Medicine Under the Microscope

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

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. Patient Safety

17. Examples • Differentiate tracheoesophageal fistula due to the cancer from TEF due to the radiation • Fluid losses from gastrointestinal mucositis vs other causes of fluid losses • Lymphedema from the radiation vs from the superior vena cava syndrome • Radiation pneumonitis vs aspiration pneumonitis in esophageal cancer pt

18. 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?

19. 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.

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

21. 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)

22. How Close Are We Now?

23. 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

24. 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)

25. 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

26. Principal Diagnosis – Describe It! 16 year old female with acute myelogenous leukemia diagnosed in 2004 who underwent consolidation chemotherapy and went into successful remission. She was doing well until she was hospitalized with syncope from severe anemia and bruising from thrombocytopenia found to be due to relapse in November 2013 and is now admitted for allogeneic bone marrow transplantation. 80 year old WF with episode of syncope in March led to findings of iron deficiency anemia and positive stool guaiac, probably due to chronic blood loss. Colonoscopy late March revealed right colon exophytic lesion with erosions. Biopsy adenoca colon. Abdominal CT showed possible evidence of solitary lesion in left lobe of liver. Right hemicolectomy performed two weeks ago with benign postoperative course. Liver biopsy positive for adenocarcinoma of colon. In now for percutaneous embolization of metastatic colon cancer in left lobe of liver.

27. Consider Issues That Make it Tough Do other conditions of the patient make the route, positioning, choice of therapies more complex? • Kyphoscoliosis? • Chronic respiratory failure? • Hypoxemic? Hypercapnic? • What’s the cause? Pleural effusion? Ascites? • Morbid obesity? • Coagulopathies?

28. Primary and Metastatic Cancer • Tell where the primary is (was) and if it was previously removed or treated and treatment is over or currently under treatment • State where the metastatic sites are and if they (any) are symptomatic and if they are currently under treatment • State if new site is found and if it led to the symptoms that required admission – ALWAYS LINK SYMPTOMS TO THE CANCER, when you can

29. Lung Cancer I-9 162 Malignant neoplasm of trachea, bronchus, and lung 162.0Trachea 162.2Main bronchus 162.3Upper lobe, bronchus or lung 162.4Middle lobe, bronchus or lung 162.5Lower lobe, bronchus or lung 162.8Other parts of bronchus or lung 162.9Bronchus and lung, unspecified

30. Laterality of Lung Cancer I-10 C34.0 Malignant neoplasm of main bronchus C34.00 Malignant neoplasm of unspec main bronchus C34.01 Malignant neoplasm of right main bronchus C34.02 Malignant neoplasm of left main bronchus C34.1 Malignant neoplasm of upper lobe, bronchus or lung C34.10 Malignant neoplasm of upper lobe, unspec bronchus or lung C34.11 Malignant neoplasm of upper lobe, right bronchus or lung C34.12 Malignant neoplasm of upper lobe, left bronchus or lung C34.2 Malignant neoplasm of middle lobe, bronchus or lung C34.3 Malignant neoplasm of lower lobe, bronchus or lung C34.30 Malignant neoplasm of lower lobe, unspec bronchus or lung C34.31 Malignant neoplasm of lower lobe, right bronchus or lung C34.32 Malignant neoplasm of lower lobe, left bronchus or lung C34.8 Malignant neoplasm of overlapping sites of bronchus and lung C34.80 Malignant neoplasm of overlapping sites of unspec bronchus and lung C34.81 Malignant neoplasm of overlapping sites of right bronchus and lung C34.82 Malignant neoplasm of overlapping sites of left bronchus and lung

31. Adrenal Gland Malignancy I-9 194.0Adrenal gland Adrenal cortex Adrenal medulla Suprarenal gland All in one

32. Laterality/Specificity I-10 C74.0 Malignant neoplasm of cortex of adrenal gland C74.00 Malignant neoplasm of cortex of unspecified adrenal gland C74.01 Malignant neoplasm of cortex of right adrenal gland C74.02 Malignant neoplasm of cortex of left adrenal gland C74.1 Malignant neoplasm of medulla of adrenal gland C74.10 Malignant neoplasm of medulla of unspecified adrenal gland C74.11 Malignant neoplasm of medulla of right adrenal gland C74.12 Malignant neoplasm of medulla of left adrenal gland

33. Colon Cancer I-9 153 Malignant neoplasm of colon 153.0Hepatic flexure 153.1Transverse colon 153.2Descending colon 153.3Sigmoid colon 153.4Cecum 153.5Appendix 153.6Ascending colon 153.7Splenic flexure 153.8Other specified sites of large intestine 153.9Colon, unspecified 154 Malignant neoplasm of rectum, rectosigmoid junction, and anus 154.0Rectosigmoid junction 154.1Rectum 154.2 Anal canal

34. Colon Cancer I-10 C18 Malignant neoplasm of colon C18.0Malignant neoplasm of cecum C18.1Malignant neoplasm of appendix C18.2Malignant neoplasm of ascending colon C18.3Malignant neoplasm of hepatic flexure C18.4Malignant neoplasm of transverse colon C18.5Malignant neoplasm of splenic flexure C18.6Malignant neoplasm of descending colon C18.7Malignant neoplasm of sigmoid colon C18.8Malignant neoplasm of overlapping sites of colon C18.9Malignant neoplasm of colon, unspecified Malignant neoplasm of large intestine NOS C19Malignant neoplasm of rectosigmoid junction Malignant neoplasm of colon with rectum Malignant neoplasm of rectosigmoid (colon)

35. ICD-9 198.5Bone and bone marrow ICD-10 C79.51 Bone C79.52 Bone marrow Mets to Bone

36. Pathologic Fracture Medical Textbook A fracture involving abnormal bone is a pathologic fracture. The abnormality may be due to disuse, a surgical defect, infection, a metabolic disorder, a primary benign tumor, a primary malignant tumor or metastatic carcinoma. The fracture occurs spontaneously or with minimal trauma Coding Guidelines A break in a diseased bone due to weakness of the bone structure by pathologic process (such as osteoporosis or bone tumors) without identifiable trauma or following only minor trauma. Only the physician can make the determination that the fracture is out of proportion to the degree of trauma

37. Pathologic Fracture If a patient with severe osteoporosis or myeloma falls from the second story of her home and suffers a compression fracture of the spine, that’s a traumatic fracture. If a patient gets the same fracture setting the table – or raising a window - with the bone weakened by SOME pathologic process, that’s a pathologic fracture Pediatric orthopedic textbooks describe over 100 causes of pathologic fracture that are not malignancies. Be sure pathologic fracture in a cancer patient is not due to another cause.

38. Osteoporosis and Pathologic Fx I-9 733.0 Osteoporosis Use additional code for history of pathologic (healed) fracture (V13.51) 733.00 Osteoporosis, unspecified 733.01 Senile osteoporosis 733.02 Idiopathic osteoporosis 733.03 Disuse osteoporosis 733.09 Other Drug-induced osteoporosis 733.1 Pathologic fracture Excludes: stress fracture (733.93-733.95), traumatic fractures (800-829) 733.10Pathologic fracture, unspecified site 733.11Pathologic fracture of humerus 733.12Pathologic fracture of distal radius and ulna 733.13Pathologic fracture of vertebrae 733.14Pathologic fracture of neck of femur 733.15Pathologic fracture of other specified part of femur 733.16Pathologic fracture of tibia and fibula 733.19Pathologic fracture of other specified site

39. Osteoporosis ICD-10 M81 Osteoporosis without current pathological fracture personal history of (healed) osteoporosis fracture, if applicable (Z87.310) M81.0 Age-related osteoporosis without current pathological fracture M81.6 Localized osteoporosis [Lequesne] Excludes1: Sudeck's atrophy (M89.0) M81.8 Other osteoporosis without current pathological fracture

40. Osteoporosis with Pathologic Fx I-10 M80 Osteoporosis with current pathological fracture Excludes1: collapsed vertebra NOS (M48.5) pathological fracture NOS (M84.4) wedging of vertebra NOS (M48.5) Excludes2: personal history of (healed) osteoporosis fracture (Z87.310) M80.0 Age-related osteoporosis with current pathological fracture M80.8 Other osteoporosis with pathological fracture drug induced, idiopathic, disuse,

41. Osteoporosis with Pathologic Fx ICD-10 Sixth digit 1 = right 2 = left Add 7th digit for episode of care 1 Shoulder 2 Humerus • Forearm • Hand • Femur • Lower leg • Ankle/foot • Vertebra

42. Traumatic Fracture vs Pathologic • 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 (excludes, osteoporosis M80.x)

43. Neoplastic and Other Pathologic Fx ICD-10 Add 7th digit for episode of care 1 Shoulder 2 Humerus • Ulna or Radius • Hand • Pelvis or Femur • Tibia or Fibula • Ankle or foot • Other site

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

45. 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.)

46. 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

47. Hodgkins cell types Small Cell Mantle zone Large cell lymphoma Lymphoblastic Burkitt Non-follicular Unspecified site Head, face, neck nodes Intrathoracic nodes Intraabdominal nodes Nodes axilla, upper limb Inguinal, lower limb Pelvic nodes Spleen Multiple sites Extranodal and solid organ sites Lymphoma Subdivisions in ICD-9

48. C81 Hodgkin’s Lymphoma C81.0 Nodular lymphocytic C81.1 Nodular sclerosing C81.2 Mixed cellularity C81.3 Lymphocyte depleted C81.4 Follicular grade IIIB C81.5 Diffuse follicular center C81.6 Cutaneous follicle center C81.8 Other specified Fifth Digit 0 – unspecified site 1 – head, face neck nodes 2 – intrathoracic nodes 3 – intraabdominal nodes 4 – axilla, upper limb 5 – inguinal, lower limb 6 – pelvic nodes 7 – spleen 8 – multiple sites 9 – unspecified site Lymphoma ICD-10

49. Fifth Digit 0 – unspecified site 1 – head, face neck nodes 2 – intrathoracic nodes 3 – intraabdominal nodes 4 – axilla, upper limb 5 – inguinal, lower limb 6 – pelvic nodes 7 – spleen 8 – multiple sites 9 – unspecified site Lymphoma ICD-10 C83.0 Small B cell C83.1 Mantle C83.3 Diffuse large B cell C83.5 Lymphoblastic diffuse C83.7 Burkitt C83.8 Other nonfollicular C84.0 Mycosis fungoides C84.1 Sezary disease C84.4 Peripheral T-cell C84.6 Anaplastic large cell (ALK pos) C84.7 Anaplastic large cell (ALK neg) C84A Cutaneous T-cell C84.9 Mature T/NK cell C85 B-cell lymphomas

50. Status of Leukemias • All leukemia codes are divided into subdivisions to demonstrate the patient’s status NOW: • Never having achieved remission • In remission • In relapse If you don’t specify, it defaults to never having achieved remission Your success in treatment depends on accuracy.