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ICD-10 CM is Delayed but NOT for Long Because We Cannot Wait

Monday, April 30th, 2012

HHS proposes a one-year delay of ICD-10 compliance date.

On April 17, 2012 the Department of Health and Human Services (HHS) published a proposed rule that would delay, from October 1, 2013 to October 1, 2014, the compliance date for the International Classification of Diseases, 10th Edition diagnosis and procedure codes (ICD-10).

Per the CMS website, “The ICD-10 compliance date change is part of a proposed rule that would adopt a standard for a unique health plan identifier (HPID), adopt a data element that would serve as an “other entity” identifier (OEID), and add a National Provider Identifier (NPI) requirement. The proposed rule was developed by the Office of E-Health Standards and Services (OESS) as part of its ongoing role, delegated by HHS, to establish standards for electronic health care transactions under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). OESS is part of the Centers for Medicare & Medicaid Services (CMS).”

HHS states that covered entities must be in compliance with ICD-10 on October 1, 2014. The statement was made that providers required the extra year to be adequately prepared for the transition.

Providers have outgrown the present ICD-9 CM system. That system is over 30 years old, implemented in 1979 and has no more room to handle needed codes for new medical conditions or technological advances. It is not always precise or unambiguous. Because the classification system is organized with specificity, each three-digit category can have only 10 subcategories and most of those numbers already have assigned diagnoses.

The ICD was developed in the late 1800s to collect data regarding mortality causes and rates. It is an international classification system endorsed by the World Health Organization (WHO) in 1994 and started to be used by WHO members in 1994. The WHO updates the classification usually every 10 years and is looking to beta test ICD- 11 next year.

ICD-10 is already being utilized in Asia, most of Europe and all of Canada and Australia enabling those 99 nations to share public health data. Implementing ICD-10 effective October 1, 2014 allows the USA to be aligned with those nations. ICD 10 is also available in 36 languages including English, Chinese, Arabic, Russian, and the Romance languages: French and Spanish. Improved clinically coded data is essential in this modern era.

Uses of the Clinically Coded Data

Benchmarking and quality measurement: to improve quality and effectiveness of patient care

Making clinical, financial, funding, expansion, and education decisions

Healthcare policy

Public health surveillance (increase ability to track and intervene if global health threats)

Reimbursement

Research- code analysis is crucial to research

Increased specificity in data means more robust design of algorithms to predict outcomes and care

Increased coding detail offers capability to find previously unrecognized relationships of diseases and variables

Why ICD-10-CM

Bring US in alignment with worldwide coding system

Greater coding specificity and accuracy with “full code definitions”

Increased capability to measure healthcare quality, safety, and efficiency.
Lower Costs through increased efficiencies
Decreased reduction in additional information sent to payors
Synergistic effects with the Electronic Health Record (EHR)
Clearer recognition of medical advances
Clearer recognition of technological advances

ICD-10 and better data for QI

Decrease in complications and improved patient safety

Improved patient outcomes

Improved ability to reassure outcome efficiency and costs

There is also improved capability to determine disease severity for audit risk adjustment.

Benefits of ICD-10 CM

Organizational Monitoring

Administrative efficiencies
Cost containment
More accurate trend and cost analysis as well as analyze trend and cost data

Improved coding accuracy and productivity

Reimbursement

Increased accuracy
Fairer reimbursement
Improved justification for medical necessity
Fewer errors and rejected claims

Reduced opportunities for fraud

To handle the complexities and shear size of the number of codes ICD-10

requires expertise in

anatomy,

physiology, and

diagnostics

Besides moving from 13,000 codes to 68,000 available codes
ICD-10 allows laterality and bilaterality

ICD-10 specificity improves coding accuracy and richness of data for analysis

The Coding specificity is far greater than ICD-9-CM and the need to better understand A&P and diagnostics is vital. Improved education for coding specialists is necessary.

A Sample Coding Preparation Plan: Phase 1

2012-2013…Assess for coder gaps

as to body system anatomy 15 hrs

as to body system physiology 15 hrs

as to diagnostics/pathophysiology 20 hrs

as to diagnostics/pharmacology 20 hrs

as to medical terminology 10 hrs

A Sample Coding Preparation Plan: Phase 2

Organizational leaders need to assess their

– Organizational readiness: forms, clinical software, documentation readiness

- Billing/Support system needs

- EHR system

- Support systems

- Case management processes

- Disease management

- Compliance software

A Sample Coding Preparation Plan: Phase 3

There needs to be:

Testing of Coding by parallel Coding ICD-9 and ICD-10 CM

Testing of Billing System for smooth transition

Look for misinterpretation by auditors/payors

Be certain everyone has past training goals i.e. understands documentation of medical necessity to code

Sample Coding Preparation Plan: Phase 4

Go Live

Evaluate processes

Evaluate Coding
Evaluate Billing

In Phase 1 there is a need to fully review each body system.

Choose 2-3 body systems for assessment of need such as:

Cardiovascular System

Identify the Anatomy and Physiology of the heart. Prepare pre/post tests.

Identify the Anatomy of the circulatory system and the role of each vessel type

Review categories 100-109 in ICD-10-CM Chapter 9, “Diseases of the Circulatory System.”

Explain ICD-10-CM terminology related to diseases of the circulatory system

Create scenarios and have coding team gatherings where learning can be fun

These scenarios will allow you to assess gaps and needs

Consider use of webinars

AHIMA or like courses

Online self study may fit certain lifestyles better

Have videos/PowerPoints of body systems available

Look at workshops, seminars, lunch and learn sessions

Each body system should be reviewed, such as below:

The Heart
- Has three layers: endocardium, myocardium, and epicardium
  - Endocardium – membrane lining interior wall
  - Myocardium – thick, middle, muscular layer
  - Epicardium – thin outer layer

Pericardium – 3 layer sac that surrounds and protects the heart
Route of Blood Flow Through the Heart
- Blood enters the right atrium from the inferior and superior vena cavas (veins)
- Blood leaves the right atrium to the right ventricle through the tricuspid valve
- Blood leaves the right ventricle through the pulmonary semilunar valve to the pulmonary artery to the lungs

Unoxygenated blood

Route of Blood Flow Through the Heart
- Blood leaves the lungs via the pulmonary veins to the left atrium
  - Oxygenated blood
Blood leaves the left atrium through the mitral valve to the left ventricle
Blood leaves the left ventricle through the aortic semilunar valve out to the body
A series of 20-30 slides could be developed to review the Cardiovascular System

These types of reviews could be excellent resources also for specific component answers such as Cardiac conduction

Route of Blood Flow Through the Heart
- Blood leaves the lungs via the pulmonary veins to the left atrium
  - Oxygenated blood
Blood leaves the left atrium through the mitral valve to the left ventricle

Blood leaves the left ventricle through the aortic semilunar valve out to the body

Cardiac Conduction
- Sinoatrial node (SA node, called the pacemaker of the heart) à Atrioventricular node (AV node) à Bundle of His à right and left bundle branches à Purkinje fibers

SA node (pacemaker) is located in the upper part of the right atrium below opening of the superior vena cava

Discuss disease processes such as:

CAD

CHF

Heart Failure

Use specific terms and processes in the discussions

Discuss diagnostic and intervention procedures as well as pharmacology
Have teams participate in establishing education plan after gaps have been identified
Make certain some kind of training takes place each month, even if it is only a memo about a specific aspect of ICD-10

Keep ICD-10 in front of everyone. Remember, you only have until 2014. Let’s get started!

Tags: E-Zine Newsletter April 2012, HHPPS CY2012, HIPPA HITECH, Home Care Coding, Home Health Software, PPACA, Select Data
Posted in CHF, Compliance, Home Health, ICD-10-CM Coding, ICD9-CM Coding, Medicare | No Comments »

Evidence-based practice in Establishing Care Plans for the Home Health Patient: CHF

Friday, June 10th, 2011

Evidenced – based practice is considered the best available evidence derived from systematic research, clinical experience, and tested expertise to achieve expected and/or improved patient outcomes (Institute for Healthcare Improvement, 2008 ). The new protocols for surveyors have moved the focus to data – driven and outcome – oriented (CMS, 2011) and the need to establish a well defined plan of care foreshadows the need to follow evidence – based practices for specific diseases to achieve the expected outcomes (even though, at this time, CMS has not yet mandated their use). The following are evidenced based practice SmartCues to remind the clinician as to specific processes/interventions to be considered in planning care.

A Focus on CHF

To significantly improve care, impact the quality of life, and reduce emergent and inpatient admissions several diagnoses require aggressive attention. That attention requires evidenced based interventions.

Congestive Heart Failure (CHF)

Chief symptoms of CHF are dyspnea and fatigue which limits tolerance to exercise and promotes fluid retention that leads to pulmonary congestion and dependent edema. Because volume overload is not always seen at the time of evaluation, sometimes the term heart failure is used instead of congestive heart failure.

CHF effects over 5.5 predominately elderly individuals with 660,000 new cases diagnosed annually. According to the Journal of the American Heart Association, CHF is the underlying cause for 12-15 million office visits and 6.5 million hospital days per year. It ranks as the primary and secondary diagnoses for all hospitalizations over the age of 65. The financial burden is in excess of $40 billion dollars annually (AHA, 2008, 2009).

It is reported by CMS that “inadequate treatment, discharge planning, and follow-up, many patients with CHF are caught in a ‘revolving door’ process” leading to rehospitalization (Jencks, S, CMS, 2005).

Home health care plan intervention per HHQI, the American Heart Association, and the National Heart, Lung, and Blood Institute would include the following SmartCues. (However, all plans of care should be approved by the patient’s physician):

Symptom: Assess for shortness of breath (dyspnea).

Instruct patient to identify its triggers.

Clinician should reassess each visit.

Symptom: Assess activity tolerance.

Instruct patient to identify activity daily and/or number of feet walked before dyspnea occurs. Consider Physical Therapy referral for muscle strengthening exercises for legs and upper arms. Teach exercise safety. Teach energy conservation when appropriate.

Clinician should note baseline and assess activity levels and dyspnea changes each visit.

Symptom: Assess for increased weakness and fatigue

Instruct patient in energy conservation to achieve ADLs life quality.

Clinician should note baseline and progress each visit.

Symptom: Assess for signs of orthopnea

Instruct patient to identify any change in number of propped pillows needed to breathe comfortably when lying down.

Clinician should note baseline and changes each visit.

Symptom: Assess for paroxysmal nocturnal dyspnea (feeling of smothering or fullness in the chest when lying down and resolves when standing up)

Instruct patient how to identify changes in symptamotology.

Clinician should assess each visit and note progress each visit. This symptom as well as increased orthopnea is usually an intermediate sign of fluid retention and per HHQI, “intervention at this point could still prevent rehospitalization.”

Symptom: Assess for symptoms of chest pain or heaviness

Instruct patient when to contact clinician or physician. Instruct as to utilization of and safety aspects of O2, if ordered by physician.

Clinician should verify any occurrence each visit and identify S3 and S4. Assess for any new or recurrent dysrhythmias or murmurs. Per HHQI, “changes in heart rhythm can lead to poor cardiac output and worsening heart failure. Note: Extra sounds can be a warning of impending heart failure exacerbation.” Clinician to also assess lung sounds to identify any changes or note wheezes, crackles, rhonchi, or diminished breath sounds.

Clinician should discuss with physician; pneumococcal vaccination and influenza immunization.

Symptom: Assess for changes in B/P especially elevated B/P

Instruct patient re proper technique to obtain B/P and heart rate (pulse).

Clinician should obtain B/P sitting/standing, Heart Rate (HR), Respiratory Rate (RR), and Jugular Venous distension each visit.

Symptom: Assess for edema of feet, ankles, hands, abdomen, or sacrum (anasaca).

Instruct patient re how to assess every day.

Clinician to obtain baseline and assess fluid retention (focus on feet/ankles, hands, sacrum, scrotal area, and abdomen) each visit.

Symptom: Assess for increase in weight of 2-3 pounds in 24 hours or 3 pounds in one week.

Instruct patient to weigh self daily and when to alert home health agency.

Clinician should weigh patient and measure abdominal girth each visit.

Symptom: Assess for diminished urinary output.

Instruct patient to report decreased urinary output.

Clinician to monitor at each visit as this is a signal of potential impending renal failure, or heart failure decomposition, or the body’s attempt to increase blood pressure.

Symptom: Assess for appetite changes especially decreased appetite.

Instruct patient on physician ordered low-fat, low-sodium diet and to record days of lowered appetite, as well as when to contact the clinician.

Clinician should assess patient appetite each visit and if diminished appetite is reported, verify if there is abdominal fluid retention which could cause feelings of fullness and satiety.

Symptom: Assess for depression or lack of interest in surroundings and difficulty with focus.

Instruct patient as to psychosocial coping skills to maintain optimum self care-management.

Clinician should assess for symptoms of depression on each visit as well as assess family and support systems.

Symptom: Assess for smoking

Instruct patient as to negative effects on health. Encourage regular exercise as tolerated and commensurate with stamina and endurance.

Clinician should ask re smoking and discourage both first and second-hand smoke.

Symptom: Assess for medication understanding and medication compliance.

Instruct patient on medication management. Meds may include an Angiotension Converting Enzyme (ACE) Inhibitor, a beta blocker, diuretic if needed, digoxin, and an anticoagulant.

Clinician will monitor medication safety and compliance and should seek blood chemistry results and INR (as ordered by physician) and obtain heart rate, B/P, and clinical status with each dosage change.

Sources:

CMS Appendix B Guidelines for Surveyors

www.homehealthquality.org

HHQI Best Practice Intervention Practice, 8SOW-PA-HHQ07 467 App, 1/2008

www.qualitynet.org

http://mhcc.maryland.gov/consumerinfo/hospitalguide/hospital_leaders/best_practices/hf..h

www.chronicconditions.org/ClearingHouse/cat/Heart%20Failure,61.aspx

Heart and Ling Sounds by 3M

http://solutions.3M.com/wps/portal/3M/en_US/Littmann/stethoscope/education/heart-lung-sounds

Decision Support Tool: Heart Failure Publication # 8SOW-PA-HH05.187

Posted in Best Practice Intervention Practice, CHF | No Comments »

Utilizing Best Practices for Patients with Heart Failure

Thursday, May 19th, 2011

Best practices are expected when providing quality home health care to heart failure patients. According to the American Heart Association, there are over 5 million cases of heart failure (HF) in the US, with an average 500,000 cases, diagnosed annually. It ranks as the primary and secondary diagnoses for all hospitalizations over the age of 65. The financial burden is in excess of $40 billion, annually, in direct and indirect costs.
Heart failure patients are among those most visited in home health care and among the five most prevalent diagnoses of homecare patients (per VNAA Chronic Care Clearinghouse). A cardiac assessment is often the primary nursing skill for homebound patients diagnosed with heart failure and involves specific knowledge of nutrition, pharmacotherapy, exercise, coping skills, and risk management. Because caring for cardiac patients is frequent, many agencies rely on the clinician’s expertise regarding assessment and planning, yet research is suggesting the establishment of agency protocols is in order.

Pathophysiology

Heart failure may occur when damage is done to the heart preventing it from adequately pumping blood to tissues to meet required metabolic needs. Because the circulatory system carries oxygen and necessary nutrients, a decreased blood flow limits needed tissue nourishment, resulting in compensation by the body as it seeks balance or homeostasis. The body is forced to stimulate the sympathetic nervous system to increase both the heart rate and blood pressure to meet oxygen and nutrient requirements. The kidneys will assist, by a process of vasoconstriction, within the tubules, to increase blood pressure and secondarily retaining and reabsorbing sodium to increase vascular pressure that will aid in also raising blood pressure. In the short term, this is effective. However, long term effects include cardiac decompensation and increased symptoms of heart failure.

Symptoms frequently seen during exacerbations

Per HHQI, Best-Practice Disease Management: Heart Failure Intervention Package, expect to see

Shortness of breath
Decreased urination
Chest pain or heaviness
Increased weakness or fatigue
Edema of the feet, ankles, hands, abdomen, or sacrum (anasaca)
Increase in weight of 2-3 pounds in 24 hours or 3 pounds in one week
Dry hacking cough or cough producing a white foamy sputum
Orthopnea (the number of pillows needed propped up to breath comfortably)
Paroxysmal nocturnal dyspnea (feeling of smothering or fullness in the chest when lying down and resolves when standing up).

An effective in-home prevention and treatment plan helps the patient control symptoms. It also helps control the costs associated with heart failure by reducing the need for emergent and/or inpatient care. Since heart failure patients are among those most often seen in emergent and inpatient settings, a home health clinical specialty heart failure program is necessary for cardiac patients to reduce this incidence. This care is a focus of CMS. New Survey Protocols, effective May 1, 2011, focus on data gathering and outcomes seen, as opposed to the focus on structure and process orientation of past surveys. Care planning and delivery with resulting outcomes of all patients will be the focus, but because heart failure is of growing incidence, expect scrutiny.

As the OASIS process measure begins to produce data, one can expect to see the evaluation and adjustment of processes brought to the forefront. Agencies must consider a specialized episode and disease management plan for heart failure patients under care. This program will assist the agency reach its goals clinically, operationally, and financially.

The CMS OASIS data items were created to measure processes of care in several areas to reflect Institute of Medicine (IOM) goals and Medicare Payment Advisory Commission (MPAC) recommendations. It was felt there is a need to focus on high-risk, high-volume, chronic conditions seen in the home health setting and although CMS indicates that the integrated OASIS-C process items are optional practices, it is believed by industry specialists and content experts that identified best practices are critical to providing efficient quality home health care with expected/predictable outcomes.

Evidence-based best practices

The rationale behind process data elements is to encourage agencies to incorporate evidence-based practices (EBP) into processes. One definition of EBP is to use the best scientific evidence available as a tool to guide clinical decision-making for the purpose of attaining the best outcomes.

Research supports that a combination of proper acute care discharge planning and post discharge care for patients with heart failure can significantly reduce hospital readmission rates, improve quality of life, and reduce cost of care. Heart failure evidence-based standards of care per the American College of Cardiology/American Heart Association (ACC/AHA) include:

Assessment for fluid retention via monitoring weight and abdominal girth.
Assessment of activity level, perceived dyspnea, fatigue, reduced exercise tolerance, sleep patterns, and patient’s activity that triggers dyspnea.
BP standing/sitting, heart rate (HR), respiratory rate (RR), jugular venous distention (JVD) every visit.
Assess edema and instruct the patient as to obtaining daily weight and complete a patient assessment of abdominal and peripheral swelling, focusing on feet/ankles, hands, sacrum, scrotal area, and abdomen.
Complete auscultation of heart and lung sounds; identify S3 or S4. Assess for new or recurrent dysrhythmias or murmurs. Per HHQI “changes in heart rhythm can lead to poor cardiac output and worsening heart failure. Note: Extra sounds can be a warning of impending heart failure exacerbation.”
Assess lung sounds to identify any changes or note wheezes, crackles, rhonchi, or diminished breath sounds.
The physician may well monitor serum electrolytes/renal function every 6 months.
Assess appetite. Expect the physician to order a low-fat, low-sodium diet; fluid restriction. When assessing appetite, look for signs of abdominal fluid retention such as feelings of abdominal fullness and early satiety. Refer to girth baseline and successive measurements.
Assess for orthopnea and paroxysmal nocturnal dyspnea. Verify number of pillows used when lying down. Both of these symptoms are usually intermediate signs of fluid retention and per HHQI, “intervention at this point could still prevent re-hospitalization.”
A thoracic impendence reading (ZO) may be ordered. Fluid status changes can signify need for intervention and possibly prevent a hospitalization.
Assess urinary output. Decreased output could signal impending signs of renal failure or heart failure decompensation, as the body attempts to raise blood pressure.
Assess diabetes control, if applicable.
Assess psychosocial coping and note symptoms of depression. Assess family and support systems. Depression intervention may be necessary to maintain optimum self care-management.
If ordered, encourage regular walks progressing to 1 hour per day 3-5 days per week..
Smoking: Discourage first-hand and second-hand smoke.

Agency Administrators

Administrators who are looking to establish a cardiac program in their agency should review the HHQI “Best Practice Disease Management: Heart Failure.” This Nurse Track is a Best-Practice Disease Management intervention package that supports the implementation, education, and application of current assessment and symptom management modalities with clinical processes to decrease active symptoms in heart failure patients. It discusses providing a structured plan for care, and supports EBP. The package describes nursing actions that support an effective disease management program.

The administrator should also include an assessment of current standards of care in relation to the number of visits incurred as well as type and depth of education provided to patients, along with early intervention for symptoms of heart failure. Once the assessment plan is completed, a review of nursing education gaps assessed, agency-wide education must occur to ensure that all clinicians are familiar with best-practice standards and provide opportunity for feedback. After that education is provided and the standards are implemented, outcomes should be analyzed, and ongoing auditing for compliance should be established to ensure the best practice standards are maintained.

Guidelines in Best-Practices for Administrators

There are many programs available regarding best-practices for care of patients with heart failure. The HHQi site offers RNs a free 2.0 Continuing Nursing Education units after completion of the 115 minute five activities for the Heart Failure Track. In addition, there are tools and podcasts to aid in reducing hospitalizations as well as a Decision Support Tool: Heart Failure

Once the program is underway, data analysis becomes an important practice allowing the administrator to review statistics and trends within the agency-specific patient populations. For the administrator planning to survive present and anticipated future changes in regulation, care delivery, and reimbursement models effective decision-support software providing data aggregation, benchmarking, and analysis opportunities for operational management will be essential.

Administrators should monitor specific patient populations for trending and analysis that include:

Hospitalization rates by diagnoses
Disciplines utilized within an episode
Visit patterns and scheduling
Number of days from SOC before therapy began care
Average number or recertifications
Therapy utilization for energy conservation training
Changes in patient education between SOC and recertification episode

In addition to monitoring heart failure outcomes through OASIS-C data, reduced hospitalization rates, compliance with the structured heart failure disease management program the agency should find ways to motivate personnel to continue use of the enhanced heart failure education. Administrators should be certain a specific skilled staff competency review regarding heart failure symptoms is administered regularly.

Best practices disease management programs can be very successful as seen in Dominion Care Home Health agency in San Antonio, TX. Their acute care hospitalization (ACH) rate declined from 41% to 28% after initiating such a program. With pay for performance in our future, newly instituted Survey Protocols, and higher expectations for improved patient outcomes, a disease management program targeting heart failure is a must.