Newton’s Third Law and ICD-10: Code changes potentially impacting quality outcomes – Part 2

Sept. 19, 2016 / By Cheryl Manchenton, RN

I have to give Sir Isaac Newton and his Third Law of Motion a nod: For every action there is an equal and opposite reaction. Does this law apply to the documentation improvement, coding and quality outcomes spheres? You bet!

Last month I discussed how specificity changes to ICD-10-CM may impact quality metrics and outcomes. This month I will highlight a few additional changes that may affect quality metrics, but note it is possible that metric changes resulting from ICD-10-CM code enhancements will not occur for a couple of years or at all. Why? Specificity in data allows for better analysis of practice patterns, resource consumption, outcomes, etc. But it is difficult (not impossible) to do a prospective analysis of outcomes (and make changes to metrics) when a code is very non-specific, such as iatrogenic pneumothorax. What types of iatrogenic pneumothorax are the most grievous, require the most costly resources and have the biggest impact on morbidity and mortality?  Hard to analyze when there is just one code. And perhaps all iatrogenic pneumothoraxes are impactful and should be tracked. Time will tell. 

We have also observed how the first year of a major code set change can be fraught with errors in code assignment/interpretation. It will be interesting to see how the first year of ICD-10-CM/PCS accuracy impacts quality metrics. And it may be difficult to determine, as the metrics are simultaneously being adjusted the same year we switched from ICD-9-CM to ICD-10-CM/PCS. Finally, meaningful metric change is difficult without a full year of coded data for analysis (and in a year with a major code adjustment). Nonetheless, changes to both codes and metrics have been deployed and we are doing our best as an industry to react to them (hopefully equally).

In the past, quality organizations such as AHRQ requested changes/code expansion to further refine certain metrics (PSI 7 and PSI 11 are great examples). When the expansion request was granted, the changes were deployed. Other times, a change to the metric comes first, with code changes following (PSI 15 underwent a major overhaul in version 6.0 and the associated codes have been expanded this fall). I will discuss the AHRQ PSI changes later, but today I want to focus on the code set changes.

Postoperative hemorrhage and hematoma

In ICD-9-CM, hemorrhage and hematoma due to procedures were assigned to two codes: intraoperative/postoperative hematoma (998.12) and intraoperative/postoperative hemorrhage (998.11). In the ICD-10-CM, hemorrhage and hematoma were assigned to one code but further specified by body system affected and during what type of operation. This year, postoperative hemorrhages and hematomas have the same specificity for body system affected but are split into two distinct code ranges. And in some cases, the codes are further split down into what type of procedure. See the example below:

• I97.610, Postprocedural hemorrhage of a circulatory system organ or structure following a cardiac catheterization
• I97.611, Postprocedural hemorrhage of a circulatory system organ or structure following a cardiac bypass
• I97.618, Postprocedural hemorrhage of a circulatory system organ or structure following other circulatory system procedure
• I97.620, Postprocedural hemorrhage of a circulatory system organ or structure following other procedure
• I97.621, Postprocedural hematoma of a circulatory system organ or structure following other procedure
• I97.622, Postprocedural seroma of a circulatory system organ or structure following other procedure
• I97.630, Postprocedural hematoma of a circulatory system organ or structure following a cardiac catheterization
• I97.631, Postprocedural hematoma of a circulatory system organ or structure following cardiac bypass
• I97.638, Postprocedural hematoma of a circulatory system organ or structure following a other circulatory system procedure

Think about the implications of this code expansion. This may allow for modifications of PSI 9 (postoperative hemorrhage and hematoma) to capture certain types of hemorrhages, hematomas or both based on data analysis and exclusion of minor and common complications such as groin hematoma after a cardiac cath or those less due to surgical errors such as seromas.

Infection due to central venous catheter

There was also a subtle change to the inclusion notes for infection due to central venous catheter. Infections (localized, infection of, and bloodstream infection) due to pulmonary artery catheters (Swan-Ganz) are assigned to the same code as that of other central line infections. I believe this is to ensure we have a complete code set reflective of all central line device infections to better measure quality of care. 

Complication of genitourinary devices

There was a major code expansion in this category. Previously, complications were split into two categories: indwelling urinary catheter and “other genitourinary devices.” Other genitourinary device complications are now subdivided into individual codes (such as cystostomy, nephrostomy, ureteral stent, etc.).

They are really taking these complications seriously!  And as I previously stated, it is not clear what this may mean for quality outcomes in the future. So why do we care? Accurate assignment of codes today leads to better data analysis and determination of metrics for quality outcomes. We have the power to affect quality metrics by carefully reviewing and assigning complication codes for an accurate data set. Let’s be proactive instead of reactive!

Cheryl Manchenton is a senior inpatient consultant and project manager for 3M Health Information Systems.