Prevention and Management of Pseudoverrucous Lesions: A Review and Case Scenarios

GENERAL PURPOSE

To present the associated risk factors, prevention measures, and assessment and management of pseudoverrucous lesions specific to a surgically created ileal conduit, as well as three clinical scenarios illustrating this condition.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant will:1. Define pseudoverrucous lesions.2. Identify the risk factors for stoma complications such as pseudoverrucous lesions.3. Select the appropriate routine care procedures to teach patients following stoma creation to help prevent pseudoverrucous lesions.4. Choose the recommended treatment options for patients who develop pseudoverrucous lesions.

Have ICD-10 Coding Practices Changed Since 2015?

Usage of ICD-10 codes in administrative data has continued to shift since mandatory adoption in 2015. Identifying changing patterns in coding behavior is imperative in producing reliable analyses and robust conclusions. We examined the granularity of ICD-10 coding over time in a cohort selected from the IBM Explorys Therapeutic Dataset, which contains the records of over 60 million patients. Our seasonality-aware trend model identified patterns of interest, such as increased use of laterality codes for pain and increased use of codes denoting concepts novel to ICD- 10 for screening encounters. Those relying on these codes should adjust for these 'learning curve' effects. This work should be extended to additional modalities of terminology usage and represents a starting point for researchers working with dynamic clinical ontologies.

Data-driven discovery of changes in clinical code usage over time: a case-study on changes in cardiovascular disease recording in two English electronic health records databases (2001-2015)

OBJECTIVES

To demonstrate how data-driven variability methods can be used to identify changes in disease recording in two English electronic health records databases between 2001 and 2015.

DESIGN

Repeated cross-sectional analysis that applied data-driven temporal variability methods to assess month-by-month changes in routinely collected medical data. A measure of difference between months was calculated based on joint distributions of age, gender, socioeconomic status and recorded cardiovascular diseases. Distances between months were used to identify temporal trends in data recording.

SETTING

400 English primary care practices from the Clinical Practice Research Datalink (CPRD GOLD) and 451 hospital providers from the Hospital Episode Statistics (HES).

MAIN OUTCOMES

The proportion of patients (CPRD GOLD) and hospital admissions (HES) with a recorded cardiovascular disease (CPRD GOLD: coronary heart disease, heart failure, peripheral arterial disease, stroke; HES: International Classification of Disease codes I20-I69/G45).

RESULTS

Both databases showed gradual changes in cardiovascular disease recording between 2001 and 2008. The recorded prevalence of included cardiovascular diseases in CPRD GOLD increased by 47%-62%, which partially reversed after 2008. For hospital records in HES, there was a relative decrease in angina pectoris (-34.4%) and unspecified stroke (-42.3%) over the same time period, with a concomitant increase in chronic coronary heart disease (+14.3%). Multiple abrupt changes in the use of myocardial infarction codes in hospital were found in March/April 2010, 2012 and 2014, possibly linked to updates of clinical coding guidelines.

CONCLUSIONS

Identified temporal variability could be related to potentially non-medical causes such as updated coding guidelines. These artificial changes may introduce temporal correlation among diagnoses inferred from routine data, violating the assumptions of frequently used statistical methods. Temporal variability measures provide an objective and robust technique to identify, and subsequently account for, those changes in electronic health records studies without any prior knowledge of the data collection process.

Vascular dementia encoding in the French nationwide discharge summary database (PMSI): Variability over the 2007-2017 period

OBJECTIVE

Vascular dementia (VaD) is the second leading cause of dementia. Diagnostic criteria have evolved from the concept of multiple infarctions to different subtypes: acute onset VaD, subcortical VaD, mixed cortical and subcortical VaD. Our aim was to analyze the evolution in the coding of these different subtypes of VaD in the French nationwide exhaustive hospital discharge database (PMSI) between 2007 and 2017.

METHOD

We included all principal diagnoses of VaD in the PMSI hospital stays from 2007 to 2017.

RESULTS

Between 2007 and 2017, we show a relative decrease in the number of hospital stays for VaD compared to all hospital stays (0.0437% to 0.0404%). The 11,654 hospital stays for VaD in 2017 represent 13.5% of mental organic disorders. Subtype analysis shows a decrease in hospital stays for multiple infarctions between 2007 and 2017 (-50%), an increase for subcortical or mixed VaD (+20%), acute onset VaD (+184%) and an increase in "other VaD" (+85%).

CONCLUSION

These data suggest a slight decrease in hospital stays for VaD, possibly related to better control of cardiovascular risk factors. They also suggest that the coding should be consistent with the evolution of diagnostic criteria.

Coding Discrepancies Between Medical Student and Physician Documentation

OBJECTIVE

Accurate medical documentation is a core competency in medical education and is critical to successful surgical practice. The following study aims to assess the coding accuracy of medical student documentation.

DESIGN

Retrospective chart review identified patient encounters in a surgery clinic that contained documentation by both a faculty member and a third-year medical student. Records were de-identified and assigned a level of service (LOS) and diagnostic code by trained, expert coders. Differences in LOS and diagnostic code were then compared between medical student and faculty documentation.

SETTING

A single academic health system.

PARTICIPANTS

Third-year medical students.

RESULTS

80 full patient evaluations and 20 postoperative visits were analyzed. Median faculty and student LOS was 4 (range 3-4) and 3 (range 0-4) respectively (p < 0.001). Students failed to document a sufficient number of elements in the evaluation, failed to specify studies ordered, and documented low medical decision making. Diagnostic code was concordant between students and faculty for only 31% of documentation.

CONCLUSION

Student documentation of clinical encounters is coded at a lower LOS than faculty documentation. These results likely reflect the lack of education regarding E/M coding in medical school, which is integral to real world practice.

SUMMARY

Accurate medical documentation is critical to the correct diagnostic coding and billing of a medical encounter. We found that compared to faculty documentation of the same patient evaluations, student documentation was typically coded at a lower level of service and assigned a different diagnostic code by professional medical coders. Addressing these topics in medical school may better prepare students for real-world practice.

Are trends in billing for high-intensity emergency care explained by changes in services provided in the emergency department? An observational study among US Medicare beneficiaries

OBJECTIVE

There has been concern that an increase in billing for high-intensity emergency care is due to changes in coding practices facilitated by electronic health records. We sought to characterise the trends in billing for high-intensity emergency care among Medicare beneficiaries and to examine the degree to which trends in high-intensity billing are explained by changes in patient characteristics and services provided in the emergency department (ED).

DESIGN, SETTING AND PARTICIPANTS

Observational study using traditional Medicare claims to identify ED visits at non-federal acute care hospitals for elderly beneficiaries in 2006, 2009 and 2012.

OUTCOMES MEASURES

Billing intensity was defined by emergency physician evaluation and management (E&M) codes. We tested for overall trends in high-intensity billing (E&M codes 99285, 99291 and 99292) and in services provided over time using linear regression models, adjusting for patient characteristics. Additionally, we tested for time trends in rates of admission to the hospital and to the intensive care unit (ICU). Next, we classified outpatient visits into 39 diagnosis categories and analysed the change in proportion of high-intensity visits versus the change in number of services. Finally, we quantified the extent to which trends in high-intensity billing are explained by changes in patient demographics and services provided in the ED using multivariable modelling.

RESULTS

High-intensity visits grew from 45.8% of 671 103 visits in 2006 to 57.8% of 629 010 visits in 2012 (2.0% absolute increase per year; 95% CI 1.97% to 2.03%) as did the mean number of services provided for admitted (1.28 to 1.41; +0.02 increase in procedures per year; 95% CI 0.018 to 0.021) and discharged ED patients (7.1 to 8.6; +0.25 increase in services per year; 95% CI 0.245 to 0.255). There was a reduction in hospital admission rate from 40.1% to 35.9% (-0.68% per year; 95% CI -0.71% to -0.65%; P<0.001), while the ICU rate of admission rose from 11.7% to 12.3% (+0.11% per year; 95% CI 0.09% to 0.12%; P<0.001). When we stratified by diagnosis category, there was a moderate correlation between change in visits billed as high intensity and the change in mean number of services provided per visit (r=0.38; 95% CI 0.07 to 0.63). Trends in patient characteristics and services provided accounted moderately for the trend in practice intensity for outpatient visits (pseudo R² of 0.47) but very little for inpatient visits (0.051) and visits overall (0.148).

CONCLUSIONS

Increases in services provided in the ED moderately account for the trends in billing for high-intensity emergency care for outpatient visits.

An integrated national mortality surveillance system for death registration and mortality surveillance, China

In China, sample-based mortality surveillance systems, such as the Chinese Center for Disease Control and Prevention's disease surveillance points system and the Ministry of Health's vital registration system, have been used for decades to provide nationally representative data on health status for health-care decision-making and performance evaluation. However, neither system provided representative mortality and cause-of-death data at the provincial level to inform regional health service needs and policy priorities. Moreover, the systems overlapped to a considerable extent, thereby entailing a duplication of effort. In 2013, the Chinese Government combined these two systems into an integrated national mortality surveillance system to provide a provincially representative picture of total and cause-specific mortality and to accelerate the development of a comprehensive vital registration and mortality surveillance system for the whole country. This new system increased the surveillance population from 6 to 24% of the Chinese population. The number of surveillance points, each of which covered a district or county, increased from 161 to 605. To ensure representativeness at the provincial level, the 605 surveillance points were selected to cover China's 31 provinces using an iterative method involving multistage stratification that took into account the sociodemographic characteristics of the population. This paper describes the development and operation of the new national mortality surveillance system, which is expected to yield representative provincial estimates of mortality in China for the first time.

What explains DRG upcoding in neonatology? The roles of financial incentives and infant health

We use the introduction of diagnosis related groups (DRGs) in German neonatology to study the determinants of upcoding. Since 2003, reimbursement is based inter alia on birth weight, with substantial discontinuities at eight thresholds. These discontinuities create incentives to upcode preterm infants into classes of lower birth weight. Using data from the German birth statistics 1996-2010 and German hospital data from 2006 to 2011, we show that (1) since the introduction of DRGs, hospitals have upcoded at least 12,000 preterm infants and gained additional reimbursement in excess of 100 million Euro; (2) upcoding rates are systematically higher at thresholds with larger reimbursement hikes and in hospitals that subsequently treat preterm infants, i.e. where the gains accrue; (3) upcoding is systematically linked with newborn health conditional on birth weight. Doctors and midwives respond to financial incentives by not upcoding newborns with low survival probabilities, and by upcoding infants with higher expected treatment costs.

What to Think About in 2015

Every organization and facility has issues that they need to address. There is no such thing as a perfect organization or a perfect process. It is easy to get overwhelmed and think the challenges are too big to tackle, but don't give up! While some issues may require immediate changes due to compliance concerns, most can be made one small step at a time. The phrase "success is a journey, not a destination" is very applicable here and for any area within our responsibility where change needs to occur. Change is our only constant so we might as well embrace it and look forward to the future with excitement on the new opportunities ahead.

ICD-10: are you ready for a brave new world?

The ICD-10 transition will be an evolutionary process. Relying on the EHR or certified coding staff alone will not be sufficient. The EHR can facilitate easy search tools that assist the provider in selecting a diagnosis. Billing staff are an invaluable resource to help validate that coding and documentation are in sync but the burden will clearly rest on the provider. The provider will be juggling a new code structure, drilling down to new levels of complexity and ensuring their documentation supports the specificity of the new codes selected, all while managing a full patient schedule. Education for the provider will be of paramount importance as they navigate this brave new world.

ICD-10 is coming an update on medical diagnosis and inpatient procedure coding

In October 2014, the United States will switch from using the ICD-9 coding system to ICD-10. This change will allow for greater specificity in describing medical conditions and the addition of new codes as medical knowledge and technology evolve. The change will be a big one for hospitals and clinics. This article describes what physicians need to know about the new system and what the organizations they work for need to consider when preparing for the change.

What really happened with pneumonia mortality in Finland in 2000-2008?: a cohort study

This cohort study examines trends in pneumonia mortality in Finland and the effects of a WHO recommendation restricting the registering of pneumonia as the underlying cause of death (COD) for several chronic diseases. All cases having pneumonia in any COD fields in 2000-2008 were extracted from the COD statistics. We examined trends in underlying-cause pneumonia mortality where pneumonia was also the immediate COD. Results are presented as age-specific and age-standardized rates. In the study period 2000-2008, there were 90 626 deaths with pneumonia in COD fields, while the underlying-cause pneumonia mortality rate decreased from 32 to 6/100 000 person-years. Immediate-cause pneumonia was less often chosen as underlying-cause towards 2008 suggesting an effect from changing coding practices. Changes in coding practices need to be considered when comparing different countries or time periods in pneumonia mortality.

ICD-9 to ICD-10: evolution, revolution, and current debates in the United States

The International Statistical Classification of Diseases and Related Health Problems (ICD) has undergone a long evolution from its initial inception in the late 18th century. Today, ICD is the internationally recognized classification that helps clinicians, policy makers, and patients to navigate, understand, and compare healthcare systems and services. Currently in the United States, hot debates surround the transition from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) to the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). This article presents an analysis of the views of the proponents and opponents of the upcoming change. We also briefly present and analyze the quality of the most frequently cited scientific evidence that underpins the recent debates focusing on two major issues: ICD-10-CM implementation costs and revenue gains and the projected clinical data quality improvement. We conclude with policy and research suggestions for healthcare stakeholders.