ICD-10’s Impact on Physician Practice
Psychiatry
Medical Necessity,
Quality Management, and
Cost Efficiency Determinants
1
Disclaimer
• This presentation is designed to provide accurate and authoritative
information in regard to the subject matter. The information includes both
reporting and interpretation of materials in various publications, as well as
interpretation of policies of various organizations. This information is
subject to individual interpretation and to changes over time.
– The speaker does not warrant that the written or oral opinions expressed in this
lecture apply to every situation. Prior to implementing any of the suggestions
discussed at this meeting, the attendee is advised to seek counsel from his or her
compliance officer or their legal counsel.
– CDIMD, the individual speakers, and all affiliated entities support accurate coding
of every clinical circumstance based upon physician documentation, recognize the
role and responsibility of treating physicians to utilize language they deem
appropriate to their circumstances, and support compliance to all local, state, and
federal laws.
2
Objectives
Subject
Task
1 ICD-10
Understand what is new and different from ICD-9
2 Risk Adjustments
What they are; How they are used
3
Quality and CostEfficiency Analysis
How it is accomplished
4
Changing
Reimbursements
Based on quality and cost-efficiency analysis and
risk adjustments
5 Literature Review
Clinical terms and the thresholds between
severities illness
• Physicians define the terms (conditions)
• The bureaucracy assigns relative weights to the
terms
Role of Clinical
6
Documentation Integrity
Translating medical language into the language of
claims processing. Helping physicians to get #1
above correct, so 2, 3, and 4 are correct
Like Explaining the Phone Book
Interesting Characters – Terrible Plot
Dictionary without
Definitions
ICD-10 Implementation Date
October 1, 2015
Diagnoses
Procedures
ICD-10-CM
(Clinical Modification)
Used by Everyone
ICD-10-PCS
(Procedure Coding System)
Inpatient Facility ONLY!!!
Used by all entities:
(providers & facilities) for diagnoses
To be used in all settings:
– Hospital inpatients
– Hospital outpatients
– Physicians offices
– Emergency department
– Home health
– Long-term care
– Rehabilitation facilities
Used by inpatient facilities ONLY
• Includes outpatient facility services
rendered within the prior 72 hours of
writing the inpatient order
• Very different than ICD-9-CM or CPT
CPT
• Physician and outpatient/observation
facility services still utilize CPT
• CPT does not change!!
5
International Classification of Disease
Evolving Versions
• First edition, known as the International List of
Causes of Death, was adopted by the International
Statistical Institute in 1893
• WHO took in 1948 when the Sixth Revision, which
included causes of morbidity for the first time, was
published.
• 1977 - ICD-9
• 1993 - ICD-10
• 2017 (tentative) - ICD-11
6
Countries in Blue Have Adopted ICD-10 for
Morbidity
• The US is the last industrialized country to adopt ICD-10
• The US is the only country to tie ICD-10 to billing & reimbursement
US Modifications – ICD-10-CM & PCS
The Cooperating Parties
• CDC
• Responsible for diagnoses
• CMS
• Responsible for inpatient
procedures
• American Hospital Assn.
• Responsible for interpreting
ICD-9 or ICD-10 (Coding Clinic)
• American HIM Assn.
• Provides input from coding
community
8
ICD-10 Basics
• ICD-10-CM/PCS (and ICD-9-CM) are NOT clinical
languages (like SNOMED)
– ICD-9-CM and ICD-10-CM/PCS are useful for
classifying healthcare data for administrative
purposes, including reimbursement claims, health
statistics, and other uses where data aggregation is
advantageous
• ICD-10-CM/PCS is based ONLY on provider
documentation of clinical language, not on a
patient’s clinical characteristics
– The provider must use the magic words that drive ICD10-CM/PCS code assignment
9
What’s Old?
ICD-9-CM
10
What’s New
ICD-10-CM
11
ICD-9 and ICD-10
Diagnoses and Procedures
Code Type
ICD-9-CM
ICD-10-CM
ICD-10 PCS
Diagnosis
14,567 codes
69,832 codes
Inpatient
Procedures
3,878 codes
71,920 codes
12
Major DSM-5 Changes
• Subtypes of schizophrenia (e.g. residual, paranoid,
disorganized) are eliminated due to their limited reliability
and validity.
• Separate diagnoses for autism, Asperger’s Syndrome, and
pervasive developmental Disorder, NOS have been
eliminated and are now classified under the new term
Autism spectrum disorder. However, in ICD-10-CM:
ICD-10 Description
Code
MS DRG
CC/MCC
APR DRG
SOI
APR DRG
ROM
F840
Autistic disorder
CC
1
1
F845
Asperger’s syndrome
CC
1
1
• Non-physiologic feeding and eating disorder of early
childhood is now classified as avoidance/restrictive food
intake disorder
Major DSM-5 Changes
• Somatiform disorders are now classified as Somatic
Symptom and Related Disorders and the terms
somatization disorder, hypochondriasis, pain disorder, and
undifferentiated somatoform disorder have been removed.
• Some new disorders described in DSM-5 include:
– Premenstrual Dysphoric Disorder
– Disruptive Mood Dysregulation Disorder of childhood (onset
before age 10 years)
– Hoarding Disorder
– Social (pragmatic) Communication Disorder
– Disinhibited Social Engagement Disorder
– Rapid Eye Movement Sleep Behavior Disorder
– Caffeine Withdrawal
ICD-10-CM Accommodations of DSM-5
• CMS and CDC Coordination and Maintenance
Committee
– Partial freeze on ICD-10 updates
– Only limited updates to ICD-10 code sets October 1, 2015
– Regular updates will not begin until October 1, 2016
– Thus, it is uncertain when the coder and CDS specialist will
see modifications to ICD-10-CM codes that reflect the
most up to date terminology and classifications. In the
interim, the new DMS-5 disorders, classifications, and
nomenclature changes can create challenges for the coder
in ascribing proper credit for the physician’s care.
DSM-5 Preparation for ICD-10-CM
• General Equivalence Mapping
– With each disorder in the DSM-5 manual, an ICD9-CM code is followed by an ICD-10-CM code in
parenthesis. A blank line indicated an ICD code is
not applicable.
– DSM-5 includes many new disorders,
nomenclature changes, and new combination
codes; hence, not always a match.
ICD-9-CM and ICD-10-CM Coding Rules
• Code assignment is based ONLY on provider
documentation
– Even if it quacks, waddles, has web feet, no code for
“duck” can be entered unless the physician says
“duck”
– Coders may not clinically interpret the record
• For inpatients, coders may not pathology or
diagnoses from IP X-ray reports
– They are allowed to obtain the anatomic location, but
not the pathology
• Coders may not code from IP pathology reports
Sign and Symptoms
Unspecified Codes
• Use of 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.
– 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.
Major DSM-5 Changes
• Substance abuse and substance dependency is
no longer separately classified. The
classification is now substance use disorder,
mild, moderate, or severe.
– The term addiction is eliminated.
– When withdrawal, intoxication, substance-induced
or other substance-related mental disorder is
present, the manual provides criteria and directs
further specific code selection based on these cooccurrences.
DSM-5 vs. ICD-10-CM Crosswalk Study
• The ICD-10 and DSM-5 reached a similar conclusion for
– Patients that did not meet alcohol use disorder diagnosis
– Patients that meet the most severe forms of alcohol use
disorder
• ICD-10 and DSM-5 discrepancy for
– Mild and moderate cases of alcohol use disorder
• Roughly one-third of DSM-5 mild cases would not receive a
diagnosis per the ICD-10 clinical version
• May lead to reduced access to treatment services for a fairly large
number of individuals
Source: Psychology & Psychiatry, March 17, 2015,
http://medicalxpress.com/print345833934.html
Principle #1
ICD-10-CM: A Dictionary w/o
Definitions
Principle #1
ICD-10-CM: A Dictionary w/o
Definitions
Principle #1
ICD-10-CM: A Dictionary w/o
Definitions
Definitions – DSM-5 – or others?
Use vs. Abuse vs. Dependency
• Use – legal use of a drug or chemical
• Abuse – Illegal or excessive use of a drug or chemical causing adverse
consequences
• Dependency (at least 2 of the following)
–
–
–
–
–
–
–
–
Item taken in larger amounts or over a longer period than intended
Persistent desire or unsuccessful efforts to cut down or control use
Great deal of time spent to obtain the chemical
Craving or a strong desire to use
Continued use despite adverse consequences due to drug/chemical
Failure to meet major role obligations at home, work, or school
Recurrent use in situations that are hazardous (2 DWIs)
Continued use despite knowledge of having a physical or mental condition
that is worsened by the chemical use
– Tolerance (need for more drug to have the same effect)
– Withdrawal symptoms when drug is discontinued
Source: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5)
Definitions – DSM-5 – or others?
Remission
• Remission - After full criteria for dependency were previously met,
none of the criteria (except for craving or a strong desire to use)
have been met for a least 3 months
– Early remission – between 3 to 12 months
– Sustained remission – over 12 months
• Intoxication - Reversible substance-specific syndrome due to recent
ingestion of a substance
• Delirium - A disturbance in attention (e.g. reduced ability to direct,
focus, or sustain) and awareness (reduced orientation to
environment that develops over a short period of time, that is
different over baseline, and tends to fluctuate in severity over the
course of a day than cannot be better explained by a preexisting
neurocognitive disorder
Source: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5)
Alcohol/Drug Use and Alcohol/Drug-Induced Organic Mental
Disorders
MS-DRG
MS-DRG title
894
ALCOHOL/DRUG ABUSE OR DEPENDENCE, LEFT AMA
ALCOHOL/DRUG ABUSE OR DEPENDENCE
895
W REHABILITATION THERAPY
ALCOHOL/DRUG ABUSE OR DEPENDENCE
896
W/O REHABILITATION THERAPY W MCC
ALCOHOL/DRUG ABUSE OR DEPENDENCE
897
W/O REHABILITATION THERAPY W/O MCC
•
Weights
0.4509
1.1939
1.5146
0.6824
Rehabilitation therapy:
– Detoxification services for substance abuse treatment with group or individual
counseling for substance abuse treatment
•
•
Cognitive, behavioral, cognitive-behavioral, 12-step, interpersonal, vocational,
psychoeducation, motivational enhancement, confrontational, continuing care,
spiritual
ICD-10-PCS root operation definition for individual or group (2 or more)
counseling (potentially qualifying for MS-DRG 895)
– The application of psychological methods to treat an individual with addictive
behavior
26
Assigned Relative Weights to AlcoholAssociated Diagnoses
ICD-10
Code
F1010
F10120
F10121
F10129
F1014
F10150
F10151
F10159
F10180
F10181
F10182
F10188
F1019
Description
Alcohol abuse, uncomplicated
Alcohol abuse with intoxication, uncomplicated
Alcohol abuse with
intoxication delirium
Alcohol abuse with intoxication, unspecified
Alcohol abuse with alcohol-induced
mood disorder
Alcohol abuse with alcohol-induced
psychotic disorder with delusions
Alcohol abuse with alcohol-induced
psychotic disorder with hallucinations
Alcohol abuse with alcohol-induced
psychotic disorder, unspecified
Alcohol abuse with alcohol-induced
anxiety disorder
Alcohol abuse with alcohol-induced
sexual dysfunction
Alcohol abuse with alcohol-induced
sleep disorder
Alcohol abuse with
other alcohol-induced disorder
Alcohol abuse with
unspecified alcohol-induced disorder
HCC
#
HCC
CM RW
HCC
IN RW
MS DRG
CC/MCC
APR DRG
SOI
1
1
APR DRG
ROM
1
1
55
0.420
0.053
55
0.420
0.053
CC
3
2
55
0.420
0.053
1
1
55
0.420
0.053
1
1
54
0.420
0.053
1
1
54
0.420
0.053
CC
1
1
54
0.420
0.053
CC
1
1
55
0.420
0.053
CC
1
1
55
0.420
0.053
CC
1
1
55
0.420
0.053
1
1
55
0.420
0.053
CC
1
1
55
0.420
0.053
CC
2
1
CC
HCC = Hierarchical Condition Category; HCC CM RW = HCC Community Relative Weight; HCC
IM RW = Institutional RW (i.e., nursing home); SOI = Severity of Illness; ROM = Risk of
Mortality
ICD-10
Code
F1020
F1021
F10220
F10221
F10229
F10230
F10231
F10232
F10239
F1024
F10250
F10251
F10259
F1026
F1027
F10280
F10281
F10282
F10288
F1029
Description
Alcohol dependence, uncomplicated
Alcohol dependence, in remission
Alcohol dependence with intoxication,
uncomplicated
Alcohol dependence with intoxication
delirium
Alcohol dependence with intoxication,
unspecified
Alcohol dependence with withdrawal,
uncomplicated
Alcohol dependence with withdrawal
delirium
Alcohol dependence with withdrawal with
perceptual disturbance
Alcohol dependence with withdrawal,
unspecified
Alcohol dependence with alcohol-induced
mood disorder
Alcohol dependence with alcohol-induced
psychotic disorder with delusions
Alcohol dependence with alcohol-induced
psychotic disorder with hallucinations
Alcohol dependence with alcohol-induced
psychotic disorder, unspecified
Alcohol dependence with alcohol-induced
persisting amnestic disorder
Alcohol dependence with alcohol-induced
persisting dementia
Alcohol dependence with alcohol-induced
anxiety disorder
Alcohol dependence with alcohol-induced
sexual dysfunction
Alcohol dependence with alcohol-induced
sleep disorder
Alcohol dependence with other alcoholinduced disorder
Alcohol dependence with unspecified
alcohol-induced disorder
HCC
HCC
CM RW
HCC
IN RW
55
55
0.420
0.420
55
MS DRG
CC/MCC
APR DRG
SOI
APR DRG
ROM
0.053
0.053
1
1
1
1
0.420
0.053
1
1
55
0.420
0.053
3
2
55
0.420
0.053
1
1
55
0.420
0.053
CC
1
1
54
0.420
0.053
CC
3
2
54
0.420
0.053
CC
1
1
55
0.420
0.053
CC
1
1
55
0.420
0.053
CC
1
1
54
0.420
0.053
1
1
54
0.420
0.053
CC
1
1
54
0.420
0.053
CC
1
1
54
0.420
0.053
2
1
54
0.420
0.053
CC
2
2
55
0.420
0.053
CC
1
1
55
0.420
0.053
CC
1
1
55
0.420
0.053
1
1
55
0.420
0.053
CC
1
1
55
0.420
0.053
CC
2
1
CC
Same for any
alcohol or
drug (e.g.,
cocaine,
marijuana,
nicotine, or
psychoactive)
use, abuse, or
dependency
Meditech 5.67
Meditech 5.67
How Does This Impact Physicians?
31
CMS’s Game Plan
What’s About
To Hit Them
What
Physicians
Understand
Now
What’s
Relatively
New to Docs
Medicare’s
Ultimate Goal
Medicare Physician Value Based
Modifier
2017 Implementation
(2015
Data)
Quality Composite Score
Cost
Medicare Physician
Value Based Modifier
Low
Average
High
Low
+0.0%
+2.0%*
+4.0%*
Average
-2.0%
+0.0%
+2.0%*
High
-4.0%
-2.0%
+0.0%
*Groups of physicians eligible for an additional +1.0x if reporting Physician Quality Reporting System quality
measures and average beneficiary risk score is in the top 25% of all beneficiary risk scores.
• Cost calculation
• Total per capita costs for all attributed beneficiaries and those with
̶ Diabetes
̶ Coronary artery disease
̶ Chronic obstructive pulmonary disease
̶ Heart failure
̶ Medicare Spending Per Beneficiary
Physician Quality and Cost Efficiency
Distributions
• Low cost – 4.5%
• Average cost – 89.4%
• High cost – 6.2%
Source: 2015 CMS Proposed Physician Rule
34
Physician Value-Based Payment
Modifier
Quality and Cost Composite
https://portal.cms.gov
35
Physician Risk-Adjustment
Observed vs. Expected Costs
Determine by Patient’s Characteristics
and Provider Care Quality
Observed Costs
Risk Adjusted Costs = ---------------------------------Expected Costs
Determined by Documentation
and Coding using ICD-9-CM
or ICD-10-CM/PCS
36
Alcohol/Drug Use and Alcohol/Drug-Induced Organic
Mental Disorders
• If the admission can be viewed as an poisoning, then poisoning
codes prevail
Definitions and thresholds not well established: Influence, intoxication, toxicity?
37
ICD-10-CM: Episode of Care
Trauma and Medication-related Events (only)
ICD-10-CM: Based on pt’s phase of healing, not physician’s encounter
• Initial encounter: making the first diagnosis or receiving
active treatment for an injury or illness.
– Fx care: Emergency physician, orthopedist, radiologist, etc.
– Poisonings – initial treatment during the hospital stay
• Subsequent encounter: care during a period of healing
or recovery.
– Cast change, suture removal, etc.
– Poisonings – could be during a hospital stay or immediate visit
• Sequela: After the healing process is complete.
– Fx care: Arthritis remotely after trauma, etc.
– Poisonings – If related to a long-standing consequence (e.g. anoxic
encephalopathy from carbon monoxide poisoning
ICD-10 Changes
Poisonings
When coding a poisoning or
reaction to the improper use of
a medication (e.g., overdose,
wrong substance given or taken
in error, wrong route of
administration)
• Add additional diagnoses
for all manifestations of
poisonings, such as:
– Toxic encephalopathy
– Acute respiratory failure
– Unconsciousness
• Codes to coma
– Many others
39
ICD-10 Changes
Medication Underdosing
• If a patient’s condition is
due to underdosing of
prescribed medications
– Seizures due to
subtherapeutic medication
level
– Hypothyroidism due to
inadequate Synthroid
compliance
– Hyperglycemia in diabetic due
to inadequate insulin
administration
• Further divided into:
– Intentional, such as due to
financial hardship or willful
noncompliance
– Unintentional, such as due
to age-related debility or
other defined reasons
Note:
• Currently does not
influence DRGs
40
Patient Noncompliance
While “Z-codes” or “external cause” codes are
not required by CMS, they do add information
useful in patient and provider profiling
Meditech 5.67
General Equivalence Mapping
This exercise will NOT capture new ICD-10 specificities
Validate all mappings using ICD-10 Index, Table, and Guidelines
General Equivalence Mapping:
Psychiatry
•
•
This exercise will NOT capture new ICD-10 specificities
Validate all mappings using ICD-10 Index, Table, and Guidelines
GEM
Phobias
Note the expansion of the phobia codes
GEM
Anxiety, Conversion, and Factitious DO
GEM
Schizophrenia
• Note that in ICD-10, the chronicity of
schizophrenia is removed
GEM
Schizophrenia
• Note that in ICD-10, the chronicity of
schizophrenia is removed
Meditech 5.67
Psychiatry
Major depressive affective DO,
recurrent
Major depressive DO, single
Obesity
Anxiety
Dementia w/ behavioral DO
Depressive D/O
Single
29620
29621
29622
29623
29624
29625
29626
29620
Major depressive affective disorder, single
episode, unspecified
Major depressive affective disorder, single
episode, mild
Major depressive affective disorder, single
episode, moderate
Major depressive affective disorder, single
episode, severe, without mention of
psychotic behavior
Major depressive affective disorder, single
episode, severe, specified as with
psychotic behavior
Major depressive affective disorder, single
episode, in partial or unspecified
remission
Major depressive affective disorder, single
episode, in full remission
Major depressive affective disorder, single
episode, unspecified
F329
F320
F321
Major depressive disorder, single episode,
unspecified
Major depressive disorder, single episode,
mild
Major depressive disorder, single episode,
moderate
Approximate
match
Exact match
Exact match
F322
Major depressive disorder, single episode,
severe without psychotic feature
Exact match
F323
Major depressive disorder, single episode,
severe with psychotic features
Approximate
match
F324
Major depressive disorder, single episode, in
Exact match
partial remission
F325
F329
Major depressive disorder, single episode, in
Exact match
full remission
Major depressive disorder, single episode, Approximate
match
unspecified
Depressive Disorder
Recurrent
29630
29630
29631
29632
29633
29634
29635
29636
Major depressive affective disorder,
recurrent episode, unspecified
Major depressive affective disorder,
recurrent episode, unspecified
Major depressive affective disorder,
recurrent episode, mild
Major depressive affective disorder,
recurrent episode, moderate
Major depressive affective disorder,
recurrent episode, severe, without
mention of psychotic behavior
Major depressive affective disorder,
recurrent episode, severe, specified as
with psychotic behavior
Major depressive affective disorder,
recurrent episode, in partial or
unspecified remission
Major depressive affective disorder,
recurrent episode, in full remission
F3340
F339
F330
F331
Major depressive disorder, recurrent, in
remission, unspecified
Major depressive disorder, recurrent,
unspecified
Major depressive disorder, recurrent,
mild
Major depressive disorder, recurrent,
moderate
Approximate
match
Approximate
match
Exact match
Exact match
F332
Major depressive disorder, recurrent
severe without psychotic features
Exact match
F333
Major depressive disorder, recurrent,
severe with psychotic symptoms
Approximate
match
F3341
Major depressive disorder, recurrent, in
partial remission
Exact match
F3342
Major depressive disorder, recurrent, in
full remission
Exact match
Meditech 5.67
HCC Capture
Recurrent Depression
Mania
Mania in Remission
• Mania in full remission adds weight
• Moderate and severe mania add inpatient med/surg weight
Meditech 5.67
Bipolar Disorders
Bipolar Disorders
Less Specific Codes
Meditech 5.67
Risk-Adjustment
Dementia
Underlying Cause of Dementia
Underlying Cause of Dementia
Meditech 5.67
Dementia
• Added value for stating if there is behaviorial
disturbance
Psychosis
Meditech 5.67
Delirium in DSM-5
Disturbance in attention (ie, reduced ability to direct, focus, sustain,
and shift attention) and orientation to the environment;
1. Develops over a short period of time (usually hours to a few days)
2. Represents an acute change from baseline not solely attributable
to another neurocognitive disorder
3. Tends to fluctuate in severity during the course of a day
4. A change in an additional cognitive domain, such as memory
deficit, disorientation, or language disturbance, or perceptual
disturbance that is not better accounted for by a preexisting,
established, or evolving other neurocognitive disorder
5. Disturbances in No. 1 and 3 must not occur in the context of a
severely reduced level of arousal, such as coma.
Delirium and Encephalopathy
• Delirium is a manifestation
• Encephalopathy is an underlying cause
– Delirium does not equal encephalopathy
– Encephalopathy does not equal delirium
“Delirium due encephalopathy of . . .”
MUSIC: “caused by,” “due to,” “resulting in”
Meditech 5.67
Toxic/Metabolic Encephalopathies
Definitions
• Toxic and metabolic encephalopathies are a group of
neurological disorders characterized by an altered mental
status
– A delirium, defined as a disturbance of consciousness characterized
by a reduced ability to focus, sustain, or shift attention that
– Cannot be accounted for by preexisting or evolving dementia and
that is caused by the direct physiological consequences of a
general medical condition.
• Confusion or delirium in Alzheimers would not be an encephalopathy
– Fluctuation of the signs and symptoms of the delirium over
relatively short time periods is typical.
Description
Toxic/Metabolic Encephalopathy
HCC
MS-DRG
CC/MCC
APR-DRG
SOI
APR-DRG
ROM
No relative
weight
MCC
3
3
74
Encephalopathy
• “Encephalopathy,” if no cause is documented,
should always be queried.
• Looking for “encephalopathy due to . . .”
– i.e., “metabolic encephalopathy due to a sodium
of 123 mEq/L”
– Admittedly, this trying to make simple, something
that is not. It is very hard. There is no good
literature on these definitions and thresholds.
Encephalopathy
Multiple Options in ICD-10-CM
Encephalopathy (acute) G93.40
- acute necrotizing hemorrhagic G04.30
- - postimmunization G04.32
- - postinfectious G04.31
- - specified NEC G04.39
- alcoholic G31.2
- anoxic —see Damage, brain, anoxic
- arteriosclerotic I67.2
- centrolobar progressive (Schilder) G37.0
- congenital Q07.9
- degenerative, in specified disease NEC
G32.89
- demyelinating callosal G37.1
- due to
- - drugs (see also Table of Drugs and
Chemicals) G92
- hepatic —see Failure, hepatic
- hyperbilirubinemic, newborn P57.9
- - due to isoimmunization (conditions in P55)
P57.0
- hypertensive I67.4
- hypoglycemic E16.2
- hypoxic —see Damage, brain, anoxic
- hypoxic ischemic P91.60
- - mild P91.61
- - moderate P91.62
- - severe P91.63
- in (due to) (with)
- - birth injury P11.1
- - hyperinsulinism E16.1 [G94]
- - influenza —see Influenza, with,
encephalopathy
- - lack of vitamin (see also Deficiency,
vitamin) E56.9 [G32.89]
- - neoplastic disease (see also Neoplasm)
D49.9 [G13.1]
- - serum (see also Reaction, serum) T80.69
- - syphilis A52.17
- - trauma (postconcussional) F07.81
- - - current injury —see Injury, intracranial
- - vaccination G04.02
- lead —see Poisoning, lead
- metabolic G93.41
- - drug induced G92
- - toxic G92
- myoclonic, early, symptomatic —see
Epilepsy, generalized, specified NEC
- necrotizing, subacute (Leigh) G31.82
- pellagrous E52 [G32.89]
- portosystemic —see Failure, hepatic
- postcontusional F07.81
- - current injury —see Injury, intracranial, diffuse
- posthypoglycemic (coma) E16.1 [G94]
- postradiation G93.89
- saturnine —see Poisoning, lead
- septic G93.41
- specified NEC G93.49
- spongioform, subacute (viral) A81.09
- toxic G92
- - metabolic G92
- traumatic (postconcussional) F07.81
- - current injury —see Injury, intracranial
- vitamin B deficiency NEC E53.9 [G32.89]
- - vitamin B1 E51.2
- Wernicke's E51.2
Encephalopathy by itself must
be queried for specificity
Red = MCC
76
Delirium vs. Encephalopathy
• Delirium (manifestation)
• Encephalopathy (condition)
– Acute change or fluctuation
in mental status and
inattention, accompanied by
either disorganized thinking
or an altered level of
consciousness
Arousable to Voice
Acute mental
status change
Inattention
DELIRIUM
Hallucinations
Delusions,
Illusions
Fluctuating
mental status
Disorganized
thinking
Unarousable
to Voice
COMA
– Global brain dysfunction
– CDIMD opinion: If the global
brain dysfunction can be
explained by an underlying
condition or its exacerbation,
then the term
“encephalopathy” is integral
to that condition
– Exacerbation of a
neurodegenerative condition
is NOT an encephalopathy
Altered level of
consciousness
77
Hypertensive Encephalopathy
• Hypertensive encephalopathy is the term applied to a relatively rapidly
evolving syndrome of severe hypertension in association with headache,
nausea and vomiting, visual disturbances, confusion, and—in advanced
cases—stupor and coma
– Multiple seizures are frequent and may be more marked on one side of the
body
– Diffuse cerebral disturbance may be accompanied by focal or lateralizing
neurologic signs, either transitory or lasting, which should suggest cerebral
hemorrhage or infarction, i.e., the more common cerebrovascular
complications of severe chronic hypertension
– A clustering of multiple microinfarcts and petechial hemorrhages in one region
may occasionally result in a mild hemiparesis, aphasic disorder, or rapid failure
of vision
• Special characteristics of signal changes in the occipital white matter may
occur
– The terms reversible posterior leukoencephalopathy (RPLE) and posterior or
reversible leukoencephalopathy syndrome (PRES)
Source: Adams and Victor's Principles of Neurology, 9th Edition, 2009
78
Hepatic Encephalopathy
• A wide array of transient and
reversible neurologic and
psychiatric manifestations usually
found in patients with chronic
liver disease and portal
hypertension, but also seen in
patients with acute liver failure
– Occurs in 50%–70% of patients
with cirrhosis
• Treatment options
– Diet – low protein
– Medications – lactulose, neomycin,
rifaximin, probiotics
• Serves as a reason for admission
– Only an MCC if with coma
Grade
0
Impairment
Intellectual function
Neuromuscular function
Normal
Normal
Minor abnormalities of
Normal examination findings.
Minimal,
visual perception or on
Subtle changes in work or
subclinical
psychometric or number
driving.
tests
Personality changes, attention
Tremor and
1
deficits, irritability, depressed
incoordination
state
Changes in sleep-wake cycle, Asterixis, ataxic gait,
2
lethargy, mood and behavioral speech abnormalities
changes, cognitive dysfunction (slow and slurred)
Muscular rigidity,
Altered level of consciousness
nystagmus, clonus,
3
(somnolence), confusion,
Babinski sign,
disorientation, and amnesia
hyporeflexia
Oculocephalic reflex,
4
Stupor and coma
unresponsiveness to
noxious stimuli
79
Mental Diseases and Disorders
Inpatient Med-Surg
MS-DRG
876
880
881
882
883
884
885
886
887
MS-DRG title
O.R. PROCEDURE W PRINCIPAL DIAGNOSES OF MENTAL ILLNESS
ACUTE ADJUSTMENT REACTION & PSYCHOSOCIAL DYSFUNCTION
DEPRESSIVE NEUROSES
NEUROSES EXCEPT DEPRESSIVE
DISORDERS OF PERSONALITY & IMPULSE CONTROL
ORGANIC DISTURBANCES & MENTAL RETARDATION
PSYCHOSES
BEHAVIORAL & DEVELOPMENTAL DISORDERS
OTHER MENTAL DISORDER DIAGNOSES
Weights
2.8172
0.6388
0.6541
0.6953
1.2682
1.0060
1.0048
0.9173
0.9795
• Consists primarily of psychological symptoms as the PDx
• Alternatives are:
– Explicitly described brain diseases (e.g., Alzheimer’s disease)
– Psychoactive drug use, abuse, or dependency (see MDC 20)
– Drug poisoning (see MDC 21)
80
Medicare Psychiatric IPPS
Determinants
• Principal Diagnosis
• Secondary Diagnosis
• Geographic Location
– Urban vs. Rural
• Emergency Department
Availability
– Yes or No
• ECT given
– Yes or No
• Presence of an
Emergency Room
• Teaching Status
• Wage Factors
• Cost of Living
Each of these have a
multiplier that determines
the per-diem reimbursement
Inpatient Prospective Payment
Inpatient Psychiatric Facility PPS Calculator RY 2009 with MS-DRGs
Note: This calculator is for estimation purposes only.
Patient Age
Principal Diagnosis
Adjustment
Patient is between 45 and 50
1.01
DRG 895: Alcohol/drug abuse or
dependence with rehabilitation
therapy
1.02
(select as many comorbidities that apply below)
Comorbidity
Comorbidity
Comorbidity
Comorbidity
Comorbidity
Length of Stay (days)
Emergency Department
Chronic Obstructed Pulmonary Disease
1.12
$11,207.93
Tracheostomy
1.06
Uncontrolled Diabetes Mellitus with or without complications
1.05
Federal Portion (Blended)
Renal Failure, Chronic
1.11
$11,207.93
(blank)
1.00
(Transition Complete)
10
1.00
Rural
1.17
No Emergency Department
1.19
Teaching Adj.
Wage Area
Cost of Living Adjustment (COLA)
Electroconvulsive Therapy (ECT)
Blend Year
1.00
Colorado
0.9704
Rest of U.S.
1.00
1
$268
Complete
1.00
After making selections (above), scroll down for payment calculation information.
Federal Per Diem Base Rate
$11,207.93
Federal Payment with Outliers
If LOS greater than 21 days, enter # of
days:
Geographic Location
Federal Payment
$637.78
056
Degenerative nervous system disorders w MCC
1.05
057
Degenerative nervous system disorders w/o MCC
1.05
080
Nontraumatic stupor & coma w MCC
1.07
081
Nontraumatic stupor & coma w/o MCC
1.07
876
O.R. procedure w principal diagnoses of mental illness
1.22
880
Acute adjustment reaction & psychosocial dysfunction
1.05
881
Depressive neuroses
0.99
882
Neuroses except depressive
1.02
883
Disorders of personality & impulse control
1.02
884
Organic disturbances & mental retardation
1.03
885
Psychoses
1.00
886
Behavioral & developmental disorders
0.99
887
Other mental disorder diagnoses
0.92
894
Alcohol/drug abuse or dependence, left AMA
0.97
895
Alcohol/drug abuse or dependence w rehabilitation
1.02
896
Alcohol/drug abuse or dependence w/o rehabilitation
therapy w MCC
0.88
897
Alcohol/drug abuse or dependence w/o rehabilitation
therapy w/o MCC
0.88
Secondary Diagnoses
Secondary Diagnosis
May 2012
Game Changer Source:
Source: http://www.tinyurl.com/2012ASPENmalnutrition
86
Adult Malnutrition
Circumstance Based
Source: White J V et al., JPEN J Parenter Enteral Nutr, 2012;36:275-283
87
Adult Malnutrition Criteria
• Acute vs. chronic illness
• Severe vs. non-severe disease
• Albumin/prealbumin don’t matter
http://tinyurl.com/2012malnutrition
88
Why Not Albumin/Visceral Proteins?
• Acute Phase Response
–
–
–
–
Inflammatory disease, illness, injury illicit cytokine-mediated response
Interleukin-1 (IL-1), interleukin-6 (IL-6), tumor necrosis factor (TNF)
Alter hormone secretion and target organ function
Favor a catabolic state
• Acute Phase Metabolic Response
–
–
–
–
–
Elevation of resting energy expenditure
Export of amino acids from muscle to liver
Increase in gluconeogenesis
Expansion of extracellular fluid
Shift towards production of positive acute phase reactants, i.e., CRP
Source: New Characteristics and Criteria to Define Adult Malnutrition, ASPEN
Clinical Nutrition Webinar, Jane V. White, PhD, RD
89
Including Malnutrition Codes Impacts the DRG
% of DRGs with malnutrition adding a CC
% of DRGS with severe malnutrition adding an MCC
Source: ProviderPrecise (consortium of Falcon Consulting & CDIMD)
90
Inpatient Prospective Payment
Inpatient Psychiatric Facility PPS Calculator RY 2009 with MS-DRGs
Note: This calculator is for estimation purposes only.
Patient Age
Principal Diagnosis
Adjustment
Patient is between 45 and 50
1.01
DRG 895: Alcohol/drug abuse or
dependence with rehabilitation
therapy
1.02
(select as many comorbidities that apply below)
Comorbidity
Comorbidity
Comorbidity
Comorbidity
Comorbidity
Length of Stay (days)
Emergency Department
Chronic Obstructed Pulmonary Disease
1.12
$11,207.93
Tracheostomy
1.06
Uncontrolled Diabetes Mellitus with or without complications
1.05
Federal Portion (Blended)
Renal Failure, Chronic
1.11
$11,207.93
(blank)
1.00
(Transition Complete)
10
1.00
Rural
1.17
No Emergency Department
1.19
Teaching Adj.
Wage Area
Cost of Living Adjustment (COLA)
Electroconvulsive Therapy (ECT)
Blend Year
1.00
Colorado
0.9704
Rest of U.S.
1.00
1
$268
Complete
1.00
After making selections (above), scroll down for payment calculation information.
Federal Per Diem Base Rate
$11,207.93
Federal Payment with Outliers
If LOS greater than 21 days, enter # of
days:
Geographic Location
Federal Payment
$637.78
• Thank you.