Month: January 2015

The Benefits of 10: Coding Preventable Medical Error

Doug Zweibel

by Rhonda Butler, senior clinical research analyst with 3M Health Information Systems.

See full article here.

Preventable errors in hospital care are the third leading cause of death, after cancer and heart disease. Updated estimates in a 2013 study in the Journal of Patient Safety say that between 210,000 and 440,000 people die in US hospitals every year because some preventable harm was done to them. The Office of the Inspector General published its own 2010 estimate only for Medicare patients, determining that poor hospital care was a contributing factor in the deaths of 180,000 of them. Even the universally accepted and much older number (published in 1999) of 98,000 is widely considered a “crisis” and a “national priority” in health care. And remember, these numbers don’t even attempt to quantify the financial and human toll of poor quality care that doesn’t kill people, but just costs us money and time and causes needless suffering.

Why can’t we accurately track something this important? Because ICD-9 lacks the detail to allow complications and errors in medical care to be easily entered in the permanent medical record so these events can be accurately measured. And as the saying goes, if you can’t measure something, you can’t understand it, and if you can’t understand it you can’t control it.

ICD-9 codes are pitifully inadequate for measuring the occurrence of preventable medical error. Instead of talking about the dumbest ICD-10 codes, we should be demanding the ICD-10 codes we need to start measuring and understanding and controlling these totally unnecessary healthcare costs.

Here are just a few examples that show the difference between what you can say about complications, adverse effects, and errors using ICD-9 and what you can say using ICD-10.

ICD-10 says T36.0X5A Adverse effect of penicillins
ICD-9 says 995.29 Unspecified adverse effect of other drug, medicinal and biological substance

ICD-10 says T88.4 Failed or difficult intubation
ICD-9 says 999.9 Other and unspecified complications of medical care, not elsewhere classified

ICD-10 says T88.51XA Hypothermia following anesthesia, initial encounter
ICD-9 says 995.89 Other specified adverse effects, not elsewhere classified

ICD-10 says T86.822 Skin graft (allograft) (autograft) infection
ICD-9 says 996.79 Other complications due to other internal prosthetic device, implant, and graft

ICD-10 says R57.1 Hypovolemic shock [shock from severe dehydration]
ICD-9 says 785.59 Other shock without mention of trauma

ICD-10 says Z20.6 Contact with and (suspected) exposure to human immunodeficiency virus [HIV]
ICD-9 says V01.79 Contact with or exposure to other viral diseases

ICD-10 says I97.711 Intraoperative cardiac arrest during other [non-cardiac] surgery
ICD-9 says 997.1 Cardiac complications, not elsewhere classified

ICD-10 says J95.71 Accidental puncture and laceration of a respiratory system organ or structure during a respiratory system procedure
ICD-9 says 998.2 Accidental puncture or laceration during a procedure, not elsewhere classified

What matters about codes is not how many there are, but how precise they are. If heaven forbid you or someone you care about suffers the consequences of a preventable medical mistake, look at the way it will be entered on the permanent medical record in ICD-10, and then look at how that exact same condition will be recorded in ICD-9. Lobbyists are fighting tooth and nail to keep using the ICD-9 system. Letting a few animal bite codes stop us from using the power of ICD-10 to measure and understand and begin to control preventable medical errors—really, how dumb is that?

Will Congress include Another ICD-10 Delay in SGR Fix?

Jason Gottlieb

by Greg Slabodkin

Next week, the House Energy and Commerce Subcommittee on Health will hold two days of hearings in an effort to find a permanent solution to the flawed Sustainable Growth Rate (SGR) formula.  At the hearings scheduled for Jan. 21 and 22, lawmakers will discuss “how to bring SGR reform to the president’s desk before the current patch expires at the end of March 2015,” according to an announcement by the subcommittee. It’s also possible that this year’s congressional SGR fix could include a further ICD-10 delay.

Last year, the House and Senate passed legislation—the Protecting Access to Medicare Act—that included a provision to delay the ICD-10 deadline by one year to Oct. 1, 2015. President Obama signed the so-called “doc fix bill” into law delaying ICD-10 implementation to this October as well as delaying Medicare payment cuts to physicians until April 1, 2015.

With the start of the new 114th Congress and as the SGR deadline looms, ICD-10 could again be on the legislative agenda. “Subcommittee members will look to build upon the bipartisan, bicameral agreement on policy reached in the 113th Congress,” states the subcommittee’s announcement regarding the SGR hearings. Witnesses to testify at the SGR hearings have yet to be announced.

Last month, the House Energy and Commerce Committee also issued a statement that it is prepared to hold a congressional hearing on ICD-10 in 2015. The committee’s interest in ICD-10 came at the same time that a letter from the Medical Society of the State of New York to Speaker of the House John Boehner (R-Ohio) was circulated to other members of Congress requesting the ICD-10 deadline be pushed back to October 2017.

Industry groups opposed to further ICD-10 delays were concerned late last month that a $1.1 trillion spending bill to fund almost all of the federal government for fiscal 2015 might contain language to delay the current ICD-10 compliance date. However, in the end, those fears were not realized.

For its part, the American Health Information Management Association strongly supports the October 1, 2015 deadline for implementing ICD-10. “The industry has already seen two delays in implementation, and each delay has cost the industry billions of dollars, as well as the untold costs of lost benefits from implementing a more effective code set,” argues AHIMA.

 

ICD-10: Defining Clearer Boundaries

Doug Zweibel

by Rhonda Butler, senior clinical research analyst with 3M Health Information Systems.

See full article here

What makes a species distinct enough that it gets its own unique name?  Like any classification system, Linnaeus’ conceptual framework for organizing and naming living things is an exercise in drawing boundaries.  Similar things are grouped together, initially by laying out general boundaries—is it animal, vegetable, or mineral?—and making progressively finer distinctions.

All classification systems work in basically the same way, because all classification systems are products of the human mind. Classification is a profoundly human endeavor. We invent systems that allow us to organize and codify our understanding of the world and ourselves.

ICD-10 is a classification system for understanding the ways our own bodies can break or be broken, and what we can do to try and fix them. ICD-10 has more codes than ICD-9 simply because it makes finer distinctions.

To the extent possible, classification systems try to ask for the same amount of detail in drawing a next level boundary. Often this is depicted in graphic form like a tree structure—the kind of thing we see in a company’s org charts all the time. As it evolved with each annual update, ICD-9 did not make a serious attempt to be systematic in the detail it added, or consistent in the types of information it classified to the same level boundary.

ICD-10 is both systematic in its application of detail and consistent in the type of information it classifies to the same level boundary. For example, the American Congress of Obstetricians and Gynecologists (ACOG) asked the CDC’s National Center for Health Statistics (NCHS) to add detail to ICD-10 that tells them whether a pregnant woman is in the first, second or third trimester of her pregnancy. So that information about trimester of pregnancy was added systematically to the obstetrics branch of the ICD-10 tree.

Systematic and complete application of detail to an entire branch of a classification system obviously increases the number of codes by a factor of the amount of meaningful detail—three trimesters = three times as many pregnancy diagnosis codes.

And that is of course the point of any good classification, to draw boundaries that are meaningful to the people in that field. Imagine telling ACOG that all trimesters are the same, that the information they asked for in ICD-10 is unnecessary and a burden to physicians, and that they can track quality, outcomes, and do sophisticated clinical research without knowing the trimester of the patient. Maybe the opponents of ICD-10 can tell them.

ICD-10 Readiness Spotlight: Dual Coding

Doug Zweibel

In the context of healthcare, “coding” refers to the process of converting words or phrases from the medical record into standardized codes that capture the conditions of a patient (diagnosis codes) and what we did to treat those conditions (procedure codes). In the inpatient world, these codes are analyzed to yield a single Diagnosis Related Group (DRG), which is the basis of reimbursement for Medicare, Medicaid, and many other payers. The codes are also used for various types of research, e.g. on outcomes and other measures of quality. The current code set is ICD-9 (ICD stands for International Classification of Diseases), and the next version will be ICD-10.

A tool called an encoder helps the coder to arrive at each diagnosis or procedure code by asking them a series of questions about the case. Next, another tool called a grouper analyzes the codes to yield a DRG for that inpatient discharge. Because the DRG is the basis for how we get paid, getting the ICD codes correct is vital to ensure appropriate reimbursement.

Dual coding refers to the assignment of both ICD-9 and ICD-10 codes to a given patient visit during a single coding session. Because ICD-10 is almost always more complex than ICD-9, the encoder provides additional prompts to the coder in order to gain the additional information that is required to produce ICD-10 codes.

Dual coding is a transition-period function that will help us prepare for ICD-10. Some motivating factors for dual coding are listed below. As part of the ICD-10 project, NYP has coded more than 5,000 inpatient cases and hundreds more outpatient cases in ICD-10 to satisfy these goals.

  1. Coder practice and proficiency. NYP employs dozens of coding professionals to translate the care documented in patients’ medical records into billable and reimbursable diagnosis and procedure codes. This group is as affected by the transition to ICD-10 as any in the organization. The more time they are provided to practice and master coding actual claims in ICD-10, the greater chance for NYP success.
  2. System and interface testing. Dual coding allows us to determine whether our systems and interfaces are capable of handling ICD-10 codes, and to take corrective action if there are issues. This applies to both our internal systems and to external systems used by payers, clearinghouses, registries, etc.
  3. Financial impact analysis. Dual coding a case generates two DRGs – one for ICD-9 and one for ICD-10.   If the DRGs (or other metrics such as Severity of Illness, or SOI) don’t match, further investigation is warranted. Sometimes a DRG shift is due to human error, and so highlights an educational opportunity. Other times, correctly coding the chart in ICD-9 and ICD-10 results in two different DRGs, which means our reimbursement could change. In these cases, we may comment to Medicare to request that they alter their methodology.
  4. Claims testing. We want to be sure that our payers are ready to process ICD-10 coded claims, and that they get the same DRGs that we do. If our DRGs don’t match, we need to explore why.
  5. Quality metrics drift. Dual coding cases that fall within the metric population for various quality metrics, e.g. core measures and patient safety indicators, allows us to see whether the metric population may shift under ICD-10, which could result in changes to our performance on those metrics.
  6. Medical Necessity testing. Dual coding can help to identify cases that met medical necessity in ICD-9 but do not in ICD-10, or vice versa.
  7. Clinical documentation improvement. The best way to prepare providers for the additional document requirements of ICD-10 is with actual examples. When the coder is responding to the encoder’s prompts during a dual coding session, if they are not able to respond to a question because of inadequate documentation, this indicates an opportunity to provide education to providers.

NYP ICD-10 Project Update: January

Jason Gottlieb

We are merely 268 days away (… again) from the October 1, 2015 implementation date of ICD-10. As we roll (… literally) out of the holiday season and into a new year, we hope everyone is refreshed, replenished, and ready to tackle the many challenges and opportunities that continue to face the ICD-10 project, NYP, and the healthcare industry. However, in case you’re not, ICD-10 has you covered with T73.3.xxS (holiday exhaustion).

December brought us good news, relatively speaking, from our friends in the federal government. Despite the minority’s best intentions, critics of ICD-10 were unsuccessful in getting any legislative provisions further delaying ICD-10 included in the most recent Omnibus spending bill. This clears the path for next three months when we will look to another attempt to couple another delay with the sustainable growth rate formula for physician payments as was accomplished last year.

January will provide the ICD-10 project with some major accomplishments and set the stage to begin our final readiness activities.

  • Operationalize a dual coding production environment. NYP will look to expand its dual coding activities to additional service lines, payers, and personnel giving us a larger and more representative spectrum of our patient population for analysis and remediation. We will also make our dual coding environment available to our NYPHS sponsored hospitals, NY Methodist and NY Hospital Queens.
  • Complete end-to-end claims testing with payers. During the last week of January, NYP will submit a small sample of claims to National Government Services (NGS), our Medicare Administrative Contractor (MAC), as part of the CMS’ end-to-end claims testing activities. Unlike their recently released acknowledgment testing results, end-to-end testing will actually process our claims and return remittance information. This provides NYP with assurances that not only can one of our largest payers receive ICD-10 coded claims but can accurately pay them as well.

Other activities will continue to progress and expand under the assumption that no further delays shall occur. For a complete overview of the project status, click here to view the Project Scorecard.

Should you have questions about what you can be doing to get your department ready for ICD-10 or would like to request an in person presentation from the ICD-10 project team, please e-mail ICD10Help@nyp.org.

Happy New Year and welcome back!

CMS announces results from November ICD-10 Acknowledgement Testing Week

Jason Gottlieb

CMS conducted another successful acknowledgement testing week last month. Acknowledgement testing gives providers and others the opportunity to submit claims with ICD-10 codes to the Medicare Fee-For-service (FFS) claims systems and receive electronic acknowledgements confirming that their claims were accepted. While providers are welcome to submit acknowledgement test claims anytime, during the November testing week, testers submitted almost 13,700 claims.

More than 500 providers, suppliers, billing companies, and clearinghouses participated in the testing week last month. Testers included small and large physician practices, small and large hospitals, labs, ambulatory surgical centers, dialysis facilities, home health providers, ambulance providers, and several other physician specialties. Acceptance rates improved throughout the week with Friday’s acceptance rate for test claims at 87 percent. Nationally, CMS accepted 76 percent of total test claims. Testing did not identify any issues with the Medicare FFS claims systems. This testing week allowed an opportunity for testers and CMS alike to learn valuable lessons about ICD-10 claims processing.

To ensure a smooth transition to ICD-10, CMS verified all test claims had a valid diagnosis code that matched the date of service, a National Provider Identifier (NPI) that was valid for the submitter ID used for testing, and an ICD-10 companion qualifier code to allow for processing of claims. In many cases, testers intentionally included errors in their claims to make sure that the claim would be rejected, a process often referred to as “negative testing.” The majority of rejections on professional claims were common rejects related to an invalid NPI. Some claims were rejected because they were submitted with future dates. Acknowledgement testing cannot accept claims for future dates. Additionally, claims using ICD-10 must have an ICD-10 companion qualifier code. Claims that did not meet these requirements were rejected.