ICD-10 “New Normal” Overview the Changing Behavior of ICD-10 Coded Information

ICD-10 “New Normal” Overview The Changing Behavior of ICD-10 Coded Information August 2015 ICD-10 Transition Impacts ICD-10 will create a “New Normal” New Terminology and Concepts, some examples: • STEMI and Non-STEMI instead of “Heart Attack” or “AMI” • Underdosing and more Borderline conditions can be coded • New scales for Asthma (4 levels), Diabetes (5 levels), Coma, and other conditions • Episode of care indicators • Pregnancy coded in trimesters • Only 1 code to use for vaccinations • Routine exams split into “with” and “without findings” categories Data will behave differently, some examples: • Fewer heart attacks (coded for 4 weeks following infarct instead of 8 in ICD-9) • More cancer cases (anemia coded 2nd in ICD-10 after cancer, ICD-9 rule was opposite) when looking at primary Dx • No V codes for rehab visits, instead this is part of the episode of care digit • Pregnancies include new code for weeks gestation • More combination codes will cause some conditions harder to locate in queries (e.g. kidney failure due to diabetes) • Abnormal test findings will appear in more records • Smokers and patients exposed to tobacco smoke will appear more often 2 ICD-10 New Normal Overview Relationship between Coding and Clinical Documentation ICD, like any medical code set, reflects the information present in the medical record. Think of ICD-10 as a mature, or enhanced, version of ICD-9, that enables the significant detail already being captured in medical records to be captured equally well in coding. **Most clinical detail captured today is lost when translated to ICD-9** Consider this quote from Dan Riskin*, MD, CEO of Health Fidelity: “ICD-10 is not about going from a small number of codes to a moderate number of codes. The patient doesn’t actually care about that. And Meaningful Use 2 is not about reporting smokers. The country doesn’t actually care about that. These things are about getting sufficiently detailed information and sufficiently broad information that actually gets used in analytics to improve care, and yet we’re not really thinking about that all that much.” *About Dr. Riskin: Dan has developed and commercialized products in the fields of healthcare analytics, healthcare services, and medical devices. He was named one of the top 35 innovators under 35 by Technology Review and won the AMA Leadership Award in 2005. He subsequently served on the Obama Campaign Healthcare Advisory Committee in 2008. He has been an invited speaker on medical technology creation and venture development at the NIH, NSF, NASA, DARPA, IBM, HP, Harvard, Stanford, and MIT. Dan’s medical credentials include a MD from Boston University, residency in surgery at UCLA, and fellowship in critical care and acute care surgery at Stanford University. He is dual boarded in surgery and critical care and is on consulting faculty at Stanford University. His business training includes a MBA with a focus in biomedical engineering from MIT Sloan School of Management and the Stanford Biodesign Fellowship. 3 What is the Same, New, and Different? DIAGNOSES ICD-10 New Normal Overview New & Different - Diagnosis Data and transactions for these conditions and reasons for visit will behave differently • Abnormal Test Findings & Borderline Diagnoses • Acute Myocardial Infarction • Adverse Effects, Dosing, & Poisoning • Atherosclerosis, Angina & Hypertension • Coma • Diabetes Mellitus • Kidney Disease & Urosepsis • OB, Pregnancy, & Newborns • Oncology & Neoplasms • Orthopedics, Musculoskeletal, Injuries & Fractures • Routine Exams / Physicals • Vaccines / Immunizations 5 ICD-10 New Normal Overview Abnormal Test Findings & Borderline Dx are Different Abnormal Test Findings • In ICD-10-CM, Many new codes exist for abnormal findings if a related diagnosis is not coded, if a confirmed diagnosis is coded, the abnormal test result is not coded • In ICD-9-CM Only confirmed diagnoses are coded, and abnormal tests were often not captured in coding • Borderline Diagnoses – “borderline” is new term in ICD-10 • Terms described by the provider as “borderline” are coded as a confirmed, not a suspected, condition unless the Index has specific entry for a borderline condition • Other abnormal glucose – Borderline diabetes mellitus, R73.09 • Elevated blood pressure reading – Borderline hypertension, R03.0 • Low bone mineral density (BMD), borderline osteoporosis – Borderline osteopenia, M85.8 Data Behavior Implication – More abnormal test findings in data, more borderline diagnoses in data 6 ICD-10 New Normal Overview Adverse Effects, Dosing, Poisoning are New & Different • Drug Effects ICD-10-CM ICD-9-CM Grouped by drug, with codes for poisonings, adverse Grouped by effect, with no codes for underdosing. effects, and underdosing • Adverse effect codes – same as ICD-9 – identifies drugs producing side effects when taken correctly – First code is the nature of the adverse effect – Second code identifies the drug or chemical – More effects and types of drugs/chemicals available • Underdosing – new concept for ICD-10-CM, means taking less of a substance than is prescribed by a provider or according to manufacturer’s instruction – First code the relapse or exacerbation of the medical condition for which the drug is prescribed – Second code the drug that was not taken properly – Noncompliance codes used to identify intent if known (e.g. financially motivated, or elderly did not remember) • Poisoning codes – same as ICD-9 – means not ingesting the drug correctly (took too much, or mixed with alcohol or other substance/drugs) – Combination codes in ICD-10 explaining two facts – identify event + drug involved – Indicate if Accidental, Self Harm, Assault & Undetermined – External Cause code not needed – this concept is built in to poisoning code meanings – Additional codes used for manifestations Data Behavior Implication – Underdosing now appears in data, better detail why poisoning occurred and drugs/chemicals involved 7 ICD-10 New Normal Overview Asthma is Different Asthma • ICD-10 requires the following scales into documentation: – Mild intermittent – Mild persistent – Moderate persistent – Severe persistent • More instructions to code tobacco use/exposure ICD-9-CM ICD-10-CM 493.22 chronic J44.1 Chronic obstructive asthma, obstructive pulmonary with status disease with (acute) asthmaticus exacerbation J45.42 Moderate persistent asthma with status asthmaticus Z72.0 Tobacco use Data Behavior Implication – The varying degrees of asthma severity will be easier to identify and separate in health care data sets, more identification of patients who smoke/exposed to tobacco smoke 8 ICD-10 New Normal Overview Acute Myocardial Infarction is Different Acute Myocardial Infarction (Heart Attack) • Duration changed from 8 weeks in ICD-9 to 4 weeks in ICD-10 – Why? – Physicians are no longer treating the heart attack after the first 4 weeks, other ongoing conditions take precedence • The terms “Acute MI” or “AMI” is no longer used. Codes reflect newer terminology and distinguishes between ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarctions – STEMI of anterior wall, inferior wall, other sites, or ICD-9-CM ICD-10-CM unspecified site – NSTEMI (subendocardial, nontransmural) 410.71 I21.4 Non-ST-elevation Subendocardial (NSTEMI) myocardial • Category I21 used for initial treatment of STEMI and NSTEMI infarction, initial infarction and all continued treatment during next 4 weeks, but use episode of care I48.91 Fibrillation, atrial Category I22 for subsequent episode: or auricular Initial STEMI or NSTEMI Subsequent STEMI or NSTEMI during next 4 weeks Category I21 code used during 4 weeks after first episode Category I22 code used for episode that occurs within 4 weeks of occurred a previous STEMI or NSTEMI, regardless of site No concept of “initial” or “subsequent” myocardial Code both the I21 and I22 category codes Infarction in ICD-10 (Patient recovering from a heart attack had a new heart attack) Data Behavior Implication – Fewer records with heart attack diagnoses in the same patient population 9 ICD-10 New Normal Overview Atherosclerosis, Angina & Hypertension are Different Atherosclerosis, Angina & Hypertension Angina often occurs in combination codes for atherosclerotic heart disease • Coronary artery disease of native vessel and bypass grafts with angina pectoris, unstable angina, documented spasm or unspecified type – Eliminates the use of a second code for the angina – Angina is coded separately only when the cause is unrelated to heart disease Only one code for essential (primary) hypertension – I10 (Letter I, digits 10) – In ICD-10-CM, hypertension not classified by type (benign, malignant, unspecified) • Hypertension causing chronic kidney disease, heart disease or both heart and kidney disease have separate category codes, similar to ICD-9 ICD-9-CM ICD-10-CM 414.00 Coronary atherosclerosis, of I25.119 Atherosclerosis heart disease of unspecified type of vessel, native or graft native coronary artery with unspecified 413.9 Other and unspecified angina angina pectoris pectoris Data Behavior Implication – Fewer records with angina diagnoses in the same patient population, risk of excluding hypertension in data if not looking at combination codes with hypertension, more smokers 10 ICD-10 New Normal Overview Coma is Different • Neurological Coma scale codes in Section R40.2 • Used with traumatic brain injury, acute cerebrovascular disease or sequela of CVA • 1 code for total coma scale score – or 3 codes for – Eyes open – Best verbal response – Best motor response •

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