Archive for February 21, 2013

ICD-10-CM Coding for Latrogenic Blood Vessel Injuries

Some of the more common causes of blood vessel injury include gunshot wounds, stab wounds, blunt trauma (including blunt trauma with fracture or dislocation) and iatrogenic injuries. With more procedures being performed using intravascular techniques of late, the number of iatrogenic injuries to blood vessels has increased. Understanding the differences between ICD-9-CM and ICD-10-CM coding for blood vessel injuries occurring as a complication of a surgical procedure will help with correct code assignment when ICD-10-CM is implemented.


In ICD-9-CM, codes for iatrogenic injuries of blood vessels are found in Chapter 17, Injury and Poisoning. An injury to a blood vessel complicating a surgical procedure is reported with one of three nonspecific codes, as follows:


998.11 Hemorrhage complicating a procedure; 998.12 Hematoma complicating a procedure; and 998.2 Accidental puncture or laceration during a procedure. 
It should be noted that no distinction is made in ICD-9-CM for intra-operative or postoperative hemorrhage or hematoma.


In ICD-10-CM, codes for intra-operative and post-procedural blood vessel injuries are found in Chapter 9, Diseases of the Circulatory System. ICD-10-CM classifies body system-specific, intra-operative and post-procedural complications within each body system chapter, rather than in Chapter 19 (Injury, Poisoning and Certain Other Consequences of External Causes Medical Transcription).


While ICD-10 codes for intra-operative and post-procedural complications affecting blood vessels are not specific to the site of the injury, they are specific to the body system affected, which in the case of blood vessel injuries is the circulatory system. Codes are also specific to the type of injury – hemorrhage and hematoma or puncture and laceration. Hemorrhage and hematoma codes are specific to whether the complication occurs during a surgical procedure or postoperatively, and these codes are also specific to some types of procedures (including cardiac catheterization, cardiac bypass, other circulatory system procedure or other procedure). Puncture and laceration codes are specific to whether the blood vessel injury occurred during a circulatory system procedure or during a procedure being performed on another body system.


For intra-operative hemorrhage and hematoma of a blood vessel or other circulatory system organs or structures, the following codes apply:

I97.410 – Use when the hemorrhage or hematoma complicates a cardiac catheterization procedure.I97.411 – Use when the hemorrhage or hematoma complicates a cardiac bypass procedure.I97.418 – Use when the hemorrhage or hematoma complicates another circulatory system procedure.I97.42 – Use when the hemorrhage or hematoma complicates a procedure on a body system other than the circulatory system.

For post-procedural hemorrhage and hematoma of a blood vessel or other circulatory system organs or structures, the following codes apply:

I97.610 – Use when the hemorrhage or hematoma complicates a cardiac catheterization procedure.I97.611 – Use when the hemorrhage or hematoma complicates a cardiac bypass procedure.I97.618 – Use when the hemorrhage or hematoma complicates another circulatory system procedure.I97.62 – Use when the hemorrhage or hematoma complicates a procedure on a body system other than the circulatory system.

For accidental puncture and laceration of a blood vessel or other circulatory system organ or structure, the following codes apply:

I97.51 – Use when the accidental puncture or laceration occurs during a circulatory system procedure.I97.52 – Use when the accidental puncture or laceration occurs during a procedure on another body system.

Abuse Hotline Revamp Reduces Response Times

The Florida Department of Children and Families – an agency that partly focuses on child welfare services – revamped its existing telephone hotline for reporting child abuse, neglect or exploitation. The $10 million update has reduced response time for investigators looking into reported cases.

According to the hotline’s website, more than 1 million children fall victim to abuse or neglect each year in Florida, and many of these cases go unreported. The Children and Families Department overhauled its legacy call center hotline system last November with a centralized phone and Internet system. In preparation for the upgrade, the department added approximately 50 additional call takers, bringing its total to 300.

David Wilkins, the department’s secretary, explained that under the previous system, reports phoned in to the abuse hotline from across the state were taken by call center representatives who then manually entered information on computer-based data entry forms. Once the report was complete, it was printed and faxed to the department’s local offices. The information was then entered into the traditional child welfare system to begin an investigation. This cumbersome process often resulted in a response from the department two days after the initial report.

“So we said, ‘Why don’t we do this function just like a retail organization does it?’ Like when you call L.L. Bean or Target on the phone, they bring up your buying history, they know what you bought last week, they know what specials they’re pushing this week,” Wilkins said. “And so they can have a collaborative conversation with you on the phone about what needs to happen to conduct that transaction.” 

The new reporting system by IBM automates the call process, prompting call center representatives to ask specific questions about the case based on the case history associated with the call. While on the phone with the person reporting the incident, call center staff can query multiple databases, including criminal records, for instance, to gather information about the individuals in question.

Previously if multiple calls were made about the same incident, each call would have prompted a response by a separate investigator. Multiple calls regarding the same incident now result in a single response by one investigator, operating with information gathered from all the calls received.

Kellie Sweat, the department’s director of child protection transformation, said child protective investigators can be notified more quickly about a reported case, based on the incident’s level of urgency.

“We’ve been working awhile to make sure our child protective investigators, the ones that go to the home, are able to spend the majority of their time in the field in the homes with the families,” Sweat said.

Wilkins said that typically in cases of abuse or neglect, many of the same families are reported repeatedly over the years. The system can keep a record of a specific family’s history when reports about them are made to the department.

The abuse hotline also allows reports to be submitted online. The online reporting feature, which lets individuals create a user name and password, immediately sends the report to the department’s central hotline system. This cabability especially comes in handy for individuals who serve as “dedicated reporters” — people in law enforcement or school counselors whose job requires them to look for cases of abuse or neglect, and report them to the department.

According to officials, the revamped hotline is currently averaging nearly 1,400 calls and 100 online submissions each weekday.

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Comparing Hospital Infection Rates via Interactive Map

Patients in U.S. hospitals experience about 290,000 surgical site infections annually. These infections are the second most common health-care associated infection in the country.

California’s Department of Public Health (CDPH) educates more than 36 million residents about health dangers like these, but it’s not an easy job. Anita Gore, deputy director of the department’s Office of Public Affairs, strategizes ways to inform citizens so they make intelligent health-care decisions. 

Unfortunately taxpayers don’t always understand the intricate health information that the department provides online. “It’s complicated information,” she said, referring to the data tables that present the information on the public health website.

Reading hyper-detailed Web pages is challenging. The department’s Healthcare Associated Infections program posts information about surgical site infections and blood-related infections, but the voluminous data may exhaust readers’ patience. Dozens of pages contain paragraph after paragraph describing sophisticated, hard-to-pronounce infection types, and there are long lists of links to reports and other health-related websites. 

“We have major pieces of data and charts and information on our website, but not necessarily user-friendly,” Gore said. “When we started releasing these reports to the public, we were criticized for them not being consumer helpful.”

The CDPH created the Healthcare Associated Infections interactive map to deliver infection information to consumers that’s less confusing. The map displays more than 300 California hospitals with symbols representing surgical infection rates for about a dozen procedures. Users click a symbol to generate a pop-up box disclosing the hospital’s stats for different surgeries. Data reveals whether the facility’s infection rates are lower, higher or equal to state or national averages. 

Gore and her colleagues designed the map to package data in ways that will have fewer Californians scratching their heads. “This is an attempt to take the information we were being given and make it usable for people,” she said.

The map offers general infection data about common operations, supplemented by more detailed information elsewhere on the CDPH website. For example, say Diane, a 30-something office assistant in Sacramento, learns she’s pregnant and wants to know more about infection rates for C-sections. 

Diane visits the interactive map to view C-section infection rates for local hospitals and weigh her options. A main menu sorts the data along multiple infection categories. One is for general surgical site infections (SSI), and the others involve bloodstream infections. The surgical site infection button has a dropdown menu with a “cesarean section” option, so Diane clicks that one to sort accordingly. 

The legend under the map says, “Rates of infection per hospital are compared with the U.S. national average for SSIs.” This is represented by four symbols: A green square means a hospital has lower-than-average infection rates, a purple circle means it’s equal to the average, an orange triangle means it’s higher, and a gray circle means no data’s available for a comparison.

Diane sees that most hospitals in Sacramento and nearby regions have purple circles, which means their C-section patients don’t get infected at higher-than-normal rates. However, she’s excited when she sees two hospitals with green squares, University of California Davis Medical Center in Sacramento and a Kaiser facility in the nearby suburb of Roseville. These hospitals’ C-section infection rates are lower than she expected, so one of those would make her feel much safer when she delivers her baby.  

But Diane won’t find detailed numbers on infection rates unless she visits other CDPH pages. Links beneath the map lead to Web pages featuring specific infection data. If she digs around, she’ll see that one of her choices, UC Davis Sacramento, performed 351 C-sections from April to December 2011 with only two infections. The other, Roseville’s Kaiser, performed 629 with no infections during the same period. In this case, the map was a great starting point for infection data, but the data’s real substance lies elsewhere.

“The map is an extra added value to make the information easily available and understandable to the consumer,” Gore said.

Successive events led to the map’s creation. They began with a 2006 California law requiring the CDPH and general acute care hospitals to create programs to monitor diseases and prevent health-care-associated infections. This prompted state hospitals to provide the CDPH with infection data.

The CDPH unveiled the map’s first iteration in January 2012. The California Healthcare Foundation supplied $75,000 in grants for the project, and designers from Stamen Studios, a San Francisco-based design studio, worked with state staff to create the map and Web page. The most recent version debuted in August 2012 after a relatively quick implementation period that began in May.

Nabil Fares, the CDPH’s CIO, is proud of the teamwork between the state’s businesses units, his IT staff and the California Healthcare Foundation. “It’s really a model for collaboration among different stakeholders and different entities,” he said.

The map was developed in Flash and is embedded into the site using JavaScript to embed it on the site. The application, roughly 367 MB in size, is self-contained and doesn’t interact with the server. The Web page itself was developed in Microsoft SharePoint.

California law requires hospitals in the state to submit infection data to the CDPH quarterly. Hospital researchers deliver the CDPH infection data in multiple spreadsheet formats, including delimited and comma-separated values. CDPH personnel feed the data to the map in comma-separated values and populate it with infection data.  

The interactive map is a young application, but it’s already gaining attention. In summer 2012, the project garnered the CDPH a Best Public Sector App award in the People’s Choice Category at Government Technology’s GTC West conference.

But despite the accolade, it may be years before the CDPH assesses the map’s usefulness in reducing hospital infections and educating citizens. “Because of the newness of the application, it’s a little bit hard to predict,” Fares said.

For now, they will support their creation and wait to see what develops.

“It certainly is the goal as the reporting continues, that we will see steps taken to decrease the number of infections that occur related to hospital stays,” Gore said.

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Opinion: Can Google Analytics Replace Public Health Workers?

As big data becomes more sophisticated, the question about whether analytics tools — like those developed by Google — could someday replace data compiled by federal agencies.

A case in point is the Google Flu Trends website, which could someday become a suitable replacement for much of the work now performed by the Center for Disease Control (CDC).

That day, however, is not likely to come for a least a few years, according to a recent opinion article in the National Journal, although many agree there is great potential in such technology if it can be honed.

A comparison of Google’s flu trend graph and the CDC’s data shows a discrepancy in findings:

Google Flu Trends map
Google Flu Trends chart



CDC flu trends chart

While Google shows the current flu outbreak as being the worst of the past six years, the Center for Disease Control shows that the current outbreak is bad, but not as bad as outbreaks of at least two years past. Furthermore, the CDC graph shows that the outbreak is already on the decline. The discrepancy can be accounted for if one looks at the simplistic nature of Google’s data, according to the article.

The CDC uses a combination of data: reports of sickness across many disease control centers along with tweaks made by public health experts with years of experience. Google’s data is based off of search results that do their best to filter out search noise, but with limited success. The things that’s missing, according to the article? The human factor. And Google admits the tool is still in an early phase of development; it has a ways to go before it can compete with human data analysis.

“We intend to update our model each year with the latest sentinel provider [influenza-like illness] data, obtaining a better fit and adjusting as online health-seeking behavior evolves over time,” Matt Mohebbi, a Google software engineer recently wrote for Forbes. “With respect to the current flu season, it’s still too early to tell how the model is performing.”

But in the future, we could see a combination of the two, said Lynnette Brammer, a flu epidemiologist with the CDC. While there may never be a substitute for human decision-making, technology could save public heath workers a lot of time, she said. “We want the data transmission to be as easy for the people providing it to us as possible,” she said. “But the thing we don’t want is to lose the connection we have with those people. Even if you have really good data coming in, you’re always going to have questions about what it means.”

When comparing the two systems, one primarily run by people and the other by a machine, it comes down to understanding complexity. “It’s really hard, certainly for us at CDC, to understand what’s causing that change,” Brammer said. “They’re seeing pretty much record levels of influenza-like illness. And while ours are high, they’re not at historical limits by any means. We just have a lot more flexibility and ability to track down and ask additional questions and find the answers to those questions.”

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