code it! - ACCD Newsletter Vol 1, No 2, March 2014
Welcome to the second edition of our code it! Newsletter.
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CONTENTS
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What's New
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Public Submission Guidelines (AR-DRG and ICD-10-AM/ACHI/ACS) as well as Query Submission Guidelines have
been updated. Please take the time to read them.
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Quarterly Coding Exercise
The second series of coding
exercises to reinforce the ICD-10-AM/ACHI/ACS Eighth Edition changes
introduced from 1 July 2013 are now available and can be found on our
ACCD website.
Any queries arising from these
exercises should be addressed through the normal coding query channels.
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Attention Health Information Managers and Clinical Coders!
We are seeking copies of
de-identified medical records for educational purposes. If you have a
discharge summary, operation report or medical record that would be
suitable for highlighting the
changes in ICD-10-AM/ACHI/ACS Eighth Edition, please email or mail us a
de-identified copy. Any questions should be directed to Belinda
Miguel at enquiries@accd.net.au.
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About CLIP and Web Browsers
The ACCD Classification
Information Portal (CLIP) works best in more recent browsers and
versions of Windows. If you are experiencing difficulties with CLIP,
you should install the latest
version of Internet Explorer, Google Chrome or Mozilla Firefox.
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ACCD Activities in Short
ACCD's technical and advisory groups
including the Classifications Clinical Advisory Group (CCAG), the DRG
Technical Group (DTG) and the ICD Technical Group (ITG) have now
been established and have had their
first meetings. Both the DTG and ITG had their inaugural meeting in
December last year and CCAG's introductory teleconference was held in
mid-February this year.
Content development for
ICD-10-AM/ACHI/ACS is well under way. With respect to progress on AR-DRG
Development, please see the article below relating to the Patient
Complication
and Comorbidity Level (PCCL) review.
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AR-DRG Update
ACCD's work on Version 8.0 of the
Australian Refined Diagnosis Related Groups (AR-DRGs) is now well
underway. The work is led by Stuart McAlister, who worked on AR-DRG
development
at the Commonwealth Department of Health
and the Independent Hospital Pricing Authority (IHPA) for many years,
Dr Trent Yeend who has been seconded from IHPA where he has led
price modelling developments and Dr
Qingsheng Zhou, who joined NCCH after a career as a policy researcher
and data analyst in a number of NSW government agencies.
The Eighth Edition of the International
Statistical Classification of Diseases and Related Health Problems -
Tenth Revision - Australian Modification, the Australian Classification
of Health Interventions (ICD-10-AM/ACHI)
and the associated Australian Coding Standards (ACS) form the basis of
the development and refinement of AR-DRG Version 8.0. Our team of
Classification Specialists and our
Principal Clinical Advisor are working closely with the AR-DRG
Development team in relation to one of our major tasks in reviewing the
Patient
Clinical Complexity Levels (PCCLs)
within the AR-DRGs. Our team will also be assessing the impact of
changes proposed within ICD-10-AM/ACHI/ACS Ninth Edition as part of the
process.
This combined team approach maximises
efficiency and ultimately improvements in both classifications without
jeopardising the integrity of ICD-10-AM/ACHI/ACS.
Our main work has been on the review of
the Complications and Comorbidities (CC) component of AR-DRGs. It was
developed in the 1990s, drawing on previous development in the United
States. In short, diagnoses are given
severity weights which vary according to the Adjacent DRG (ADRG) which
applies to a specific hospital in-patient episode. The Australian
development process is described in
Volume 3 of the AR-DRG Classification Version 4 (Department of Health
and Aged Care, 2000).
Given the amount of time which has
elapsed since its inception, a review of the system is long overdue. The
availability of patient-level data and associated cost information
is much improved, and the computing
capacity to analyse big data sets is many times greater than it was in
the 1990s.
ACCD has assembled a comprehensive data
set covering admitted patient characteristics and costs, for the six
years from 2006-07 to 2011-12, based on the Australian Institute of
Health and Welfare's (AIHW's) admitted
patient collection (APC) and IHPA's National Hospital Cost Data
Collection (NHCDC). Our initial review of the data shows that the
existing
CC system is inadequate at measuring
additional resource use due to complications and comorbidities.
Subsequently, ACCD is considering
alternative methods. A first proposal was discussed on 27 February by
ACCD's DRG Technical Group (DTG). Using the available data for public
hospitals for 2009-10, 2010-11 and
2011-12, a standardised relative cost (SRC) has been compiled for each
diagnosis within each adjacent DRG (ADRG). DTG members welcomed this
innovative approach, recognising that
the work to date is preliminary, with some issues of detail remaining to
be settled.
The work raised the important question
of whether the principal diagnosis within an ADRG could affect severity
loadings as well as complications and comorbidities (additional
diagnoses). The analysis shows that
there is considerable variation in cost within some ADRGs according to
the principal diagnosis.
In light of the DTG discussion,
development of a revised approach is continuing. Once a draft list of
SRCs has been developed, substantial clinical review will be required to
consider the appropriateness of the list
and also the exclusion rules that should apply to related/associated
diagnoses. This review will be led by ACCD's Classification Clinical
Advisory Group (CCAG).
The ACCD review of the CC system is to be submitted to IHPA by 30 June 2014.
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Impact of ICD-10-AM/ACS Seventh Edition Obstetric Code Changes to AR-DRG V7.0
Background
In early February 2014, ACCD was made
aware of a significant change in the distribution of cases within
Adjacent DRG (ADRG) O60 Vaginal delivery in AR-DRG V7.0. ADRG O60
contains
three complexity levels for DRGs. These
are:
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O60A Vaginal delivery with catastrophic or severe complication or comorbidity.
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O60B Vaginal delivery without catastrophic or severe complication or comorbidity.
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O60C Vaginal delivery, single uncomplicated.
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The matter was investigated to determine
the underlying cause and whether changes to AR-DRG V7.0 were required,
prior to implementation on 1 July 2014.
Reason for change in distribution of cases within ADRG O60 Vaginal delivery
The significant change in the
distribution of episodes within ADRG O60 is a result of updates to the
International Statistical Classification of Diseases and Related Health
Problems, Tenth Revision, Australian
Modification (ICD-10-AM) and the Australian Coding Standards (ACS)
undertaken for Seventh Edition. ICD-10-AM and the ACS Seventh Edition
were
implemented in 2010 without an
accompanying AR-DRG version.
AR-DRG V6.0 and V6x were both developed
for ICD-10-AM Sixth Edition. Therefore, for AR-DRG grouping purposes,
ICD-10-AM Seventh Edition coded data was mapped back to Sixth Edition
codes to maintain the DRG assignment
when using AR-DRG V6x or earlier DRG versions. Consequently, the
obstetric ICD-10- AM classification changes in Seventh Edition have not
yet
been reflected in the AR-DRG
classification.
AR-DRG V7.0 will be the first version of
DRGs where these ICD-10-AM obstetric classification changes will become
active. AR-DRG V7.0 was developed for ICD- 10-AM Eighth Edition
and the obstetric classification changes
implemented in ICD-10-AM Seventh Edition have been maintained in
ICD-10-AM Eighth Edition.
The following points summarise the background leading to this issue:
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These updates resulted from a
review of national inconsistencies in coding of obstetric episodes as
well as evolving clinical views on what constitutes a normal
uncomplicated delivery. The
World Health Organization's ICD-10 codes between O80 - O84 were used as a
base for these changes.
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Updates were also made to the
Australian Coding Standards (ACS) to clarify the coding of principal
diagnosis in episodes with a delivery. The aim was to ensure all
obstetric
episodes had a delivery code as
the principal diagnosis to reflect the reason for admission, except in
circumstances where a mother was admitted specifically for management of
an antepartum condition.
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Previous editions of ICD-10-AM
forced the assignment of O80 Single spontaneous delivery only in the
absence of other codes classifiable elsewhere in Chapter 15 Pregnancy,
childbirth and the puerperium,
assuming O80 alone was equivalent to a normal delivery. However clinical
advice indicated that there is non-consensus as to the definition of a
normal delivery and that single spontaneous deliveries can occur with a
range of comorbidities and complications.
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Modifications to ICD-10-AM
Seventh Edition more accurately distinguish spontaneous vaginal
deliveries with minimal or no assistance from those with assistance by
manipulation, instrumentation or
surgery (e.g. forceps, vacuum, caesarean sections and other assisted
deliveries). This was achieved by allowing O80 Single spontaneous
delivery to be assigned in
conjunction with other codes classifiable elsewhere within Chapter 15
Pregnancy, childbirth and the puerperium.
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Delivery episodes now allow O80
to be assigned as the principal diagnosis with additional diagnosis
codes assigned to describe antepartum, delivery and postpartum
conditions that occur with a
spontaneous vaginal delivery (e.g. gestational diabetes, premature
rupture of membranes, perineal lacerations, postpartum haemorrhage,
etc).
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The ICD-10-AM changes went
through the usual extensive consultation process at the time. This
included clinical consultation, the creation of a sub-committee of the
Coding
Standards Advisory Committee
(CSAC) to examine the issues with obstetric coding and a trial of the
new obstetric codes and associated ACS. Following this development work,
CSAC endorsed the modifications
for implementation in ICD-10-AM Seventh Edition in 2010.
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Impact of ICD-10-AM/ACS coding changes on O60 Vaginal delivery
The Seventh Edition ICD-10-AM/ACS coding
changes have resulted in a considerable number of cases moving from the
more resource intensive O60A and O60B DRGs to the less
resource-intensive O60C DRG. These DRG
changes are due to a higher proportion of episodes being assigned a
principal diagnosis of O80 Single spontaneous delivery as a result of
the Seventh Edition coding changes
detailed above. The following points illustrate the current criteria
used to split ADRG O60:
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Episodes with a principal
diagnosis of O80 automatically group to O60C in AR-DRG V7.0, regardless
of the number and type of additional diagnoses assigned to each episode.
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Episodes with a principal
diagnosis from Chapter 15 (other than O80) but with an additional
diagnosis with a Patient Clinical Complexity Level (PCCL) of >2 group
to O60A.
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All other episodes with a
principal diagnosis from Chapter 15 (other than O80) group to O60B.
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Investigation of 2011/12 data shows that
in AR-DRG V7.0, the number of cases in O60A and O60B have dropped when
compared to AR-DRG V6x. However the distribution of cases, mean cost and
average length of stay (LOS) between
O60A, O60B and O60C is more consistent with the instinctive pattern of
cases within ADRGs across the AR-DRG classification (ie lower partitions
have a greater volume of cases than the
partition above them with the "A" partition having the smallest volume
of cases).
The mean cost of O60A and O60B has
increased, which reflects the cheaper and less complex cases being
assigned to O60C. The mean cost of O60C has also increased due to the
increase
in more costly episodes transferring
from O60A and O60B. This transfer of episodes and changes in costs has
been taken into account for weight calculations as data coded in
ICD-10-AM Seventh Edition has been used
in these calculations.
Conclusion
There has been a change in the
distribution of cases within ADRG O60 Vaginal delivery for AR-DRG V7.0.
This is as a result of an intentional change to the underlying
ICD-10-AM/ACS
classification to reflect the current
clinical situation in obstetrics.
The Seventh Edition ICD-10-AM/ACS
changes went through an extensive consultation process at the time. This
included clinical consultation, the creation of a sub-committee of the
Coding Standards Advisory Committee to
examine the issues with obstetric coding and a trial of the new codes
and coding standards across several jurisdictions, including New
Zealand.
Following an analysis of the impact of
ICD-10-AM/ACS Seventh Edition changes to the obstetric codes (maintained
in Eighth Edition in which AR-DRG V7.0 is based), DRG O60A, O60B and
O60C appear to be performing as
expected. The average LOS within these DRGs are indicative of the level
of severity/resource consumption, with O60A being the most
severe/resource
consuming within this ADRG.
The Independent Hospital Pricing
Authority has agreed that the current classification structure for ADRG
O60 Vaginal delivery in AR-DRG V7.0 is to be maintained. Further work
will
occur on ADRG O60 as part of the wider
review of the PCCLs being carried out by ACCD for the development of
AR-DRG V8.0.
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ACCD Stakeholder Survey Results
ACCD conducted a survey during
October/November 2013 to assist in our understanding of the needs and
expectations of our stakeholders. The feedback from the survey will help
to inform our planning and development
for the ongoing development of the ICD-10-AM/ACHI/ACS classifications.
The survey was distributed at the
National Health Information Management Association of Australia (HIMAA)
Conference in October 2013 and was also available through the ACCD
website
for completion online. The survey
questions related to the ACCD website, the Classification Information
Portal (CLIP), the newsletter, communication from ACCD, and delivery of
education.
There were a total of 350 respondents, with the breakdown of respondents' roles as follows:
The following is a summary of the survey
results and the action taken by ACCD to date in response to the
feedback.
ACCD Website
62% of respondents had visited the ACCD
website. Of those who had not yet visited the website, the majority
indicated time constraints or a lack of awareness of the website as
the main reasons.
The HIMAA Conference introduced ACCD to
the Health Information Management and clinical/coder workforce through
keynote presentations and an information booth to raise awareness
of the AR-DRG Classification System
development and refinement project.
Of the respondents who had visited the
website, 75% thought the design and layout of the website was
good/excellent. However some respondents identified difficulties when
locating the Coding Rules, previous
editions of Coding Matters and Errata. The website menu layout has since
been modified and a "Quick Links" option included on the top of the
screen to enable users to easily locate
this type of information.
70% of respondents were unaware of a
link to provide website feedback to the ACCD. This link is now available
under the Contacts menu and clearly labelled "Website Feedback".
CLIP
Pleasingly, 69% of survey respondents
had already registered with CLIP and many of those who had not yet done
so, were able to register at the ACCD booth at the HIMAA Conference.
Changes were also made to the ACCD
website to ensure that the link to CLIP was more obvious.
Survey respondents raised issues with
functionality including searching, printing and saving Coding Rules
within CLIP. Investigation of these issues highlighted potential
problems
with different browsers and versions of
browsers being used by stakeholders. Enhancements have now been made to
CLIP to help overcome these issues and streamline functionality.
Detailed instructions for
searching/printing and saving/exporting were published in the December
issue of the code it! newsletter.
Comments from respondents in relation to
the formatting of the Coding Rules and in particular the print version
have been taken on board and addressed by changes to the print
functionality within CLIP.
Newsletter
Approximately 90% of respondents
indicated their preference for clinical updates and coding exercises to
be incorporated in the newsletter. The first edition of our quarterly
code it! newsletter was
published in December 2013 and included a link to a coding exercise.
This will now become a regular inclusion. Clinical updates are also
planned
for future editions. Regular updates on
the ACCD's work program was requested by 85% of survey respondents. This
edition of code it! communicates some important background
information about the AR-DRG Classification System development and refinement project.
Updates on training and upcoming
conferences, and the progress of ICD-11 development were also
suggestions made by respondents, and this information will be included
in code it! as it becomes available. Other respondents requested profiles of ACCD staff, and these are available on the ACCD website.
Communication
The vast majority of respondents
indicated that their preference for communication from ACCD was via
email (to CLIP registrants). ACCD is currently and will continue to
provide
notifications via email to CLIP
registrants about the publication of coding advice (Coding Rules),
release of errata etc. Over 70% of respondents were happy to receive
information
via ACCD website updates and through the
newsletter. These channels of communication will continue to be used,
including updates in the "What's New" section on the ACCD website.
There was very little demand for
communication via social media, with less than 7% of respondents
indicating an interest in using this method as a communication tool.
At this stage ACCD is not pursuing the
social media option.
Education
Regarding alternative options for
education delivery, online tutorials were the most preferred method,
selected by 87% of respondents, followed by 65% preferring conference
coding workshops. Nearly 40% of
respondents selected video conferencing/webinars, however it was noted
by some respondents that there can be limitations to accessing this
technology at present.
ACCD is exploring innovative options for
the delivery of education in the future. Coding workshops are currently
planned for the combined HIMAA/NCCH National Conference to be held in
Darwin in October 2014.
The survey feedback has provided a
valuable resource to the ACCD. Thank you to everyone who contributed by
completing the survey!
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Upcoming Events
Activity Based Funding Conference 2014
Melbourne Convention Exhibition Centre (MCEC)
23-25 June
IHPA will organise and promote the
Activity Based Funding Conference (ABF) 2014 as a forum for the
dissemination of ABF-related education, training and research. The
conference
aims to provide high quality education
in ABF and the underlying classification, costing and data collection
systems to key health sector personnel. It will include major plenary
sessions, concurrent smaller
presentations, workshops/training, exhibitions and social activities.
More information is available at their conference website.
HIMAA/NCCH 2014 National Conference - "Health information management: driving the information highway"
Double Tree by Hilton Hotel, Esplanade Darwin
7-9 October
This year, HIMAA is teaming up with the
National Centre for Classification in Health (NCCH) to deliver an
informational and learning opportunity for HIMs, Clinical Coders and
other
professionals associated with the
management and use of health information.
The 2014 HIMAA/NCCH conference will
explore how local and international health information professionals are
navigating eHealth initiatives and funding reform through a dynamic
period of change. As well as an
important networking opportunity, the joint conference will include
presentations and workshops in the areas of clinical coding, data
governance,
financial management, performance
reporting, eHealth standards, workforce challenges, quality and safety
and international classifications - all in the context of the HIM and
Clinical Coding streams.
Call for Abstracts is now open.
HIC Conference 2014
Melbourne
11-14 August
Please visit the conference website.
AHIMA Convention & Exhibit 2014
San Diego, USA
27 September-2 October 2014
Watch this space.
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What's New in CLIP - Coding Rules
Recently, ACCD was alerted to instances
where coding advice should have been retired/superseded as well as
instances where advice was inadvertently retired. Consequently over
December 2013/January 2014 ACCD
undertook a thorough review of all Coding Rules in CLIP to ensure that
it only contains current coding advice. This review resulted in the
reinstatement of some Coding Rules and
the removal or updating of other Coding Rules. Please note that if you
have exported and printed the Coding Rules prior to
February 2014 they will no longer be
current.
Since removing the retired and
superseded coding advice from CLIP we have had requests for access to a
listing of all the retired and superseded advice from some stakeholders.
To
this end, we now have two pdf files
available in the Downloads
section of the ACCD website. One pdf file
contains a listing of the superseded
advice and the other contains a listing of the retired advice.
New Coding Rules
22 new Coding Rules have been published in CLIP as at 15 March 2014. Click here to view them.
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