to malignant disease – effect of the tumor!*** 285.29 – anemia due to a specific chronic illness – and name that illness (chronic hepatitis, lupus, osteomyelitis, etc.)

28. Anemia***/Cytopenias in Malignancy There is no code for “anemia of chronic disease” 280.0 D50.0 anemia due to chronic blood loss from bleeding colon cancer 284.11 D61.810 pancytopenia from chemo 284.12 D61.811 pancytopenia from other drugs 284.2 D61.82 pancytopenia from cancer taking over bone marrow (myelophthisis) – code the cancer causing it 284.89 D61.1 aplastic anemia due to chemo, other drugs 284.89 D61.2 radiation induced aplastic anemia 285.22 D63.0 anemia due to neoplastic disease – code the cancer causing it 285.3 D64.81 antineoplastic chemotherapy induced anemia

29. Blood Cell Lines DeficiencyUnspecified CodesJustify Ordering Tests 288.00 D70.9 Neutropenia, unspecified 288.01 D70.0 Congenital neutropenia 288.02 D70.4 Cyclic neutropenia 288.03D70.1 Chemotherapy induced neutropenia 288.03D70.2 Other drug induced neutropenia 288.04 D70.3 Neutropenia due to infection 288.09 D70.8 Other neutropenia

30. Sickle Cell Disease ICD-9 282.5Sickle cell trait 282.60 Sickle cell disease unspecified 282.61 Hb-SS disease without crisis 282.62 Hb-SS disease with crisis 282.63 Hb-C disease without crisis 282.64 Hb-C disease with crisis 282.68 Other sickle cell disease without crisis 282.69 Other sickle cell disease with crisis Use additional code for: Acute chest syndrome (517.3), Splenic seq (289.52)

31. Sickle Cell Disease ICD-10 0 = without crisis 11 = with acute chest syndrome 12 = with splenic sequestration 19 = unspecified D57.0xx Hb-SS disease with crisis D57.1 Sickle-cell disease without crisis D57.2xx Sickle-cell/Hb-C disease D57.3 Sickle-cell trait D57.4xx Sickle-cell thalassemia D57.8xx Other sickle-cell disorders (Hb-SD disease, Hb-SE disease)

32. Hypercoagulable States ICD-9 289.81Primary hypercoagulable state Activated protein C resistance Antiphospholipid antibody syndrome Antithrombin III deficiency Factor V Leiden mutation Lupus anticoagulant with hypercoagulable state Protein C deficiency Protein S deficiency Prothrombin gene mutation Systemic lupus erythematosus [SLE] inhibitor with hypercoagulable state 289.82Secondary hypercoagulable state 289.84 Heparin-induced thrombocytopenia

33. Hypercoagulable States ICD-10 D68.5 Primary thrombophilia (Primary hypercoagulable states) D68.51Activated protein C resistance (Factor V Leiden mutation) D68.52Prothrombin gene mutation D68.59Other primary thrombophilia Antithrombin III deficiency Hypercoagulable state NOS;Primary hypercoagulable state NEC Primary thrombophilia NEC Protein C deficiency; Protein S deficiency Thrombophilia NOS D68.6 Other thrombophilia Other hypercoagulable states D68.61Antiphospholipid (anticardiolipin) syndrome D68.62Lupus anticoagulant syndrome D68.69Other thrombophilia (Hypercoagulable states NEC) D75.82 Heparin induced thrombocytopenia

34. Coagulation Defects ICD-9 286.0 Congenital factor VIII disorder (hemophilia A) 286.1 Congenital factor IX disorder (Christmas disease, hemophilia B) 286.2 Congenital factor XI deficiency (Rosenthal’s disease, hemophilia C) 286.3 Congenital deficiency of other clotting factors 286.4 von Willebrand's disease 286.5 Hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors 286.52 Acquired hemophilia 286.53 Antiphospholipid antibody with hemorrhagic disorder 286.59 Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors 286.6 Defibrination syndrome (DIC) 286.7 Acquired coagulation factor deficiency 286.9 Other and unspecified coagulation defects

35. Coagulation Defects ICD-10 D65Disseminated intravascular coagulation [defibrination syndrome] D66Hereditary factor VIII deficiency (Hemophilia A) D67Hereditary factor IX deficiency (Christmas disease, Hemophilia B) D68 Other coagulation defects D68.0Von Willebrand's disease D68.1Hereditary factor XI deficiency (Rosenthal’s dis, hemophilia C) D68.2Hereditary deficiency of other clotting factors D68.3 Hemorrhagic disorder due to circulating anticoagulants D68.31 Hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors D68.311Acquired hemophilia D68.312Antiphospholipid antibody with hemorrhagic disorder D68.318Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors D68.32Hemorrhagic disorder due to extrinsic circulating anticoagulants D68.4Acquired coagulation factor deficiency

36. Myelofibrosis Issues 289.83 D75.81 Secondary myelofibrosis NOS 238.76D47.1 Primary myelofibrosis 238.76D47.4 Idiopathic myelofibrosis – myelofibrosis in myeloproliferative disease 238.79D47.1 Myeloproliferative syndrome 238.79C94.4 Acute panmyelosis with myelofibrosis C94.40 never having achieved remission C94.41 in remission C94.42 in relapse

37. Other Hematopoietic Issues ICD-9 238.71 Essential thrombocythemia 238.72 Low grade myelodysplastic syndrome lesions Refractory anemia (RA), Refractory anemia with excess blasts-1 (RAEB-1) Refractory anemia with ringed sideroblasts (RARS), Refractory cytopenia with multilineage dysplasia (RCMD), Refractory cytopenia with multilineage dysplasia and ringed sideroblasts (RCMD-RS) 238.73High grade myelodysplastic syndrome lesions Refractory anemia with excess blasts-2 (RAEB-2) 238.74Myelodysplastic syndrome with 5q deletion 238.75 Myelodysplastic syndrome, unspecified 238.76Myelofibrosis with myeloid metaplasia Excludes: myelofibrosis NOS (289.83) myelophthisic anemia (284.2) myelophthisis (284.2) secondary myelofibrosis (289.83)

38. Splits Out Myelodysplastic Syndromes ICD-10 D46 Myelodysplastic syndromes D46.0 Refractory anemia without ring sideroblasts, so stated D46.1 Refractory anemia with ring sideroblasts RARS D46.2 Refractory anemia with excess of blasts D46.20 Refractory anemia with excess of blasts, unspecified RAEB NOS D46.21 Refractory anemia with excess of blasts 1 RAEB 1 D46.22Refractory anemia with excess of blasts 2 RAEB 2 D46.A Refractory cytopenia with multilineage dysplasia D46.B Refractory cytopenia with multilineage dysplasia and ring sideroblasts RCMD RS D46.CMyelodysplastic syndrome with isolated del(5q) chromosomal abnormality Myelodysplastic syndrome with 5q deletion D46.4 Refractory anemia, unspecified D46.Z Other myelodysplastic syndromes D46.9 Myelodysplastic syndrome, unspecified

39. Repositions Essential Thrombocythemia D47.1Chronic myeloproliferative disease Excludes: myelofibrosis NOS (D75.81) myelophthisic anemia (D61.82) myelophthisis (D61.82) secondary myelofibrosis NOS (D75.81) D47.2 Monoclonal gammopathy Monoclonal gammopathy of undetermined significance [MGUS] D47.3 Essential (hemorrhagic) thrombocythemia Essential thrombocytosis Idiopathic hemorrhagic thrombocythemia D47.4 Osteomyelofibrosis Chronic idiopathic myelofibrosis Myelofibrosis (idiopathic) (with myeloid metaplasia) Myelosclerosis (megakaryocytic) with myeloid metaplasia Secondary myelofibrosis in myeloproliferative disease

40. Porphyria ICD-9 Porphyria (acute) (congenital) (constitutional) (erythropoietic) (familial) (hepatica) (idiopathic) (idiosyncratic) (intermittent) (latent) (mixed hepatic) (photosensitive) (South African genetic) (Swedish)277.1 • acquired277.1 • Cutanea tarda • hereditaria277.1 • symptomatica277.1 • due to drugs correct substance properly administered277.1 • secondary277.1

41. Porphyria ICD-10 E80.0Hereditary erythropoietic porphyria Congenital erythropoietic porphyria Erythropoietic protoporphyria E80.1Porphyria cutanea tarda E80.2 Other and unspecified porphyria E80.20Unspecified porphyria E80.21Acute intermittent (hepatic) porphyria E80.29Other porphyria

42. It’s Not Only the Blood • Still must describe your patient fully • Certain organs suffer due to hematopoietic conditions (demand cardiac ischemic, liver function, brain function, etc.) • Certain organs contribute to hematopoietic conditions (liver failure, CKD with GFR < 45 cc/min) • Certain diseases augment the effects of the hematopoietic system

43. Malnutrition • Be wary of BMI in patients with ascites, pleural effusions, anasarca from hypoproteinenia • Work with dietary to use ASPEN eval of pt to stratify malnutrition when it exists • Malnutrition quick estimates • Mild - < 10% body mass loss • Moderate – 10 – 20% body mass loss • Severe - > 20% body mass loss

44. Malnutrition • One third of hospital patients are affected by moderate or severe malnutrition • Capability to tolerate tests, treatments, surgeries significantly impaired with moderate to severe malnutrition • What we see: • Cachexia • 20 lb wt loss in past month • Poor nutrition due to dysphagia

45. Infectious Disease Although sepsis and septicemia determined to be two different entities (local infection with systemic impact through release of kinins from macrophages vs infection of the blood stream), both have same code now - A41 Bacteremia R78.81, viremia B34.9, fungemia B49 have specific codes, none of which carry severity

46. Specific “Sepsis/Septicemia” Anthrax sepsis A22.7 Septicemia of plague A20.9 Salmonella sepsis A02.1 Listeria sepsis A32.7 Meningococcemia Acute A39.2 Chronic A39.3 Streptococcal sepsis – specify group Toxic shock syndrome A48.3 Sepsis not specified A41

47. ICD-9-CM 995.91 Sepsis (SIRS due to infection without organ dysfunction 995.92 Severe sepsis (SIRS due to infection with organ dysfunction 995.93 SIRS due to noninfection without organ dysfunction 995.94 SIRS due to noninfection with organ dysfunction ICD-10-CM ***** R65.20 Severe sepsis without septic shock R65.21 Severe sepsis with septic shock R65.10 SIRS due to noninfection without organ dysfunction R65.11 SIRS due to noninfection with organ dysfunction The Future Must Be Started Now

48. Sepsis due to: UTI Pneumonia Ascending cholangitis Infected decubitus Osteomyelitis Infected vascular cath Subphrenic abscess All are infections! SIRS due to: Hemorrh pancreatitis Burns (not infected) Pulmonary embolism (clot, fat, amniotic fluid) Multiple trauma Allergy None are infections! Conditions Related to …

49. Severe Sepsis Intent is to identify sepsis with distant organ failure. Organs may include: Acute renal failure (due to sepsis) ARDS/acute respiratory failure Shock liver/ acute hepatic necrosis Demand NSTEMI Disseminated intravascular coagulopathy Encephalopathy (metabolic – due to sepsis) Critical care myopathy Circulatory system failure – inability to perfuse vital organs

50. Indwelling Device Infections • Specific code sets apply when infection or “septicemia” is related to indwelling: • Vascular access catheter for dialysis • Urinary tract catheter or device • Orthopedic appliance • Artificial heart valve • Prosthesis for vascular bypass or for hernia support MAKE THE LINK