Traumatic Brain Injury in the Military After Transition to ICD 10

Traumatic Brain Injury Webinar Traumatic Brain Injury in the Military After Transition to ICD 10 1-2:30 p.m. January 11, 2018 Medically Ready Force Ready Medical Force 1

Presenters/ Moderator Presenters Yll Agimi, PhD, MPH, MS Lead Surveillance Epidemiologist (SME) Contractor Support to DVBIC Office of Surveillance Silver Spring, MD Lauren Earyes, MPH, BSN Clinical Epidemiologist Contract Support to DVBIC Office of Surveillance Silver Spring, MD Moderator Donald Marion, MD Senior Traumatic Brain Injury Consultant Defense and Veterans Brain Injury Center Department of Defense Silver Spring, MD Medically Ready Force Ready Medical Force 2

Resources Available for Download Today s presentation and resources are available for download in the Files box on the screen, or visit http://dvbic.dcoe.mil/training/webinars Medically Ready Force Ready Medical Force 3

Webinar Details Live closed captioning is available through Federal Relay Conference Captioning (see the Closed Captioning box) Webinar audio is not provided through Adobe Connect or Defense Collaboration Services Dial: CONUS 888-455-0936 International 773-799-3736 Use participant pass code: 3788688 Question & answer (Q&A) session Submit questions via the Q&A box Medically Ready Force Ready Medical Force 4

Continuing Education Details All who wish to obtain continuing education (CE) credit or certificate of attendance, and who meet eligibility requirements, must register by 3 p.m.(et) Jan.11, 2018 to qualify for the receipt of credit. DHA-J7 awarding of CE credit is limited in scope to health care providers who actively provide psychological health and traumatic brain injury care to active-duty U.S. service members, reservists, National Guardsmen, military veterans and/or their families. The authority for training of contractors is at the discretion of the chief contracting official. Currently, only those contractors with scope of work or with commensurate contract language are permitted in this training. Medically Ready Force Ready Medical Force 5

Continuing Education Accreditation (continued) This continuing education activity is provided through collaboration between DHA-J7 Continuing Education Program Office (CEPO) and Professional Education Services Group (PESG). Credit Designations include: 1.5 AMA PRA Category 1 credits 1.5 ACCME Non Physician CME credits 1.5 ANCC Nursing contact hours 1.5 CRCC 1.5 APA Division 22 contact hours 0.15 ASHA Intermediate level, Professional area 1.5 CCM hours 1.5 AANP contact hours 1.5 AAPA Category 1 CME credit 1.5 NBCC contact hours Medically Ready Force Ready Medical Force 6

Continuing Education Accreditation (continued) Physicians This activity has been planned and implemented in accordance with the essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME). Professional Education Services Group is accredited by the ACCME as a provider of continuing medical education for physicians. This activity has been approved for a maximum of 1.5 hours of AMA PRA Category 1 Credits. Physicians should only claim credit to the extent of their participation. Nurses Nurse CE is provided for this program through collaboration with the Professional Education Services Group (PESG). Professional Education Services Group is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. This activity has been approved for a maximum of 1.5 contact hours of nurse CE credit. Nurses should only claim credit to the extent of their participation. Occupational Therapists (ACCME Non Physician CME Credit) For the purpose of recertification, The National Board for Certification in Occupational Therapy (NBCOT) accepts certificates of participation for educational activities certified for AMA PRA Category 1 Credit from organizations accredited by ACCME. Occupational Therapists may receive a maximum of 1.5 hours for completing this live program. Physical Therapists Physical Therapists will be provided a certificate of participation for educational activities certified for AMA PRA Category 1 Credit. Physical Therapists may receive a maximum of 1.5 hours for completing this live program. TM AMA PRA Medically Ready Force Ready Medical Force 7

Continuing Education Accreditation (continued) Psychologists This Conference is approved for up to 1.5 hours of continuing education. APA Division 22 (Rehabilitation Psychology) is approved by the American Psychological Association to sponsor continuing education for psychologists. APA Division 22 maintains responsibility for this program and its content. Physical Therapists Physical Therapists will be provided a certificate of participation for educational activities certified for AMA PRA Category 1 Credit. Physical Therapists may receive a maximum of 1.5 hours for completing this live program. Psychologists This Conference is approved for up to 1.5 hours of continuing education. APA Division 22 (Rehabilitation Psychology) is approved by the American Psychological Association to sponsor continuing education for psychologists. APA Division 22 maintains responsibility for this program and its content. Rehabilitation Counselors The Commission on Rehabilitation Counselor Certification (CRCC) has pre-approved this activity for 1.5 clock hours of continuing education credit. Speech-Language Professionals This activity is approved for up to 0.15 ASHA CEUs (Intermediate level, Professional area). TM AMA PRA Medically Ready Force Ready Medical Force 8

Continuing Education Accreditation (continued) Case Managers This program has been pre-approved by The Commission for Case Manager Certification to provide continuing education credit to CCM board certified case managers. The course is approved for up to 1.5 clock hours. PESG will also make available a General Participation Certificate to all other attendees completing the program evaluation. Nurse Practitioners Professional Education Services Group is accredited by the American Academy of Nurse Practitioners as an approved provider of nurse practitioner continuing education. Provider number: 031105. This course if offered for 1.5 contact hours (which includes 0 hours of pharmacology). Physician Assistants This Program has been reviewed and is approved for a maximum of 1.5 hours of AAPA Category 1 CME credit by the Physician Assistant Review Panel. Physician Assistants should claim only those hours actually spent participating in the CME activity. This Program has been planned in accordance with AAPA s CME Standards for Live Programs and for Commercial Support of Live Programs. Counselors This activity is approved for up to 1.5 National Board of Certified Counselors (NBCC) continuing education hours. Other Professionals Other professionals participating in this activity may obtain a General Participation Certificate indicating participation and the number of hours of continuing education credit. CCM Medically Ready Force Ready Medical Force 9

Questions and Chat Throughout the webinar, you are welcome to submit technical or content-related questions via the Q&A pod located on the screen. Please do not submit technical or content-related questions via the chat pod. The Q&A pod is monitored during the webinar; questions will be forwarded to presenters for response during the Q&A session. Participants may chat with one another during the webinar using the chat pod. The chat function will remain open 10 minutes after the conclusion of the webinar. Medically Ready Force Ready Medical Force 10

Webinar Overview Clinicians practicing within the Military Health Systems (MHS) treat their patients and code their own administrative data using a combination of diagnostic and procedure codes. The data generated from these administrative codes informs key strategy and reporting criteria circulated throughout and beyond the Department of Defense (DoD). As a provider, are you confident that your coding accurately portrays the patient s presentation and the content of the medical visit? Are you familiar with the defense health applications of the data extracted from your medical encounter records? Are you able to access current statistics on traumatic brain injury (TBI) in the DoD to help frame your discussions with patients and their families? And, are you aware of common pitfalls in data interpretation and feel confident that you are able to discuss aggregated DoD TBI data while avoiding these pitfalls? Presenters will answer these questions as well as familiarize participants with how the Defense and Veterans Brain Injury Center (DVBIC) leverages clinician-entered administrative data on an ongoing basis and publishes quarterly reports produced by the Office of Surveillance, DVBIC. Medically Ready Force Ready Medical Force 11

Webinar Overview (continued) At the conclusion of this webinar, participants will be able to: Examine how provider coding connects to ongoing efforts to estimate the incidence and prevalence of traumatic brain injury in the military Demonstrate how clean coding practices can improve the accuracy of data that providers generate Integrate DVBIC TBI surveillance data into their clinical practice and communications with confidence 12

Yll Agimi, PhD, MPH, MS Yll Agimi, doctorate, is the Lead Epidemiologist at the Defense and Veterans Brain Injury Center (DVBIC) Office of Surveillance. He is a graduate of the University of Pittsburgh Graduate School of Public Health, where he obtained his doctorate and Masters degrees in Public Health and Epidemiology. He has been with DVBIC since 2011 Medically Ready Force Ready Medical Force 13

Lauren E Earyes, MPH, BSN Clinical Epidemiologist, Office of Surveillance, Defense and Veterans Brain Injury Center Acute Care Nurse, Medical and Neuro Intensive Care Unit Prior Defense Center of Excellence Outreach Clinician for TBI and Psychological Health Masters of Public Health (MPH), Johns Hopkins University, Bloomberg School of Public Health Recipient of National Institute for Occupational Safety and Health Trainingship Graduate Certificate, Environmental & Occupational Health, Johns Hopkins University, Bloomberg School of Public Health Graduate Certificate, Risk Sciences & Public Policy, Johns Hopkins University, Bloomberg School of Public Health Bachelor of Science in Nursing (BSN), George Mason University Summa Cum Laude; Recipient of The George Mason Presidential Scholarship; Sigma Theta Tau International Honor Society Medically Ready Force Ready Medical Force 14

DVBIC TBI Webinars Traumatic Brain Injury in the Military After Transition to ICD 10 1-2:30 p.m. January 11, 2018 Medically Ready Force Ready Medical Force 15

Disclosures & Acknowledgements Dr. Yll Agimi and Ms. Lauren Earyes have no relevant financial relationships to disclose relating to the content of this activity. The views expressed in this presentation are those of the author and do not necessarily reflect the official policy or position of the Department of Defense, nor the U.S. Government. This continuing education activity is managed and accredited by PESG in collaboration with the DHA-J7 CEPO. PESG, DHA-J7 CEPO, as well as all accrediting organizations, do not support or endorse any product or service mentioned in this activity. PESG, DHA-J7 CEPO staff, activity planners and reviewers have no relevant financial or non financial interest to disclose. Commercial support was not received for this activity. Medically Ready Force Ready Medical Force 16

Poll #1 Please identify your area of practice from the following choices: A: Medic/Corpsman/first responder B: Emergency Medicine C: Primary care, family medicine or internal medicine D: Behavioral health E: Neurology F: Rehabilitative or physical medicine G: Another area of clinical specialty H: Health Care Administration, in any modality I: Other Medically Ready Force Ready Medical Force 17

Surveillance Measurement of TBI in the Military Medically Ready Force Ready Medical Force 18

Surveillance Definition Public health surveillance goes by many names including: epidemiological surveillance, clinical surveillance and syndromic surveillance. The World Health Organization [(WHO), 2017] defines public health surveillance as "the continuous, systematic collection, analysis and interpretation of health-related data needed for the planning, implementation, and evaluation of public health practice." Medically Ready Force Ready Medical Force 19

Webinar Outline Update viewers on surveillance definition and DVBIC surveillance products What TBI incidence numbers, also known as Worldwide TBI numbers, do and do not say about TBI in the military A discussion of key factors of TBI coding that are often overlooked Examples of information gleaned from TBI coding data combined with chart reviews. Medically Ready Force Ready Medical Force 20

TBI Research and Surveillance, Different but Sometimes Difficult to Distinguish Collection and analysis of health information to move knowledge forward Research: build a knowledge base on TBI diagnosis, treatment and outcomes, strengthening TBI surveillance efforts. Both: Build evidence basis for TBI programs, policies and interventions. Surveillance: Conditional to timelines.separate authority granted. Develops hypotheses and stimulates research. Lussier, et al. (2012) Medically Ready Force Ready Medical Force 21

DVBIC TBI Surveillance TBI Surveillance at DVBIC is: Sourced from Military Health System Data Repository (MDR) Augmented by Theater Medical Data Store(TMDS) and Armed Forces Health Longitudinal Technology Application (AHLTA) data. Passive Both interval based and on demand Not Research Why is it not research? Draws from an entire population rather then a screened and qualified sample Driven by data entered by hundreds of DoD staff Surveillance activity can generate hypotheses. Research can test hypotheses. Medically Ready Force Ready Medical Force 22

DVBIC TBI Surveillance Overall Incidence of TBIs (timely data, assess validity, reliability of estimates) Period prevalence, co-morbidities, disability relative to TBI Research recruitment Risk of sustaining a TBI (Service, age, occupational specialty, location, time of day, day of week) Care patterns (where, who, how many, repeat visits, source/referral patterns) Patient profiles (patient complexity to inform care) Coding practices (coding compliance, ICD-9-CM/ICD-10-CM) Medically Ready Force Ready Medical Force 23

DVBIC TBI Surveillance Medically Ready Force Ready Medical Force 24

Becoming Familiar with DVBIC TBI data Medically Ready Force Ready Medical Force 25

TBI Definition A traumatically induced structural injury or physiological disruption of brain function as a result of external force that is indicated by new onset or worsening of at least one of the following clinical signs immediately following the event: Any alteration in mental status (e.g., confusion, disorientation, slowed thinking, etc.) Any loss of memory for events immediately before or after the injury Any period of loss of or a decreased level of consciousness, observed or self-reported External forces may include any of the following events: the head being struck by an object, the head striking an object, the brain undergoing an acceleration/deceleration movement without direct external trauma to the head or forces generated from events such as a blast explosion, including penetrating injuries. (Department of Defense, 2015) Medically Ready Force Ready Medical Force 26

DVBIC: Surveillance Responsibilities Responsibility: The Defense and Veterans Brain Injury Center (DVBIC) is designated as the single office of responsibility for the consolidation of all TBI related incidence and prevalence information for DoD, reporting to Deputy Assistant Secretary of Defense for Force Health Protection and Readiness (DASD, FHP&R), now reporting to DHA, Research and Development (J-9). Statutory authority: Assistant Secretary of Defense (Health Affairs) Memorandum: Consolidation of Traumatic Brain Injury Initiatives in the Department of Defense. March 23, 2007 http://dvbic.dcoe.mil/dod-worldwide-numbers-tbi Medically Ready Force Ready Medical Force 27

TBI Surveillance Background 01 October 2007 ASD (HA) Memorandum; Traumatic Brain Injury; Definition and Reporting Establish a common definition for TBI and reporting requirements Designated DVBIC as the single office of responsibility for the consolidation of all TBI-related incidence and prevalence information for the DoD. Directed DVBIC reporting on surveillance to the office of the Deputy Assistant Secretary of Defense for Force Health Protection and Readiness. June 2010 (change 22 Feb11) DTM 09-033, Policy Guidance for Management of Concussion/Mild Traumatic Brain Injury in the Deployed Setting directed the; Development of reporting guidelines, event tracking activities and submission of monthly tracking reports to JTAPIC. Sept 2012 DoD Instruction 6490.11 DoD Coordinate mtbi/concussion exposure surveillance and data analysis and promote data sharing for deployment-associated TBIs Generate comprehensive, retrospective analytical reports of event triggered data Apr 2015 Memorandum TBI: Updated Definition and Reporting : DVBIC, Office of Surveillance performs sub-analysis of data to improve surveillance methods and provide indepth analyses using: MDR, AHLTA, DMDC. 28

Total DoD TBI Worldwide Numbers Medically Ready Force Ready Medical Force 29

Army TBI Worldwide Numbers Medically Ready Force Ready Medical Force 30

Navy TBI Worldwide Numbers Medically Ready Force Ready Medical Force 31

Air Force TBI Worldwide Numbers Medically Ready Force Ready Medical Force 32

Marines TBI Worldwide Numbers Medically Ready Force Ready Medical Force 33

Surveillance Requests for Specific Project and Research Needs Example of data provided in fulfillment of tailored requests to DVBIC surveillance Data Source: MDR Medically Ready Force Ready Medical Force 34

Discussing data. Speaking from an informed approach. Medically Ready Force Ready Medical Force 35

Coding Myths There is a single International Coding of Diseases (ICD) Clinical Modification (CM) code for each TBI severity, mild, moderate or severe (not true) My coding as a provider informs data analysts of minimally necessary injury information such as the date and the cause of injury (not true) Clinical coding in the military health system communicates each TBI sustained during military service (not true) Medically Ready Force Ready Medical Force 36

Myth: There is a Single ICD Code for each TBI Severity There are over 200 ICD-10 CM that DVBIC recognizes as a TBI diagnosis. There are multiple combinations of the codes above when certain trailing digits are needed to tell the complete story. The final digit in a TBI code designates where the patient is along their continuum of TBI care. Each code can only have one severity assigned: Mild, Moderate, Severe or Penetrating. (DVBIC Surveillance Methodology, 2017) Medically Ready Force Ready Medical Force 37

Myth: The DHA Can Easily Access Injury Dates and Cause of Injury for New Cases of Traumatic Brain Injury False The Military Health System (MHS) Comprehensive Ambulatory/ Professional Encounter Record (CAPER) system provides data on ambulatory care. Ambulatory care makes up more than 90% of TBI care in the military system, but 60% of such cases are missing the ICD-10 CM data on cause of injury and 0% include a code that reflects a date of injury. So what do we do? Additional details not available within clinician coding can be accessed from other data sources Date of injury and cause of injury can be extrapolated from either prior research, gathered through chart review, or merged into coding data sets from external sources. Source MSMR: Medical Surveillance Monthly Report. External causes of traumatic brain injury, 2000-2011. March 2013, Volume 20/3 Medically Ready Force Ready Medical Force 38

Poll #2 Among your TBI patients, what percentage had two or more likely concussions during the course of their military service? A: None, 0% B: A very small minority C: 25% D: 50% E: >50% Medically Ready Force Ready Medical Force 39

Myth: TBI Numbers Reflect Each TBI Sustained During Military Service and Only TBI Sustained While in the Military The current DoD TBI definition allows for only one TBI per service member lifetime. Second brain injuries documented in a patient s AHLTA record are not counted under the current DoD definition of one TBI per lifetime. The Armed Forces Health Surveillance Branch (AFHSB) interprets Z87.820 and DOD0101-DOD0105, as new cases of TBI, and credit the incidence of that case to the day, month and year that code appeared in the service member s record, regardless of actual date the injury occurred. Medically Ready Force Ready Medical Force 40

TBI Occurrence vs. Diagnosis vs. Surveillance Recognition Incident 1 st Encounter Recognition Incident 1 st Encounter Recognition MVA Oct 1, 2017 Bystander calls EMS, who arrives at the scene. MVA motor vehicle accident EMS Emergency Medical Services EMS Oct 1, 2017 Finds driver dazed but conscious. Driver cannot recall what he was doing immediately prior to crash. ER Physician Oct 1, 2017 EMS recommends transport and evaluation. Concussion is diagnosed in the ER. ER Emergency Room Patient A Patient B Medically Ready Force Ready Medical Force 41

TBI Surveillance Data: Clinician Compiled, Clinician Influenced Medically Ready Force Ready Medical Force 42

Clinical Documentation vs. Medical Coding Clinical Documentation A limited data source when retrieving aggregated data. Very helpful to a trained researcher who has time and bandwidth to comb through a patient record encounter by encounter. May be entirely thorough and yet communicate little to researchers Medical Coding Retrievable via surveillance methodology Allows for trend analysis and cluster monitoring Informs Congress, command, and medical command. Not equivalent to the accuracy and thoroughness of clinical documentation. Medically Ready Force Ready Medical Force 43

Coding Pitfalls Recycling the same concussion code for every patient that comes into the clinic. Recycling the same concussion code for every mild TBI case that comes into the clinic. Choosing an incomplete TBI code that would be nonbillable. Choosing a TBI code that is not as specific as the diagnosis (also unbillable) or information that the clinician has before them. Coding a very old injury as if it was a new injury. Medically Ready Force Ready Medical Force 44

Real Life Coding Examples of Coding Habits Service Member is seen five times at a TBI clinic over a period of one month. At each visit a TBI code with an A in the 7 th place is entered. The clinic is essentially recycling the code. A patient is seen in an ER for a new head injury. The code entered has an A in the 7 th place. Two days later, the patient follows up with her primary care provider (PCP) as directed. The PCP chooses the same TBI code but takes care to replace the A with a D in the 7 th digit. Two weeks later, the patient is referred to neurology. The code chosen continues with a D and corrects the sixth digit to 0 to reflect that the patient reports he did not sustain an LOC. Medically Ready Force Ready Medical Force 45

Visual Aid: DVBIC Coding Guidelines http://dvbic.dcoe.mil/files/resources/ dvbic_4383_icd-10-coding-guidancetbi_v1.4_2017-09-06.pdf Medically Ready Force Ready Medical Force 46

Clinician Data Entry Feeds Surveillance TBI Incidence New Cases of TBI Product name: DoD TBI Worldwide Numbers Information accessible to the public on DVBIC website, http://dvbic.dcoe.mil/dodworldwide-numbers-tbi TBI Prevalence At any given time, how many people have TBI? How is that defined? An active disease state? Symptomatic? What about lingering symptoms or sequelae? Product Name: TBI Medical Encounters Reports Product produced for key advisors and command leadership. Medically Ready Force Ready Medical Force 47

Improving Surveillance Data Clinician coding is the major modality DoD public health surveillance is informed of traumatic brain injury incidence and prevalence in the DoD. Is your coding telling the story you want to tell? TBI coding portrays the patient s presentation and the content of the medical visit Medically Ready Force Ready Medical Force 48

This is not an instructional coding webinar, however, education on TBI coding in the MHS, post ICD-10 adoption is readily available and recommended. Medically Ready Force Ready Medical Force 49

Training Resources Army Training Network Traumatic Brain Injury Training Support package [need a DoD Logon or a common access card (CAC) to access] ICD-10 Concussion Coding Training Product 1-hour web-based course Access at: https://atn.army.mil/ Medically Ready Force Ready Medical Force 50

DVBIC: ICD-10 Coding Guidance for Traumatic Brain Injury Training Slides Guidance for medical and rehabilitation providers in coding initial and subsequent visits in proper sequence, for specific TBI diagnoses, including TBI screening and symptom codes https://dvbic.dcoe.mil/material/icd-10-coding-guidance-traumatic-brain-injury-training-slides Medically Ready Force Ready Medical Force 51

Improving Data Medically Ready Force Ready Medical Force 52

Clean TBI Documentation and Coding Key Documentation Elements Date of Injury Cause of Injury Contributory Factors LOC, AOC, Post Traumatic Amnesia? How long? Was it witnessed? ICD-10 Coding Medically Ready Force Ready Medical Force 53

DVBIC: ICD-10 Coding Guidance for Traumatic Brain Injury Training Slides Guidance for medical and rehabilitation providers in coding initial and subsequent visits in proper sequence, for specific TBI diagnoses, including TBI screening and symptom codes https://dvbic.dcoe.mil/material/icd-10-coding-guidance-traumatic-brain-injury-training-slides Medically Ready Force Ready Medical Force 54

Clean Documentation Did You Code a Screening? DOD0121 Screening for traumatic brain injury (TBI), negative findings DOD0122 Screening for traumatic brain injury (TBI), positive findings DOD0123 Screening for traumatic brain injury (TBI), declined by patient DOD0124 Screening for traumatic brain injury (TBI), not performed due to existing diagnosis of TBI DOD0125 Screening for traumatic brain injury (TBI), not performed due to reason other than existing TBI diagnosis dvbic.dcoe.mil/files/resources/dvbic_4383_i cd-10-coding-guidance-tbi_v1.4_2017-09- 06.pdf Medically Ready Force Ready Medical Force 55

Clean TBI Coding Among all new TBI diagnosed after the implementation of ICD 10 (Oct. 1, 2015) through Oct. 1, 2017, less then 10% had a TBI screening code of any type on the date of diagnosis or even up to three weeks prior to the diagnosis. Likely screenings are being done, they re just not being coded. It s not incorrect to code a screening if you reviewed the screening with the service member (SM) and factored it in to your diagnosis. Medically Ready Force Ready Medical Force 56

Clean TBI Documentation PCS, F07.81 What does Post Concussion Syndrome (PCS) mean to you? Let s take a look: It s a neurology diagnosis It s regarded as a diagnosis related to mild concussion. Mayo Clinic (2017) notes PCS symptoms occur within the first seven to 10 days and go away within three months. Sometimes, they can persist for a year or more. It s a diagnosis of symptom persistence, not of initial symptom presentation, especially in the acute TBI period. Epidemiologist s pet peeve: a PCS diagnosis attached 24-72 hours after concussive event occurred. Medically Ready Force Ready Medical Force 57

Clean TBI Documentation Z87.820 Keep in mind that if TBI has not been previously documented in the patient s record, you re now adding this individual as a case. Are you confident in recollection? Medically Ready Force Ready Medical Force 58

Clean TBI Coding S06.ELSE-eitiology, location, severity, encounter. If there was no LOC, make sure the third terminal digit is a 0 If there is LOC, please chose a number, 1-9. This is a really hard ask, but if it s a brand new TBI, use an A. If another provider has coded a TBI for this injury with an A code already, code a D. TBI EPI Dream-On Wish List: A code to signify a NEW tbi, that is only used ONCE per concussive event. If a SM had 6 such codes over 20 years of service, they had 6 individual TBI s. dvbic.dcoe.mil/files/resources/dvbic_4383_icd-10-codingguidance-tbi_v1.4_2017-09-06.pdf Medically Ready Force Ready Medical Force 59

Not all Cases are Equal in Timeliness The ICD-10 Code that classified a 2017 DoD TBI case and the Time Lag between Date of Injury as reported by the SM or Clinician and the Date that the ICD-10 code was recorded in the service member s record. 79/160 (49.4%) of new TBI injuries were recognized with traditional ICD-10 injury codes. Of these 79 injury codes, the vast majority, 64/79 (81%) had a terminal A for initial visit. Data Source: MDR and AHLTA, Q42017. Medically Ready Force Ready Medical Force 60

Causes of Injury in one Weighted Sample Leading Causes of Injury in Active Duty Service Members, FY 2017 Total Sports 9% ND 8% MVA 17% (CDC: 14.3%) Hard landing 4% GSW Fall 1% 23% (CDC: 40.5%) Blow to head 16% (CDC: 15.5%) Blast 15% Assault 7% (CDC: 10.7%) ND = Not Documented MVA = Motor Vehicle Accident GSW = Gun Shot Wound Data source: AHTLA chart review, 2017. Medically Ready Force Ready Medical Force 61

Cause of Injury by Service, ADSM, 2017 Army Navy Air Force Marines Assault 2.50% 15% 2.50% 7.50% Blast 25% 5% 2.50% 27.50% Blow to head 10% 25% 15% 15% Fall 22.50% 25% 20% 22.50% GSW 0% 0% 2.50% 0% Hard landing 15% 2.50% 0% 0% MVA 12.50% 15% 30% 10% Sports 0% 7.50% 15% 15% Not Documented 12.50% 5% 12.50% 2.50% Data source: AHTLA chart review, 2017 Medically Ready Force Ready Medical Force 62

Case Study 1 A service member presents at your practice stating that while deployed seven years ago, she sustained three blast exposures; she has no prior documentation of brain injury or concussion in her medical record. How do you code the statement of blast exposure she makes? She states that she had no LOC but felt dazed, maybe. Does your diagnosis change if she is complaining of headache at today s visit? A1: S06.0X0A, R51.X, Ext. Cause of Morbidity Code, Place of Occurrence Code, activity code, DOD0102 A2: R51.X, S06.0X0S A3: R51.X, DOD0102 A4: F07.81, G44.301, DOD0102 Medically Ready Force Ready Medical Force 63

Case Study 2 You are practicing in a specialty area and you receive a referral from primary care to evaluate a service member post moderate TBI. This is the first time you are seeing the patient for her TBI. While gathering a subjective history from the patient of her injury, she reports she hit the right side of her head, and lost consciousness for about an hour. What is the TBI code, in addition to any other codes applicable to the visit that you chose for this patient today? A1: S06.013A, DOD0103 A2: S06.013D, DOD0102 A3: S06.013D, DOD0103 A4: S06.013A, DOD0102 Medically Ready Force Ready Medical Force 64

Key Take Aways Surveillance and Research are not equal. Each has unique purposes, methodology, funding, regulations, and degrees of confidence. DVBIC conducts ongoing surveillance on TBI in the military using clinician coding from medical encounters. The MHS coding environment does not obligate the completion of key fields like date or cause of injury. Surveillance data is strengthened by provider adherence to standardized ICD-10 coding guidance (links provided). As a provider feel confident in your ability to frame patient-provider TBI discussions using up to date TBI information accessed via DVBIC website. Additionally, if presenting or publishing on TBI and accessing surveillance data, remember that TBI occurrence and TBI report/recognition may lag. Medically Ready Force Ready Medical Force 65

References Centers for Disease Control and Prevention (CDC). (2017). International classification of diseases, tenth revision, clinical modification/procedure coding system (ICD-10-CM/PCS ). Retrieved from: http://www.cdc.gov/nchs/icd.htm Defense and Veterans Brain Injury Center (DVBIC). (2017). DoD worldwide numbers for TBI. Retrieved from: http://dvbic.dcoe.mil/dod-worldwide-numbers-tbi Defense and Veterans Brain Injury Center. (2017). ICD-10 coding guidance for traumatic brain injury, version 1.4. Retrieved from: https://dvbic.dcoe.mil/files/resources/dvbic_4383_icd-10-coding-guidance-tbi_v1.4_2017-09- 06.pdf Department of Defense Coding Guidance Subgroup. (2017). Military Health System Specific Coding Guidelines, Version 1. (2018). Medically Ready Force Ready Medical Force 66

References (cont.) Department of Veterans Affairs Health Services Research and Development Service. (2013). Complications of mild traumatic brain injury in veterans and military personnel: A systematic review. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmedhealth/pmh0063757/pdf/pubmedhealth_pmh0063757.pdf Lussier, M.T., Richard, C., Bennett, T.L., Williamson, T., & Nagpurkar, A. (2012). Surveillance or research: What s in a name? Canadian Family Physician, 58(1), 117. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3264028/pdf/0580117.pdf Mayo Clinic. (2017). Post-concussion syndrome. Retrieved from: https://www.drugs.com/mcd/post-concussionsyndrome Medical Surveillance Monthly Report. (2013). External causes of traumatic brain injury, 2000-2011. March 2013, Volume 20/3. (2018). Medically Ready Force Ready Medical Force 67

References (cont.) World Health Organization (WHO). (2017). Public health surveillance. Retrieved from: http://www.who.int/topics/public_health_surveillance/en/ Medically Ready Force Ready Medical Force 68

Questions Submit questions via the Q&A box located on the screen. The Q&A box is monitored and questions will be forwarded to our presenters for response. We will respond to as many questions as time permits. Medically Ready Force Ready Medical Force 69

How to Obtain CE Credit 1. You must register by 3 p.m. (ET) Jan. 11, 2018, to qualify for the receipt of continuing education credit or certificate of attendance. 2. After the webinar, go to URL http://dhaj7.cds.pesgce.com 3. Select the activity: 11 Jan TBI Webinar 4. This will take you to the log in page. Please enter your e-mail address and password. If this is your first time visiting the site, enter a password you would like to use to create your account. Select Continue. 5. Verify, correct, or add your information AND Select your profession(s). 6. Proceed and complete the activity evaluation. 7. Upon completing the evaluation you can print your CE Certificate. You may also e-mail your CE Certificate. Your CE record will also be stored here for later retrieval. 8. The website is open for completing your evaluation for 14 days. 9. After the website has closed, you can come back to the site at any time to print your certificate, but you will not be able to add any evaluations. Medically Ready Force Ready Medical Force 70

Chat and Networking Chat function will remain open 10 minutes after the conclusion of the webinar to permit attendees to continue to network with each other. Medically Ready Force Ready Medical Force 71

Save the Date Next Connected Health Webinar Department of Defense Mobile Health Practice Guide 3 rd Edition Feb. 22, 2018; 1-2:30 p.m. (ET) Next DVBIC Traumatic Brain Injury Webinar DVBIC: A Quarter Century of Advancements in Clinical Care Mar. 8, 2018; 1-2:30 p.m. (ET) Medically Ready Force Ready Medical Force 72

DCoE Contact Info Psychological Health Resource Center 866-966-1020 (toll-free) dcoe.mil resources@dcoeoutreach.org Medically Ready Force Ready Medical Force 73