Value Based Value Based Purchasing, Changes for Purchasing, Changes for ICD-10 and the Impact of ICD-10 and the Impact of

PathologyPathologyRobert S. Gold, MDRobert S. Gold, MD

Medicine Under the Microscope

• Morbidity • Mortality• Cost per patient• Resource utilization• Length of stay• Complications• Outcomes • ARE YOU SAFE –

avoiding harm, avoidable readmissions?

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.

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

• 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

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.

Is There a Diagnosis?

Assessment/Plan82 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

So What’s the Difference?Principal Diagnosis Chills and Fever Sepsis

Secondary Diagnoses Altered Mental Status Septic Shock

Acute Respiratory Failure

Aspiration PneumoniaAcute Renal Failure (or AKI)Respiratory AcidosisMetabolic Encephalopathy

Medicare MS-DRG 864 Fever w/o CC/MCC 871 Septicemia or severe Sepsis w/o MV 96+ hrs w/ MCC

APR-DRG 722 Fever 720 Septicemia & Disseminated infection

APR-DRG Severity Illness 1 – Minor 4 – Extreme

APR-DRG Risk of Mortality

1 – Minor 4 - Extreme

Medicare MS-DRG Rel Wt 0.8153 1.8437

APR DRG Relative Weight 0.3556 2.9772

National Mortality Rate (APR Adjusted)

0.04% 62.02%

What Is An Index?

What Is An Index?

• 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

Profiles Come from Severity Adjusted

Statistics

Observed mortalityExpected mortalityFrom severity adjusted DRGs

=1; as good as the next guy

<1; preferred provider – significantly better

>1; excessive mortality; find another provider -

Univ. VA Univ VA VCU Retreat Martha Augusta Rockingham2009 2013 2013 Doctors Jefferson Health Memorial

Respiratory Diseases

Pneumonia

Hosp plus 6 months

COPD

Hosp plus 6 monthsCritical Care

Respiratory Failure

Hosp plus 6 months

Sepsis

Hosp plus 6 monthsCardiac Diseases

Heart Failure

Hosp plus 6 months

Acute MI

Hosp plus 6 monthsCardiac Surgery

CABG

Hosp plus 6 months

Interv Cardiology

Hosp plus 6 months

Heart Valve

Hosp plus 6 monthsSurgery

ORIF Hip Maj Compl

GI Surgery

Hosp plus 6 months

THA Maj Compl

Cholecystectomy Maj C

Patient SafetyWorse than

Better than

Average Average

Death in procedures where mortality is usually very low ●Pressure sores or bed sores acquired in the hospital ●Death following a serious complication after surgery ●Collapsed lung due to a procedure or surgery in or around the chest ●Catheter-related bloodstream infections acquired at the hospital ●Hip fracture following surgery ●Excessive bruising or bleeding as a consequence of a procedure or surgery ●Electrolyte and fluid imbalance following surgery ●Respiratory failure following surgery ●Deep blood clots in the lungs or legs following surgery ●Bloodstream infection following surgery ●Breakdown of abdominal incision site ●Accidental cut, puncture, perforation or hemorrhage during medical care ●

Foreign objects left in body during a surgery or procedure

Average

0 Events

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

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.

CMS Bundled Payment Plans

September 2, 2011

• Bundles physician and hospital payment into one lump sum could represent a long-term, revolutionary solution to that age-old question.

• Testing four new bundled payment plans, according to a Fact Sheet released August 23

• Three models involve retrospective payment, one a prospective payment determined by MS-DRG

• Aggregate Medicare payment for the episode will be reconciled against the target price. Savings beyond the discount reflected in the target price will be paid to the participants to share among the participating providers.

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.

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.

19

Patient in Proper Environment

Outpatient, OBS, Impatient Care

• Extended postop management in same day surgery cases

• Inappropriate admissions for workup of symptoms in stable patient

• Inappropriate admissions for treatment of diseases expected to resolve in hours

• Closed system, protocol driven OBS unit efficient and cost effective

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.

Interdisciplinary Approach

• Management of malignancy is now in the domain of the multi-disciplinary team and all members of the cancer team must work together.

• Conventional radiology, general or oncologic surgery or IR input begins with establishing the initial diagnosis of cancer

• Involvement extends to major or minimally invasive treatment of malignancy, often in combination with other modalities.

• All members of the team have to assume an important place in the management of the complications of malignancy, which may result from malignancy itself or secondary to treatment.

• And it involves other disciplines working together.

Patient Safety Indicators

Hospital acquired preventable diagnoses• Hospital falls that lead to patient damage (fractures, etc.) • Mediastinitis post-CABG (36.10 – 36.19 + 519.2)• Catheter-associated UTIs (996.64 + 599.0)*• Vascular catheter associated infections (996.62) vs

999.31• Pressure ulcers (707.00 – 707.09)

NEVER Events • Object accidentally left in patient (998.4) • Air embolism (999.1)

• Reaction from blood incompatibility (999.6)

Participation and Success in Reporting of

Core Measures• Acute MI• Heart failure• Pneumonia• Postoperative wound infections• Venous thromboembolism• Stroke• Asthma in children’s hospitals

Goals of Implementation – Prove You Are Value Based

• Exemplary severity adjusted mortality statistics

• Reasonable occurrence of PSIs, HACs

• Lower than average Readmissions for Pneumonia, Heart Failure, AMI

• Cooperation with quality initiatives

• Patient satisfaction

Coding Guidelines for Path

Pathology claims for biopsy specimens Coding Clinic, First Quarter 1990 Page: 22 Effective with discharges: March 15, 1990 Question:

How should the pathologist code a biopsy specimen which turns out to be normal after examination? Most specimens do not include any information from the referring physician, so including a secondary diagnosis is difficult.

Answer:

Pathology claims will start with the code V72.6, Laboratory examination. The secondary diagnosis should reflect any diagnostic information from the referring physician, if it is available. If a diagnosis, symptom, or condition is absolutely not available, and the specimen turns out to be normal, the pathologist can use the code 799.9, Other ill-defined and unknown causes of morbidity and mortality, Other unknown and unspecified causes. Biopsies are not included in patient screening, and therefore reflect concern on the part of the referring physician that something is amiss.

Unexpected Findings on Path

Coding Clinic, Second Quarter 2002 Page: 18 Effective with discharges: August 1, 2002

Question:

A patient is admitted to the hospital where she undergoes a hysterectomy for possible endometriosis. The pathology report revealed adenocarcinoma of the endometrium. The discharge summary was not available at the time of coding. Is it appropriate for the coder to assign a diagnosis code for the adenocarcinoma based on the pathology report?

Answer:

As previously stated, the advice published in Coding Clinic, First Quarter 2000, was only intended for coding and reporting for outpatient services, where physician documentation is sometimes quite limited. It does not apply to inpatient coding. For inpatient coding, if the attending physician does not confirm the pathological findings, query the attending physician regarding the clinical significance of the findings and request that appropriate documentation be provided.

Metastatic Sites from Path Report

Coding Clinic, Second Quarter 2002 Page: 18

Effective with discharges: August 1, 2002

Question:A patient is admitted to the hospital where she undergoes a

hysterectomy for possible endometriosis. The pathology report revealed adenocarcinoma of the endometrium. The discharge summary was not available at the time of coding. Is it appropriate for the coder to assign a diagnosis code for the adenocarcinoma based on the pathology report?

Answer:For inpatient coding, if the attending physician does not

confirm the pathological findings, query the attending physician regarding the clinical significance of the findings and request that appropriate documentation be provided.

Change in the Entire System

ICD-9

ICD-10

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)

Example - Specificity

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

Category 1–3

Etiology, anatomic site, severity, other detail 4–6

Extension 7

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)

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

Specificity is NOT Always Possible

Sign/Symptom/Unspecified CodesIn both ICD-9-CM and ICD-10-CM, 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.

When sufficient clinical information isn’t known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate “unspecified” code (e.g., a diagnosis of pneumonia has been determined, but not the specific type).

In fact, unspecified codes should be reported when they are the codes that most accurately reflects what is known about the patient’s condition at the time of that particular encounter. 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.

Source: Cooperating Parties for ICD-10-CM/PCS and ICD-9-CM Coding, May 2013.

Don’t Wait Till Tomorrow for ICD-10

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

ICD-O-3 for MalignanciesPurpose/DefinitionUsed principally in tumor or cancer registries for

coding the site (topography) and the histology (morphology) of neoplasms, usually obtained from a pathology report.

Classification structureA multi-axial classification of the site, morphology,

behaviour, and grading of neoplasms.The topography axis uses the ICD-10 classification

of malignant neoplasms (except those categories which relate to secondary neoplasms and to specified morphological types of tumours) for all types of tumours, thereby providing greater site detail for non-malignant tumours than is provided in ICD-10. In contrast to ICD-10, the ICD-O includes topography for sites of haematopoietic and reticuloendothelial tumours.

Lung Cancer I-9

162 Malignant neoplasm of trachea, bronchus, and lung162.0 Trachea162.2 Main bronchus162.3 Upper lobe, bronchus or lung162.4 Middle lobe, bronchus or lung162.5 Lower lobe, bronchus or lung162.8 Other parts of bronchus or lung162.9 Bronchus and lung, unspecified

Laterality of Lung Cancer I-10

C34.0 Malignant neoplasm of main bronchusC34.00 Malignant neoplasm of unspec main bronchusC34.01 Malignant neoplasm of right main bronchusC34.02 Malignant neoplasm of left main bronchus

C34.1 Malignant neoplasm of upper lobe, bronchus or lungC34.10 Malignant neoplasm of upper lobe, unspec bronchus or lungC34.11 Malignant neoplasm of upper lobe, right bronchus or lungC34.12 Malignant neoplasm of upper lobe, left bronchus or lung

C34.2 Malignant neoplasm of middle lobe, bronchus or lungC34.3 Malignant neoplasm of lower lobe, bronchus or lung

C34.30 Malignant neoplasm of lower lobe, unspec bronchus or lungC34.31 Malignant neoplasm of lower lobe, right bronchus or lungC34.32 Malignant neoplasm of lower lobe, left bronchus or lung

C34.8 Malignant neoplasm of overlapping sites of bronchus and lungC34.80 Malignant neoplasm of overlapping sites of unspec bronchus and lungC34.81 Malignant neoplasm of overlapping sites of right bronchus and lungC34.82 Malignant neoplasm of overlapping sites of left bronchus and lung

Pleural Effusion

• Distinguish causative disease– Malignancy and origin

– Trauma or postsurgical

– Liver or renal failure

– Chylothorax

– Peripneumonic effusion – exudative or transudative

• Empyema (pyothorax)

• Other cause of exudative identifiable

– Etc.

Adrenal Gland Malignancy I-9

194.0 Adrenal gland

Adrenal cortex

Adrenal medulla

Suprarenal gland

All in one

Laterality/Specificity I-10

C74.0 Malignant neoplasm of cortex of adrenal glandC74.00 Malignant neoplasm of cortex of unspecified adrenal glandC74.01 Malignant neoplasm of cortex of right adrenal glandC74.02 Malignant neoplasm of cortex of left adrenal gland

C74.1 Malignant neoplasm of medulla of adrenal glandC74.10 Malignant neoplasm of medulla of unspecified adrenal glandC74.11 Malignant neoplasm of medulla of right adrenal glandC74.12 Malignant neoplasm of medulla of left adrenal gland

Colon Cancer I-9153 Malignant neoplasm of colon

153.0 Hepatic flexure153.1 Transverse colon153.2 Descending colon153.3 Sigmoid colon153.4 Cecum153.5 Appendix153.6 Ascending colon153.7 Splenic flexure153.8 Other specified sites of large intestine153.9 Colon, unspecified

154 Malignant neoplasm of rectum, rectosigmoid junction, and anus154.0 Rectosigmoid junction154.1 Rectum154.2 Anal canal

Colon Cancer I-10C18 Malignant neoplasm of colon

C18.0 Malignant neoplasm of cecumC18.1 Malignant neoplasm of appendixC18.2 Malignant neoplasm of ascending colonC18.3 Malignant neoplasm of hepatic flexureC18.4 Malignant neoplasm of transverse colonC18.5 Malignant neoplasm of splenic flexureC18.6 Malignant neoplasm of descending colonC18.7 Malignant neoplasm of sigmoid colonC18.8 Malignant neoplasm of overlapping sites of colonC18.9 Malignant neoplasm of colon, unspecifiedMalignant neoplasm of large intestine NOS

C19 Malignant neoplasm of rectosigmoid junctionMalignant neoplasm of colon with rectumMalignant neoplasm of rectosigmoid (colon)

RetinoblastomaICD-9

190.5 Differentiated190.5 UndifferentiatedSame code for melanoma

of retina ???Add 198.4 for invasion of

optic nerve or choroidAdd 365.7x for

neovascular glaucoma

ICD-10C69.2 DifferentiatedC69.2 UndifferentiatedSame code for melanoma

of retina ???Add C79.49 for invasion of

optic nerve or choroidAdd H40.5xx for glaucoma

due to neoplasm of eye6th digits1 – right eye2 - left eye3 – bilateral9 - unspecified

Severity of glaucoma 5th digit:1 mild2 moderate both ICD-93 severe and ICD-10

Renal Malignancies ICD-9

189.0 Kidney, except pelvis (includes Wilms tumor, renal cell carcinoma, urothelial cell ca)

189.1 Renal pelvis189.2 Ureter189.3 Urethra189.4 Paraurethral glands189.8 Other specified sites of urinary organsMalignant neoplasm of contiguous or

overlapping sites of kidney and other urinary organs whose point of origin cannot be determined

189.9 Urinary organ, site unspecified

Renal Malignancies ICD-10

C64.1 Malignant neoplasm of right kidney, except renal pelvis (includes all cell types)

C64.2 Malignant neoplasm of left kidney, except renal pelvis (includes all cell types)

C64.9 Malignant neoplasm of unspecified kidney, except renal pelvis (includes all cell types)

C65 Malignant neoplasm of renal pelvisC65.1 Malignant neoplasm of right renal pelvisC65.2 Malignant neoplasm of left renal pelvisC65.9 Malignant neoplasm of unspecified renal pelvis

C66Malignant neoplasm of ureterC66.1 Malignant neoplasm of right ureterC66.2 Malignant neoplasm of left ureterC66.9 Malignant neoplasm of unspecified

Registered Concerns

• No breakdown as to cell types

• Wilms tumor (nephroblastoma), renal cell carcinoma and urothelial cell carcinoma all assigned to C64, malignant neoplasm of kidney

• C65 dedicated to malignancy of renal pelvis but urothelial cell carcinoma (Transitional Call Carcinoma - TCC), a renal pelvis cancer, groups to C64

Mets to Bone

ICD-9

198.5 Bone and bone marrow

ICD-10

C79.51 Bone

C79.52 Bone marrow

Barrett’s Esophagus Expansion

ICD-9

530.85 Barrett's esophagus

ICD-10K22.70 Barrett's esophagus

without dysplasia

K22.71 Barrett's esophagus with dysplasia

K22.710 Barrett's esophagus with low grade dysplasia

K22.711 Barrett's esophagus with high grade dysplasia

K22.719 Barrett's esophagus with dysplasia, unspecified

Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is an idiopathic disease caused by a dysregulated immune response to host intestinal microflora. The 2 major types of inflammatory bowel disease are ulcerative colitis (UC), which is limited to the colon, and Crohn disease (CD), which can involve any segment of the gastrointestinal tract from the mouth to the anus, involves "skip lesions," and is transmural. There is a genetic predisposition for IBD, and patients with this condition are more prone to the development of malignancy.

Crohn’s Disease

• Identify level(s) of intestine involved: (terminal) ileum, jejunum, colon

• Specify when with – Gastrointestinal bleed– Obstruction– Fistula– Abscess

Ulcerative Colitis

• Identify level(s) of intestine involved– Pancolitis– Proctitis– Rectosigmoid– Left-sided

• Identify complications– GI bleed– Obstruction– Fistula– Abscess

Diverticular Disease• Clarify when diverticulosis vs diverticulitis• Clarify when acute diverticulitis• Identify level(s) of intestine involved:

– Small intestine– Large intestine– Both

• Identify complications– GI bleed– Obstruction– Fistula– Abscess

Anemia Designations

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.)

D62

D50.0

D63.1

D63.0

D63.8

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 cancer284.11 D61.810 pancytopenia from chemo284.12 D61.811 pancytopenia from other drugs284.2 D61.82 pancytopenia from cancer taking over bone

marrow (myelophthisis) – code the cancer causing it284.89 D61.1 aplastic anemia due to chemo, other drugs284.89 D61.2 radiation induced aplastic anemia285.22 D63.0 anemia due to neoplastic disease – code

the cancer causing it285.3 D64.81 antineoplastic chemotherapy induced

anemia

288.00 D70.9 Neutropenia, unspecified 288.01 D70.0 Congenital neutropenia 288.02 D70.4 Cyclic neutropenia 288.03 D70.1 Chemotherapy induced

neutropenia288.03 D70.2 Other drug induced

neutropenia 288.04 D70.3 Neutropenia due to infection 288.09 D70.8 Other neutropenia

Blood Cell Lines DeficiencyUnspecified Codes Justify Ordering Tests

289.83 D75.81 Secondary myelofibrosis NOS

238.76 D47.1 Primary myelofibrosis238.76 D47.4 Idiopathic myelofibrosis –

myelofibrosis in myeloproliferative disease238.79 D47.1 Myeloproliferative syndrome238.79 C94.4 Acute panmyelosis with

myelofibrosis C94.40 never having achieved remissionC94.41 in remissionC94.42 in relapse

Myelofibrosis Issues

REAL• First classified by cell

type – the cell which, if normal, most closely looks like the tumor cell– B-cell tumors

– T-cell tumors

– Natural killer cell tumors

– And other minor groups

Our Subdivisions• 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

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

Measures of success in treatment depends on ICD accuracy.

Myelogenous Leukemia ICD-9

205 Myeloid leukemia205.0 Acute205.1 Chronic205.2 Subacute205.3 Myeloid sarcoma205.8 Other myeloid leukemia205.9 Unspecified myeloid leukemia

5th digit specificity0 – never having achieved remission1 – in remission2 – in relapse

Myelogenous Leukemia ICD-10

C92.0 Acute myeloblastic leukemiaC92.1 Chronic myeloid leukemia,

BCR/ABL-positiveC92.2 Atypical chronic myeloid

leukemia, BCR/ABL-negativeC92.3 Myeloid sarcomaC92.4 Acute promyelocytic leukemiaC92.5 Acute myelomonocytic leukemiaC92.6 Acute myeloid leukemia with

11q23-abnormalityC92.A Acute myeloid leukemia with

multilineage dysplasiaC92.Z Other myeloid leukemia C92.9 Myeloid leukemia, unspecified

5th digit specificity0 – never having achieved remission1 – in remission2 – in relapse

Pathologic FracturePathologic Fracture• Medical TextbookA 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 GuidelinesA 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

Pathologic FracturePathologic 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.

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 (eg., osteoporosis M80.x)

Fifth Digit for the Bone0 Head1 Neck2 Thorax3 Abd/low back/pelv4 Shoulder/upper arm5 Elbow/forearm6 Wrist/hand7 Hip/thighs8 Knee/lower leg9 Ankle/foot/toes

Be Acquainted with Sixth Digit

Paint the picture of Paint the picture of the patient properly the patient properly

with WORDSwith WORDS

So the coder can paint the same picture with codes.

What you want…

what you might get.

may notbe…

Motto For The AgeMotto For The Age

“If you don’t look good, we don’t look good” Vidal

sassoon, ca 1985Father of modern medical economics

Questions and Answers

Your Ideas and Comments