when clinical and coding worlds collidestatic.aapc.com/e7fe2e86-ee05-475b-ac2c-bdc28fea95...the...

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When Clinical and Coding

Worlds Collide

James M. Taylor, MD, CPCMedical Director: Revenue Cycle/Medicare

Kaiser Permanente, Colorado Region

Chair: Board of Directors: Colorado Permanente Medical Group

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Who is Kaiser Permanente -Colorado

Kaiser Permanente Nationwide

– $40 billion total operating revenue

– 8 Regions – 8.8 million members

– 14,600 physicians in 431 offices and 35 medical centers

– 167,000 employees

Kaiser Permanente Colorado

– 500,000 members

– 800 doctors in 18 medical office buildings, 5,400 employees

– Only 10-15 coders 5 years ago

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Who is Dr. Taylor?

Family Medicine physician

– 8 years Private Practice in Xenia, Ohio

– Full service FP: OB; Surgery; ICU/CCU; Infusion Center

16 years Kaiser Permanente

– 5 years Medical Director of Coding

– 5 years Medical Director of Revenue Cycle

Coding Certification: CPC

CPMG: Board of Directors, Chair

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The Mandate

• Your Mission: Teach 1,000 providers in an

HMO who have never coded before and came to the

HMO specifically so they didn‟t have to code….. how

to code

• EHR Context – EPICSYSTEMS (HealthConnect)

• Physician/Clinician jargon not coding jargon

• As simple as possible

• Stumbled over things that just didn‟t make sense

which led to… THE COLLISIONS

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The Collision: Clinical v. Coding1. Cancer vs. History of Cancer

– The disconnect: Organ level vs. Cellular level

2. Health Maintenance: What is age

appropriate?

3. Etiology/Manifestation Codes

– Why do you get to choose what is linked?

4. Asthma: may I have more codes please?

5. New Collisions: DVT and ICD-10-CM

You want me to say what…???

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Our Evaluation Process

• The Collision: Definition

• Research: Coding

• Research: Clinical

• Decision

• Education Efforts to Support/

Electronic Medical Record: Decision

Support

• Communication Strategy

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The Collision: Clinical vs. Coding1. Cancer v. History of Cancer



appropriate?

3. Etilogy/Manifestation Codes





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#1 - Cancer/History of:

The Collision Definition

• THE COLLISION: History of Cancer

• Organ gone/treatment finished = History of CA

• Problem: the 1 year survival is dismal

– Organ is gone, treatment is finished but…

• Ovarian Cancer

• Pancreatic Cancer

• Melanoma

• Doctors know it is still there at the cellular level

• Coders tell them it must say History of…

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Cancer/History of: Research: Coding

“A personal history of malignant neoplasm identifies

a malignancy that has been previously treated or

removed but for which there is no current

treatment for the condition and no evidence of the

disease.” 5

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“When a primary malignancy has been previously excised or

eradicated from its site and there is no further treatment

directed to that site and there is no evidence of any existing

primary malignancy, a code from category V10, Personal

history of malignant neoplasm, should be used to indicate the

former site of the malignancy. Any mention of extension,

invasion, or metastasis to another site is coded as a

secondary malignant neoplasm to that site. The secondary

site may be the principal or first-listed with the V10 code

used as a secondary code.”

Coding Clinic First Quarter 2005.

Cancer/History of:Research: Coding

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Cancer/History of: Research: Clinical

OVARIAN CANCER EXAMPLE:

• Most have spread throughout the peritoneum before

becoming clinically evident7

• 5 yr survival after a negative second-look = 50%8

• Most are not clinically evident until after metastatic spread9

• Up to 75% thought to be clinically and radiographically free

of disease had persistent disease at a 2nd look operation10

• As many as 70% will have persistent disease after 1°

treatment however, “they are rarely cured”11

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CLINICIAN’S CONCERNS

1. Known microscopic spread at time of diagnosis

2. It will be back

3. If the organ is gone; treatment finished yet the

survival is dismal, so what did they die of?

– The doctor says ovarian cancer

– The death certificate says ovarian cancer

– The coder says history of ovarian cancer

because the organ is gone and the treatment is

finished


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CLINICIAN’S CONCERNS

1. The CA125 goes up, the patient dwindles and we

know its their cancer back but they are too sick or

just tired of being sick so we don‟t do any further test

to find the “secondary malignant neoplasm to that

site”.

2. The patient has access to the EHR online and sees

they are dying from a History of Cancer. This

creates interesting conversations at their next visit.


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Cancer/History of: Decision

EXPLAIN THE COLLISION

CODING: ORGAN LEVEL

CLINICIAN: CELLULAR LEVEL

SOLUTION: clearly document the patients

condition

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Make it Match

• Don‟t say “NED” and “Ovarian Cancer”

• If you know they still have the disease…

Clearly document their condition:

“Pt is s/p TAH/BSO, finished with chemo/radiation

rx; although no clinical evidence of disease, pt is

aware cancer still exists on a cellular level; pt elects

no further treatment until clinical recurrence

warrants additional therapy.”

Cancer/History of:Decision

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Cancer/History of:Communication Strategy

• EHR Intervention: Best Practice Alert (BPA)

• Every Breast and Prostate Cancer Entry

• Clinician Reminded of the Collision when they

type in the cancer in the Diagnosis Entry Field

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Make it Match:

Every High Utilizing or High Discrepancy Department

got additional training

First Pilot Clinic had 96% accuracy rate of

documentation in chart = diagnosis in chart

Currently Auditing each BPA firing and query goes to

provider if it doesn‟t match


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Make it Match: Prostate Cancer

• Alert fires with each Prostate CA entry

• Regional Implementation: 90% accurate (from 50%)

– 10% queried with initial 5% correction

– Other 5% in process

Make it Match: Breast Cancer

• More entries/auditing

• Initial accuracy just below Prostate CA

• Queries in process


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The Collision: Clinical vs. Coding1. Cancer v. History of Cancer



appropriate?






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#2 – Health Maintenance Exam

Periodic Health Exam:

age/gender appropriate

– What is age appropriate anyway?

– Is all this really (medically) necessary?

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Age/Gender: The Collision Definition

THE COLLISION: Age/gender appropriate exams

• The coding rules require an age appropriate

comprehensive history and exam

• Coding/Billing rules suggest much must be asked

and done in order to qualify for reimbursement

• Clinical guidelines suggest:

not as much needs to be done

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Age/Gender: Research: Coding

• Specific preventive medicine services for varying age and

sex patients will vary but the basic components for

CPT®‟s preventive medicine services codes (99381-

99397) are consistent:

– A comprehensive history and physical examination

– Anticipatory guidance, risk factor reduction intervention

or counseling

– Appropriate Immunizations/Labs

– Management of insignificant problems

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• “The preventive-visit examination is multi-system, but the

precise content and extent of the exam is based on the

patient‟s age, gender and identified risk factors.” 13

• “For example, HCPCS code G0101 only includes a breast

and pelvic examination; it does not include other elements

normally included in a preventive exam, such as taking

vital signs, examining the skin, hearing, lungs, etc,” 14

Age/Gender:Research: Coding

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1. The examination is “multi-system” but what you do in

the multiple systems is dependent on the patient‟s

age/sex/risk factors. How many is “multi”?

2. “Comprehensive” is the descriptor used for

examination with a disclaimer that it does not mean

the same as for other E&M code‟s “comprehensive”.

Comprehensive: “covering completely or broadly”.

3. Implication from articles discussing the topic includes

thyroid/heart/lungs/abdomen examinations as

examples of the comprehensive health maintenance

exam.

Age/Gender: Research: Coding

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Age/Gender:

Research: Clinical

Most Recent Summary Article on “annual physicials”16

• Started in 1861 to screen for TB

• 1920‟s: AMA recommended yearly physicals

• WW II: Yearly physical exams for officers

• Post WW II: Yearly exams for corporate executives

• 1970‟s: Evaluation by Various Health Agencies

– “unlikely to be of benefit”, (broad) “laboratory screening…is of no value”

• 1979: Canadian Task Force on the Periodic Health Exam

– “do not require an annual examination”

• Currently: USPSTF; ACP; USPHS

– “annual checkups for healthy adults be abandoned”

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• Annual exams: $7.8 billion a year in US17

• “for much of the traditional physical examination, there is

little evidence for inclusion in the PHE”18

• “1/3 of USPSTF screening done in illness visits”19

• 80% of preventive care done outside the PHE20

Age/Gender:Research: Clinical – Other Considerations

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• 8% of doctor visits are for PHE; if every US adult got an

annual exam: 145 million additional visits needed21

• Counseling has biggest impact when only done on a few

elements; too many topics overwhelmed the patient18

• “welcome to Medicare visit”: “there is a lack of clear

evidence demonstrating the PHE improves pt outcomes

or reduces health care costs”22

Age/Gender:Research: Clinical – Other Considerations

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Age/Gender: Research: Clinical

United States Preventive Services Task Force

• Formed in 1984

• 15 member independent experts in primary care,

clinical prevention, evidenced based medicine

• Systematically review evidence for effectiveness

• Considered the “gold standard”

• USPSTF and American Cancer Society are the 2 major

health care policy makers in the U.S.

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United States Preventive Services Task Force

RECOMMENDATIONS

• A Strongly Recommends; Improves health outcomes

• B Fair evidence;

• C No Recommendation: No Harm, No Benefit

• D Against; ineffective or Harm > Benefit

• I Insufficient Evidence; evidence of effectiveness is

lacking; conflicting evidence


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Comprehensive Exam?

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CLINICAL EVIDENCE SUMMARY:

1. Most preventive care is done outside the preventive visit.

2. There is little evidence that the yearly visits are helpful

yet they consume $7.8 billion of health care dollars

3. For many age/gender groups: weight and blood pressure

ARE the “comprehensive” exam.

4. Too much counseling in one encounter is overwhelming

and counterproductive.

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Rather than a specific list of what should be there,

we look for elements of the general categories:

– 80% preventive care done outside the PHE

– “opportunistic” preventive care common in sick visits

– For adults under 50, not much exam required

Too much counseling can be counterproductive.

We look for modifier 25 eligible services

– New significant problems

– Old significantly exacerbated problems

– Non-PHE related procedures (wart/SK/AK)

Age/Gender: Decision

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Age/Gender: Communication Strategy

Compliance/Coding/Collision Conundrum

Most of the exam is not clinically necessary

If I don‟t document a “comprehensive” or “multi-system”

exam, I risk a rejected claim

If I do and document the clinically unnecessary

procedures (exam), I will get reimbursed

What are doctors doing?

$7.8 billion paid out per year mostly for no apparent

clinical or cost benefit…but the medically unnecessary

visit passed the audit.

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Prompting Medical Necessity

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The Collision: Clinical vs. Coding1. Cancer vs. History of Cancer



appropriate?






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#3 - Etiology/Manifestation CodesCOLLISION DEFINITION

THE COLLISION: Etiology/Manifestation Code

• Rules mandate a doctor link clinical conditions

• The underlying premise is that the conditions occur together frequently enough and have a cause/effect relationship.

– Some must be linked by text in the note

• Example: Diabetes and Neuropathy

– Others are mandated to be linked even if there is no linking documentation in the note

• Example Renal Failure and Hypertension

Unfortunately…

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All I need to know about coding I learned by

watching movies…

“Your conclusions were all wrong!”

Said by Captain Marko Ramius to Jack Ryan about his book written

about Admiral Halsey‟s battle strategies.

The Hunt for Red October – Tom Clancy

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Etiology/Manifestation CodesResearch: Coding

Diabetes and its manifestations:“The documentation may indicate conditions “with” diabetes, but

this does not necessarily mean the condition is due to diabetes.

Although diabetic patients are vulnerable to chronic conditions

affecting other body systems (e.g., renal, ophthalmologic,

vascular), this does not indicate a direct correlation. Clarification

must be obtained from the physician as to the cause and effect

relationship of the condition. Documentation should identify a

direct relation by statements such as “due to,” “caused by,” or

“secondary to” before diabetic complication codes are assigned.”*

Similar language is stated in the ICD-9-CM OFFICIAL

GUIDELINES FOR CODING AND REPORTING in our

ICD-9-CM for Physicians –Vol. 1&2

*Turner: Coder‟s Desk Reference for Diagnoses. Copyright 2008 Ingenix, page 262.

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RENAL FAILURE/HYPERTENSION

“Assume a relationship between the hypertension and the chronic kidney

disease, whether or not the condition is so designated.”*

Similar language is stated in the ICD-9-CM OFFICIAL

GUIDELINES FOR CODING AND REPORTING in our

ICD-9-CM for Physicians –Vol. 1&2

Recent Coding Clinic rulings have granted some leniency in

certain clinical situations but the underlying principle still

stands. The mandate changed from all the time to

probably most of the time.

*Turner: Coder‟s Desk Reference for Diagnoses. Copyright 2008 Ingenix, page 262.

Etiology/Manifestation CodesResearch: Coding

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RENAL FAILURE/HYPERTENSION

Diseases contributing to End Stage Renal Disease

Diabetes (49.3%)

Hypertension (26.9%)*

One could conclude that since diabetes causes

ESRD almost twice as often as HTN, DM would

have the mandated association and HTN would

be required to specifically linked in the text of the

note.

Once again to quote Captain Marko…

*US Renal Data System Statistics, 2004.

Etiology/Manifestation CodesResearch: Clinical

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Diabetes and Proliferate Retinopathy

Proliferative Retinopathies are the number one

cause of blindness in the United States.

Diabetes is the number one cause of

Proliferative Retinopathies.

Once again, a mandated text linkage in the note

is required by coding rules.

Etiology/Manifestation CodesResearch: Clinical

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CLINICAL EMR: Administrative Code 500621

BILLING SUITE EMR: Administrative Code 500621

500621 deleted and 250.50 + 362.01 added

Claim Diagnoses: 250.50 + 362.01

Etiology/Manifestation CodesDecision

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Document what you see. Code what you document.

If you can‟t find a 2-fer, you don‟t need one.

Two-fers: I meant them for good…

Coding Mandated vs. Convenience Coding

Etiology/Manifestation CodesEducational Support/ EMR Decision Support

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Etiology/Manifestation CodesRESULTS

97% Diagnosis Accuracy• 20,000+ diagnoses audited per month

• No cheat sheets taped to the computers

– Is this one of the manifestations?

• Clinical Impact: since you can no longer forget to

put in the manifestation code, our disease

registries are more complete and accurate which

drive the quality of care.

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appropriate?






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#4 -Asthma Codes:Collision Definition

• The treatment of asthma is complicated yet very

regimented.

• The major delineation in asthma in the clinical realm is

severity of the illness as well as level of control. It does

not matter whether it is intrinsic or extrinsic. Severity and

how well controlled the asthma is drives treatment

options.

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#4 -Asthma Codes:Collision Definition

Coding offers 51 different coding options for asthma,

none of which mention neither severity nor control

(outside of exacerbation). The majority of the additional

asthma codes do not relate to common clinical conditions.

• EMR Collision:

If I am coding correctly, I am clinically irrelevant.

If I am clinically relevant, I am coding incorrectly.

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Asthma Coding RulesResearch: Coding

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Coding Clinic

“In ICD-9-CM, asthma is classified as extrinsic, intrinsic, chronic

obstructive, or unspecified. Extrinsic asthma is asthma due to

allergenic exposure to substances such as pollen, house dust, animal

dander, molds, food or beverages, vapors, or drugs. Most prevalent in

children, this condition is associated with abnormally high levels of IgE

immunoglobulins, indicating an allergic reaction. Intrinsic asthma is

asthma due to nonallergenic factors such as emotional stresses,

fatigue, endocrine changes, irritants (nonallergenic) such as dust and

chemicals, and acute respiratory infection. More prevalent in adults,

intrinsic asthma is associated with normal IgE immunoglobulin levels,

indicating a nonallergic reaction. This differentiation between

extrinsic or intrinsic is considered archaic by many clinicians

because manifestations of both extrinsic and intrinsic diseases

commonly occur in the same patient.”

Asthma Coding RulesResearch: Coding

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Severity Of Illness/Level of Control

Asthma Coding RulesResearch: Clinical

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Once this surfaced in our audits we realized the

collision and also realized:

the EMR allows us to accommodate both

Asthma Coding RulesDecision

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• Document what you see. Code what you document.

• Type in the fragments: Asthma, per, ex:

Asthma Coding RulesEducation Strategy/EMR Support

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97% Diagnosis Accuracy in Asthma

Asthma errors have all but disappeared

– Disease registries have been cleaned up

– Coding errors have been minimized

Asthma Coding RulesResults

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appropriate?






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Our Latest Collision: DVTCollision Definition

• CODING: Acute vs. Chronic DVT

• CLINICAL:DVT Hx Of

DVT Recurrent

DVT Post-Thrombotic Syndrome

• Relevance: HCC Model for Part C - $3k or $0

• DRG 299/300 or no DRG

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Our latest collision: ICD-10-CM Collision Definition

• Higher specificity = better clinical care?

• No studies from Australia, Canada or EU

• If it doesn‟t make any clinical or financial

difference, why are we doing this when

resources are thin?

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When our worlds collide:

1. Develop allies; Seek clinical input/understanding

2. Explain the collision: there is middle ground

– Organ level vs. Cellular level

3. Look good in gray (PHE)

– It‟s really not all black and white

– Develop a compliant compromise

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When our worlds collide:

4. Don‟t argue!

– “I‟m really sorry they don‟t see it your way. Would

you like to be right or would you like to be

reimbursed.”

5. Develop a relationship with physicians

– We are obsessive compulsive, trained data

assassins and, at times, enjoy a friendly joust.

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APPENDIX: Sources1 Rakel: Textbook of Family Medicine. 7th ed, Copyright 2007 W.B. Saunders Company, Chapter 24 Pulmonary Medicine (on-line

edition).

2 Available at: www.goldcopd.org. Accessed: 4-21-08.

3 “Tobacco related disease: the role of gender.” Dan Bull Med 2000:47;115-131.

4 Noble: Textbook of Primary Care Medicine, 3rd ed, Copyright 2001 Mosby Inc, Chapter 75 Chronic Obstructive Pulmonary

Disease (on-line edition).

5 Available at:https://kaiser.webstrat.com/HSS/WebStrat/WebStrat.aspx. Accessed 5-4-08.

6 Coding Clinic First Quarter 2005.

7 Abeloff: Clinical Oncology. 3rd ed, Copyright 2007 Churchill Livingstone, Chapture 23:2312-2338.

8 Ibid.

9 Ibid.

10 Ibid.

11 Ibid.

12 Goldman: Cecil Medicine. 23rd ed, Copyright 2007 Saunders, Chapter 209 Gynecologic Cancers (on-line edition)

13 Hill, Emily. “Making Sense of Preventive Medicine Coding.” Family Practice Management April 2004: p.50.

14 Ibid, p. 53.

15 AMA. CPT Assistant 12, no. 5 (May 2002):1-4.

16 Chako KM, Anderson RJ. “The Annual Physical Examination: Important or Time to Abandon?” The American Journal of

Medicine. 120, 7(July 2007).

17 “Experts question value of yearly exam.” The Buffalo News (10/21/07).

18 Rakel: Textbook of Family Medicine. 7th ed, Copyright 2007 W.B. Saunders Company, Chapter 10 The Periodic Health

Examination (on-line edition).

19 Kikano GE, Flocke SA, Gotler RS, Stange KC. “Are You Practicing „Opportunistic‟ Prevention?” Family Practice Management

7,3(March 2000)on-line edition.

20 Available at: www.emedicinehelath.com/script/main/art.asp?articlekey=84088. Accessed November 1, 2007.

21 Ibid.

22 Boulware LE, Marinopoulos S. “Systematic Review: The Value of the Periodic Health Evaluation.” Annals of Intermal Medicine

146,4(February 2007)289-300.

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http://www.goldcopd.org/

http://www.emedicinehelath.com/script/main/art.asp?articlekey=84088

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