Health Information Management

ICD-10 and value-based healthcare

HIM-HIPAA Insider, July 7, 2014

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CMS and Obamacare have increasingly been moving healthcare toward a more value-based model. They want to pay physicians for how well they treat patients and not by the volume of services they provide. Even outpatient hospital services are moving that way as CMS increasingly packages services into one payment.
What happens when ICD-10 enters this value-focused mix? Imagine how much information physicians and coders can’t capture today because we just don’t have the codes to represent the true clinical picture of the patient’s illness.
For example, in ICD-9, we have no way of knowing whether a patient broke his or her right or left arm. We can code for the specific bone (radius or ulna) and the area of the bone (upper end, shaft, or lower end). We can even specify open or closed.
What we can’t tell is which side. Why does that matter? Well, consider this scenario. George comes in with a closed fracture of the distal end of the radius (In ICD-9-CM, you would use code 813.43. In ICD-10-CM, we would use a code from the S52.5- series, but we need a lot more information to select the most specific code).
Dr. Bones treats George and sends him on his way. Unfortunately for George, he is back in three weeks with another fracture. Suppose Dr. Bones documents a closed fracture of the distal end of the radius, our 813.43 ICD-9-CM code again. Do you think our payer might be a little suspicious about that?
However, in ICD-10-CM, you could show that George broke the right radius first, then was unlucky enough to break the left one. We’ll have separate codes for each fracture. For example, if George suffered a displaced oblique fracture of the shaft of the right radius, we would report S52.331A for the initial encounter.
When Dr. Bones sees him for the left radial fracture, she documents a nondisplaced comminuted fracture of the shaft of the radius of the left arm (S52.355A). Two different injuries, two different codes.
We’ll also be able to track how well an injury is healing. ICD-10-CM includes seventh characters that specify the encounter. The three most common are:
  • A, initial encounter
  • D, subsequent encounter
  • S, sequela
Those choices expand for fractures that include:
  • D, routine healing
  • G, delayed healing
  • K, nonunion
  • P, malunion
The main code will stay the same; the seventh character will tell you how well the fracture is healing. Suppose George’s right arm fracture was showing malunion when he came in for the initial treatment of the left arm fracture. We could report two codes for that visit and those codes will tell our payer that Dr. Bones treated two separate injuries on that day. If you’re wondering, the codes would be S52.331P and S52.355A.
Notice that the code for the malunion is almost exactly the same as the code for the initial visit for the right arm fracture. In ICD-10-CM that fracture code will run through the entire course of treatment for the injury. That will make it easier to pull data about how well a treatment works, how a patient responds to a particular treatment, and what the physician does to treat that particular injury over the course of healing.
And all of that leads us back to quality measures. If you see a patient who suffers a lot of fractures, the physician should look for an underlying reason. Is George clumsy? Does he work in a high-risk environment? Does he have another condition that makes him more susceptible to fractures?
On the other hand, if George keeps coming in for treatment of the same fracture over and over, maybe Dr. Bones isn’t doing a good job.
ICD-10-CM will make it easier to figure that out because we will have more granular data and we’ll actually be able to tell (to some extent) what quality of treatment a physician is providing.
“We can’t pay for value if we don’t know the outcomes and what the value of the treatment really is,” says Sue Bowman, MJ, RHIA, CCS, FAHIMA, senior director of coding policy and compliance for AHIMA in Chicago. “ICD-10 will really help give us more specific data, so we can see what the outcomes really are and we can judge what is good value.”
This article originally appeared on HCPro’s ICD-10 Trainer blog.

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