Medicine Under the Microscope

1. Value Based Purchasing, Changes for ICD-10 and the Future of Orthopaedic SurgeryRobert 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. 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

5. 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

7. 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.

8. 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

9. So What’s the Difference?

10. What Is An Index?

11. 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

12. 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 - 

14. Patient Safety

15. Surgery Bundling Test Model • Disclosed May 16, 2008 • ACE (Acute Care Episode) project • Combine Part B payments with Part A • “Value Based Centers” started with Texas, Oklahoma, New Mexico and Colorado • Value based purchasing • 28 cardiac and 9 orthopedic inpatient surgical services • Gainsharing also permitted here • Based on severity adjusted financial outcomes

16. Florida Blue and Mayo Clinic Introduce Knee Replacement Bundled Payment Program Friday, December 14, 2012 JACKSONVILLE, Fla. — Florida Blue and Mayo Clinic jointly announce a new collaboration aimed at providing the utmost in quality care for knee replacement patients in Florida. The two Florida health care leaders are teaming up to create a bundled payment agreement specific to the treatment of knee replacement surgery. Knee replacement surgery is the most common joint replacement procedure. According to the Agency for Healthcare Research and Quality, health care professionals perform more than 600,000 knee replacements annually in the United States.

17. Florida Blue and Holy Cross Create Accountable Care Arrangement Jacksonville and Fort Lauderdale, Fla. – Florida Blue, Florida’s Blue Cross and Blue Shield Company, and Holy Cross Physician Partners are pleased to announce that effective January 1, 2013, Holy Cross Physician Partners will participate in the Florida Blue Accountable Care Program. “Florida Blue is excited to expand our relationship with Holy Cross surrounding this exciting new partnership,” said Dr. Jonathan Gavras, chief medical officer and senior vice president for Florida Blue. “In the age of reform, both organizations realize the importance of moving away from the fee-for-service model to one that focuses on quality outcomes that will benefit our members in South Florida.”

18. Aetna, Baptist Memorial Health Care Announce Collaborative Care Agreement Thursday, April 25, 2013 4:11 pm EDT MEMPHIS, Tenn.--(BUSINESS WIRE)--Aetna (NYSE: AET) and Baptist Memorial Health Care today announced a collaborative care agreement to bring a new health care model to Aetna members and introduce Aetna Whole HealthSM, a commercial health care product. This collaboration will give employers and their workers access to highly coordinated care from physicians and facilities in the Baptist Select Health Alliance. The Baptist Select Health Alliance is a clinically integrated group of physicians focused on tracking outcomes, sharing data and measuring clinical standards to improve quality and efficiency. In collaborative care models, a group of health care providers delivers more coordinated care for patients to drive better quality and lower overall costs. Through Baptist Memorial Health Care, Aetna members will receive an enhanced level of coordinated care in addition to the member benefits of their current Aetna plan.

19. Getting Studies Paid ForLaboratory/Radiographic • Bundled payment modes rely on payment being made for lab or x-ray studies • Validation of reason for performing any procedure or test depends on Medical Necessity • Local Medical Review Policies (LMRPs), Local or National Coverage Determinations (LCDs, NCDs) • Not giving a reason for a test you order (symptom or diagnosis) could result in: • Advance Beneficiary Notification (ABN) saying patient may have to pay for the test • Somebody bugging you for a reason for the test

20. 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.

21. Readmissions Initiative Identify hospitals with excess readmissions for certain selected conditions beginning in FY 2013 for discharges on or after October 1, 2012. Acute myocardial infarction (i.e., heart attack) Heart failure Pneumonia Definition of readmission: “occurring when a patient is discharged from the applicable hospital and then is admitted to the same or another acute care hospital within a specified time period from the time of discharge from the index hospitalization.” The specified time period would be 30 days. 21

22. Patient Safety Indicators Hospital acquired preventable diagnoses Hospital falls that lead to patient damage (fractures, etc.) Mediastinitis post-CABG Catheter-associated UTIs Vascular catheter associated infections Pressure ulcers Object accidentally left in patient Air embolism Reaction from blood incompatibility

23. What Does This Mean? • Properly identify complication of care when complication – specify when due to a disease • We don’t want to assign complication codes when not complication • If event due to disease, not a complication • If even doesn’t exist, not a complication • Don’t use the word “post-op” in the post-op period!

24. Is an Adverse Event Always a Complication? • Not at all. • Stuff happens. • Diseases cause adverse effects • Anemia due to blood loss is usually due to the disease and not to the surgery State so: anemia of chronic blood loss due to right colon cancer; anemia of acute blood loss due to femur fracture • Adverse effects are easily explained and defended in a patient with more risk factors. If you didn’t name these, you lose.

25. NOT Acute Respiratory Failure • Patients being purposely maintained on the ventilator after surgery because of weakness, chronic lung disease, massive trauma are NOT in acute respiratory failure – unless they are • Abdominal compartment syndrome is a well-known complication after abdominal trauma and is increasingly recognized as a potential risk factor for renal failure and mortality after adult orthotopic liver transplantation (OLT). • Prevention of acute respiratory failure from angioedema, stroke, trauma when patient does NOT HAVE acute respiratory failure when intubated for airway protection

26. Participation and Success in Reporting of Core Measures • Acute MI • Heart failure • Pneumonia • Postoperative wound infections • Venous thromboembolism • Stroke • Asthma in children’s hospitals

27. Goals of Implementation – Prove You Are Value Based • Low incidence of HACs • Reasonable occurrence of PSIs • Lower than average Readmissions for Pneumonia, Heart Failure, AMI • Cooperation with quality initiatives • Decent responses to a new questionnaire on discharge

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

29. 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)

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

31. 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

32. Be Acquainted with Second Digit http://www.ncbi.nlm.nih.gov 0 Head • Neck • Thorax • Abd/low back/pelv • Shoulder/upper arm • Elbow/forearm • Wrist/hand • Hip/thighs • Knee/lower leg • Ankle/foot/toes

33. 0 Contusion Open wound Fracture Dislocation Injury nerves Injury vessels Muscle/fascia/tendon Crush injury Traumatic amputation Unspecified Proximal or distal Displaced or nondisplaced Eponyms of specific fracture types (Colles, Barton’s, etc.) Third Digit 4/5 Greater SpecificityGeneral type of injury of location of injury

34. Be Acquainted with Sixth Digit

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

36. Seventh Digit - Code extension Type of Encounter for Injuries – Chapter 19 Initial Encounter Active treatment Surgery ED E/M by new phys Subsequent Encounter Routine care Healing or recovery phase Sequelae Complications or conditions that arise as a direct result of the injury Identifies injury responsible for sequelae

37. 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

38. 7th Digit Understanding A, B, C Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and treatment by a new physician. The appropriate 7th character for initial encounter should also be assigned for a patient who delayed seeking treatment for the fracture or nonunion. D, E, F Fractures are coded using the appropriate 7th character for subsequent care for encounters after the patient has completed active treatment of the fracture and is receiving routine care for the fracture during the healing or recovery phase. Examples of fracture aftercare are: cast change or removal, removal of external or internal fixation device, medication adjustment, and follow-up visits following fracture treatment.

39. A  Initial encounter for closed fracture B  Initial encounter for open fracture type I or II C  Initial encounter for open fracture type IIIA, IIIB, or IIIC D  Subsequent encounter for closed fracture with routine healing E  Subsequent encounter for open fracture type I or II with routine healing F  Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing G  Subsequent encounter for closed fracture with delayed healing H  Subsequent encounter for open fracture type I or II with delayed healing

40. J  Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing K Subsequent encounter for closed fracture with nonunion M Subsequent encounter for open fracture type I or II with nonunion N Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion P Subsequent encounter for closed fracture with malunion Q Subsequent encounter for open fracture type I or II with malunion R Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion S  Sequela

41. 7th Digit Understanding • Care of complications of fractures, such as malunion and nonunion, should be reported with the appropriate 7th character for subsequent care with nonunion (K, M, N,) or subsequent care with malunion (P, Q, R). • Closed fracture code • Open fracture with Gustilo classification designation

42. Forearm (S52), Femur (S72) and lower leg (S82) Open Fractures Seventh character extensions to identify open fractures (Gustilo classification) I Low energy, wound less than 1 cm II Greater than 1 cm with moderate soft tissue damage III High energy wound greater than 1 cm with extensive soft tissue damage IIIA Adequate soft tissue cover IIIB Inadequate soft tissue cover IIIC Associated with arterial injury

43. Gustilo Open Fracture Classification

44. Allay the Fears • Think about the fracture and how you would describe it to an internist • Name the bone • Name the part of the bone involved • Name the kind of fracture (Colles, Barton’s) if there is a common name • Identify if it’s displaced or not, open or closed • If open, describe how extensive is the local damage • Choose the code that has those words in it

45. Clavicle Fractures • According to the American Academy of Family Physicians (AAFP), the anatomic site of the clavicle fracture is typically described using the Allman classification, which divides the clavicle into thirds. • Group I (midshaft) fractures occur on the middle third of the clavicle; • Group II fractures on the lateral (distal) third; and • Group III fractures on the medial (proximal) third.

46. Clavicle Fractures • According to the American Academy of Family Physicians (AAFP), the anatomic site of the clavicle fracture is typically described using the Allman classification, which divides the clavicle into thirds. • Group I (midshaft) fractures occur on the middle third of the clavicle; • Group II fractures on the lateral (distal) third; and • Group III fractures on the medial (proximal) third.

47. Coding Clavicles S42.0       Fracture of clavicle S42.01     Fracture of sternal end of clavicle S42.011 anterior displaced right – 5th digits S42.012 anterior displaced left S42.014 posterior displaced right S42.015 posterior displaced left S42.017 nondisplaced right S42.018 nondisplaced left S42.02     Fracture of shaft of clavicle S42.03     Fracture of lateral end of clavicle Should never use 4th digit of 0 for unspecified part of clavicle nor 5th digit of 3, 6 or 9 for not knowing if right or left clavicle

48. How Do You Describe It? Posterior displaced left midshaft clavicular fracture – then is it involving the vessels? Which?

49. 820.0 Transcervical fracture, closed 820.00 Intracapsular section, unspec. 820.01 Epiphysis (separation) (upper) 820.02 Midcervical section 820.03 Base of neck 820.09 Other (head, subcapital) 820.1 Transcervical fracture, open 820.10 Intracapsular section, unspec. 820.11 Epiphysis (separation) (upper) 820.12 Midcervical section 820.13 Base of neck 820.19 Other 820.2 Pertrochanteric fracture, closed 820.20 Trochanteric section, unspecified (greater, lesser, etc.) 820.21 Intertrochanteric section 820.22 Subtrochanteric section 820.3 Pertrochanteric fracture, open 820.30 Trochanteric section, unspec. 820.31 Intertrochanteric section 820.32 Subtrochanteric section S72.00 Fracture unspec part neck of femur S72.01 Unspecified intracapsular fracture R/L S72.02 Fracture (separation) epiphysis femur (displaced, nondisplaced digits, R/L) S72.03 Midcervical fracture (d, nonD, R/L) S72.04 Base of neck fracture (d, nonD, R/L) S72.05 Unspecified fracture head R/L S72.06 Articular fracture head of femur (d, nonD, R/L) S72.09 Other fx head and neck of femur R/L S72.10 Unspec trochanteric fracture R/L S72.11 Fracture greater trochanter (d, nonD, R/L) S72.12 Fracture lesser trochanter (d, nonD, R/L) S72.13 Apophyseal fracture (d, nonD, R/L) S72.14 Intertrochanteric fracture (d, nonD, R/L) S72.2 Subtrochanteric fracture (d, nonD, R/L) Femoral Neck Fractures – 9 vs 10

50. Femoral Neck Fractures • Name the part of the neck as usual • Identify if it’s nondisplaced or displaced • State which side of the body • It just makes sense