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Updated on: March 22, 2016

Putting Your I-10 Data Analytics to Work

Original story posted on: December 12, 2012

EDITOR’S NOTE: This is the final installment in a three-part series on data analytics.

As indicated in my article in the October 30, 2012, ICD-10 Monitor, providers must perform data analytics now so that they can drill down and identify documentation weaknesses.  Phase one includes running your data, and phase two focuses on identifying the population of records to be audited.

Phase three involves reviewing documentation to uncover opportunities for improvement—information that can be used to educate physicians and clinical documentation specialists (CDSs) as well as to show coding professionals how to navigate the new ICD-10 coding system.

Phase Three: The Chart Audit

Assigning the most accurate diagnosis and procedure codes requires a careful review of the medical record documentation. The medical-record example below shows how a physician’s documentation affects the code assignment and subsequently the payment.

The physician documented an incision and drainage of subcutaneous tissue of the buttock for therapeutic purposes. The coding professional assigned the following codes:

For the principal diagnosis of cellulitis and abscess of the buttock, code 682.5 (buttock, gluteal region) was assigned. For the secondary diagnoses (hypertension with end stage renal disease [ESRD]), codes 585.6 (end stage renal disease)—considered a major complication and comorbidity (MCC)—and 403.91 (unspecified hypertensive chronic kidney disease) were assigned. (Note that other secondary diagnoses also were coded but are not included here because they do not affect the MS-DRG assignment.)

Code 86.04 (other incision and drainage of skin and subcutaneous tissue) was assigned for the principal procedure—incision and drainage of skin and subcutaneous tissue.

The above-assigned ICD-9 codes group to MS-DRG 602 (cellulitis with an MCC), which carries a weight of 1.4597. The fiscal year (FY) 2012 average Medicare base rate is $5,209.74.  (Note that this rate changes annually and will change with the implementation of ICD-10 on October 1, 2014.) To arrive at the reimbursement amount for this MS-DRG, multiply the weight 1.4597 times the average Medicare base rate of $5,209.74, which equals reimbursement of $7,604.65.

The assignment of ICD-10 codes could potentially cause this case to move to MS-DRG 579 (other skin, subcutaneous tissue, and breast procedure with MCC), which has a weight of 2.9576. Using the same calculation as above (i.e., multiplying the MS-DRG weight times the average Medicare base rate) equals a potential reimbursement of $15,408.32—a difference of $7,803.67.

ICD-10 Code Assignments

Determining this potential MS-DRG change requires analyzing the specificity of the diagnoses and/or procedures that the physician documented and comparing ICD-9 and ICD-10 code assignments.

In ICD-10, L02.31 would be assigned for the principal diagnosis of abscess of the buttock and N18.6 for the secondary diagnosis of hypertension with ESRD. ICD-10 code I12.0 describes the hypertension with the ESRD, which is a secondary diagnosis recognized as a MCC.

The ICD-10 procedure code assigned would be 0J990ZZ. As you may know, each character in the code identifies a very specific part of the documentation.

First character: The procedure in our example falls into the Medical and Surgical Section in the ICD-10-PCS. This section is identified as a zero (0)—the first character.

Second character: Next the coding professional must ask: Which part of the body system did this procedure affect—the skin or the subcutaneous tissue? The documentation shows that the answer is subcutaneous tissue, which results in a second character of J.  Note that in ICD-9, the procedure code of 86.04 is assigned to the incision and drainage of both skin and subcutaneous tissue. However, in the ICD-10 coding system these are recognized as two different body systems.



Third character: The root operation performed was drainage of the abscess, which would be assigned as the third character of 9.

Fourth character: Identifying the body part where the procedure was performed comes next, which, in our example, is the buttock.

Fifth character: The physician stated that he used an open approach to perform the procedure. The presence of the word “open” instead of “percutaneous” lets coding professionals know to choose the zero (0) for this character.

Sixth character: No device was left in the patient’s body during the procedure, so a Z is assigned.

Seventh character: This final character identifies the qualifier.  Because this procedure was a therapeutic incision and drainage, not a diagnostic procedure, a Z would be assigned. For diagnostic procedures, an X would be assigned.

When you put all of the characters together, you get the final code of 0J990ZZ—a therapeutic incision and drainage procedure of the subcutaneous tissue on the abscess of the buttock.

Follow-up Required

A review of the above DRG cluster shows many opportunities for documentation improvement. In this example, the only definitive procedure indications were “incised and drained the abscess” and “incised and drained the abscess of the leg.” To improve documentation, physicians must be educated to identify the body system (or the “depth” of the procedure, such as whether it was performed on the surface of the skin or in the subcutaneous tissue) and to identify the specific body part (such as upper leg, lower leg, right, left, etc.) where the procedure was performed.

In this case, physician-education efforts will include multiple departments of the medical staff because such procedures could be performed in the emergency department (ED), inpatient bedside, and the operating room. Medical staff departments receiving education include ED physicians, hospitalists, podiatrists, and surgeons, just to name a few.

The bottom line: Better documentation equals more accurate code assignment and better payment.

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Kim Charland, BA, RHIT, CCS

Kim Charland is senior vice president, clinical consulting services, Panacea Healthcare Solutions, Inc., St. Paul, MN.

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