Transcript ConiferHealth_PowerPoint Template

OB/GYN
and Other Common Documentation Tips
ICD 10 Documentation Specificity Needed
based on Conifer ICD 10 CDI Queries
ICD 10 Documentation Specialty Introduction
ICD 10 is being mandated by CMS. Compliance date is set at October
2015.
 ICD-9 Diagnosis Codes = 14,000
 ICD-10 Diagnosis Codes = 69,000
 ICD-9 Procedure Codes = 3,800
 ICD-10 Procedure Codes = 71,000
The CDI team is here to help with inpatient provider documentation
specificity needed in I-10.
Based on Conifer ICD 10 Updated queries, the attached pages will
assist with the documentation needed in I-10.
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Table of contents
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
Anemia
4

BMI – high
5

Pancreatitis
18

BMI –low
6

Pneumonia-Specificity
19

Diabetes
7

Premature infant
20

Endometriosis
8

Pressure Ulcer
21

Headache/ Migraine
9

Renal Failure—acute
22

Hypertension
10

Renal failure-chronic
23

Hyponatremia
11

Sepsis
24

Metabolic—acidosis/ alkalosis
12

Shock
25

Mood Disorder
13

Substance abuse
26

Neoplasm
14

Testicular Torsion
27

Malnutrition
15

Urosepsis
28

Pregnancy
16

UTI
29

Ovarian Cancer
17

Hospital specific

Documentation Specialists contact info 30-37
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ICD10 documentation specificity needed
ICD9 Documentation
ICD10 Documentation Needed
Anemia
[ ] Acute blood loss anemia
[ ] Post-op anemia related to acute blood loss
[ ] Anemia:
[ ] Aplastic [ ] Nutritional
[ ] Drug induced (specify)________
[ ] Hemolytic: [ ] Hereditary [ ] Acquired
[ ] Autoimmune [ ] Non-autoimmune
[ ] Enzyme disorder
[ ] Anemia due to Neoplasm:
[ ] Primary [ ] Secondary
[ ] Due to Chemotherapy
[ ] Due to Radiotherapy
[ ] Chronic anemia – other etiology:
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Same as in ICD 9
ICD10 documentation specificity needed
ICD9 Documentation
ICD10 Documentation Needed
BMI > 40 with associated diagnosis
Morbidly Obese
of:
[ ] Morbid (Severe) Obesity
[ ] Morbid (Severe) Obesity
[ ] Due to excess calories
[ ] Overweight
[ ] Obesity (unspecified)
[ ] Familial
[ ] Endocrine
[ ] with Alveolar Hypoventilation
(Pickwickian syndrome)
[ ] Drug-induced (Name of drug: _____)
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ICD10 documentation specificity needed
ICD9 Documentation
BMI < 19 with associated
diagnosis of: (check one)
[ ] Underweight
[ ] Protein Calorie Malnutrition:
[ ] Mild [ ] Moderate
[ ] Severe
[ ] Unspecified
[ ] Cachexia
[ ] Emaciation due to
malnutrition
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ICD10 Documentation Needed
Same as ICD 9
ICD10 documentation specificity needed
ICD9 Documentation
Diabetes
ICD10 Documentation Needed
IDENTIFY TYPE, ETIOLOGY, CONTROL and
any MANIFESTATIONS
TYPE: [ ] Type I [ ] Type II [ ] Insulin Use
Etiology:
[ ] Drug / chemical induced
[ ] Due to underlying condition (specify)________
[ ] Other specified type_____
Control: [ ] Inadequate [ ] Out of control [ ] Poor
[ ] Hypoglycemia
[ ] Hyperglycemia
Manifestation:
[ ] Ketoacidosis
[ ] Neurological complications (specify) __
[ ] Kidney complication (specify) ______________
[ ] Skin complication (specify) ____________________
[ ] Other (specify)________________________
[ ] Gastropathy/ Gastroparesis [ ] Osteomyelitis
[ ] Cellulitis [ ] CKD
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ICD10 documentation specificity needed
ICD9 Documentation
Endometriosis
ICD10 Documentation Needed
IDENTIFY Implant Site
[ ] Uterus
[ ] Fallopian tube: [ ] Right
[ ] Left
[ ] Ovary:
[ ] Left
[ ] Right
[ ] Other site: ____________________ (e.g.
intestine, parametrium, peritoneal, rectrovaginal
septum, vaginal, vulva)
8
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ICD10 documentation specificity needed
ICD9 Documentation
ICD10 Documentation Needed
Migraine
IDENTIFY SPECIFICITY
Headache
[
[
[
[
] With Aura [ ] With Refractory Migraine
] Intractable
] Persistent
] Other __________________
[
[
[
[
[
[
[
] With CVA
[ ] Hemiplegic
] Intractable
] With Status Migrainosus
] Menstrual
] Cyclical vomiting
] Periodic Headache Syndrome
] Ophthalmologic
IDENTIFY SPECIFICITY
[
[
[
[
[
[
[
[
[
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] Tension
] Primary thunderclap
] Associated with sex, cough, exertion
] Cluster
] Post-traumatic
] New daily persistent
] Vascular
] Drug- induced
] Other_________________________
ICD10 documentation specificity needed
ICD9 Documentation
Hypertension
[ ] Malignant Hypertension
[ ] Accelerated Hypertension
[ ] Benign Hypertension
[ ] Unspecified Hypertension
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ICD10 Documentation Needed
Same as ICD 9
ICD10 documentation specificity needed
ICD9 Documentation
Hyponatremia
ICD10 Documentation Needed
Identify specificity
[ ] Hyponatremia, unknown cause
[ ] Hyponatremia due to Sodium Deficiency
[ ] Hyponatremia due to SIADH (Syndrome of
Inappropriate Secretion of Antidiuretic
Hormone)
[ ] Insignificant lab value
11
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ICD10 documentation specificity needed
ICD9 Documentation
Acidosis/Alkalosis
ICD10 Documentation Needed
Identify Type of Acidosis or Alkalosis
[ ] Acidosis:
[ ] Metabolic
[ ] Respiratory
[ ] Lactic
[ ] Renal
[ ] Alkalosis:
[ ] Metabolic
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[ ] Respiratory
ICD10 documentation specificity needed
ICD9 Documentation
Mood Disorder
ICD10 Documentation Needed
IDENTIFY Type, Status and Severity
Type (check appropriate):
[ ] Manic
[ ] Bipolar
[ ] Manic
[ ] Depressive
[ ] Major Depressive Disorder
[ ] With Psychosis
[ ] Persistent Mood Disorder
[ ] Without Psychosis
Status:
[ ] Single past episode
[ ] Current episode
[ ] In remission [ ] Partial [ ] Full
[ ] With Psychosis
[ ] Without Psychosis
Severity:
[ ] Mild
[ ] Moderate
[ ] Severe
[ ] Unspecified
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[ ] Mixed
ICD10 documentation specificity needed
ICD9 Documentation
Neoplasm
ICD10 Documentation Needed
Identify Site, Laterality, Type,
Malignancy and associated
conditions
Site:
Identify:_______________
Laterality:
[ ] Right
[ ] Left
Type:
[ ] Primary
[ ] Secondary
[ ] Bilateral
[ ] In situ
[ ] Overlapping primary
[ ] Secondary sites
[ ] Malignant [ ] Benign
[ ] Unspecified Behavior
[ ] Other__________
Malignancy:
[ ] Excised [ ] Eradicated
[ ] Treatment still provided for primary and/or
metastatic site
[ ] Evidence of remaining malignancy at primary site
[ ] Conditions associated with neoplasm: (Specify)
____________________________
[ ] Any associated diagnoses / condition
____________________________________
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ICD10 documentation specificity needed
ICD9 Documentation
Malnutrition
Same as ICD 9
[ ] Under-nutrition / Malnutrition:
[ ] Mild
[ ] Moderate
[ ] Severe
[ ] Unspecified
[ ] Protein Calorie Malnutrition:
[ ] Mild
[ ] Moderate [ ] Severe
[ ] Unspecified
[ ] Marasmus
[ ] Nutritional Edema
[ ] Other Malnutrition (please specify)
_______________________________
15
ICD10 Documentation Needed
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ICD10 documentation specificity needed
ICD9 Documentation
Pregnancy
ICD10 Documentation Needed
Identify trimester, if preterm,
gestational diabetes and any other
associated diagnosis/conditions
Specify trimester
[ ] First (less than 14 weeks, 0 days)
[ ] Second (14 weeks, 0 days to less than
28 weeks, 0 days)
[ ] Third (28 weeks until delivery)
[ ] Preterm labor/Preterm Delivery
[ ] Gestational Diabetes
[ ] Diet controlled
[ ] Insulin controlled
[ ] Associated diagnosis/conditions
(please specify): ________
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ICD10 documentation specificity needed
ICD9 Documentation
Ovarian Cancer
ICD10 Documentation Needed
Identify laterality
[ ] Ovarian Cancer
[ ] Right
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[ ] Left [ ] Bilateral
ICD10 documentation specificity needed
ICD9 Documentation
Pancreatitis
ICD10 Documentation Needed
Identify acuity, cause, gangrenous and
alcohol induced
[ ] Acute:
[ ] Gallstone [ ] Biliary
[ ] Idiopathic
[ ] Other
[ ] Chronic:
[ ] Cystic
[ ] Infectious [ ] Interstitial
[ ] Recurrent
[ ] Gangrenous
[ ] Alcohol-induced: [ ] Abuse [ ] Dependence
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ICD10 documentation specificity needed
ICD9 Documentation
Pneumonia- identify specificity
[ ] Gram Negative Pneumonia [ ] Gram Positive Pneumonia
[ ] MRSA Pneumonia
[ ] MSSA Pneumonia
[ ] Pneumonia due to ________ (specify organism / underlying
disease)(e.g. E. Coli, Klebsiella, Pneumococcus,
Pseudomonas, Other Staph)
[ ] Community acquired (simple) Pneumonia
[ ] Healthcare / Hospital Acquired Pneumonia (outside facility /
prior hospitalization)
[ ] Aspiration pneumonia
[ ] Ventilator – associated pneumonia
[ ] Radiation induced pneumonia
[ ] Associated illness: [ ] Respiratory failure [ ] Sepsis
[ ] Underlying lung disease [ ] Other _______________
[ ] Pneumonia of unknown etiology
[ ] Infiltrates without evidence of Pneumonia
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ICD10 Documentation Needed
Similar to ICD 9
ICD10 documentation specificity needed
ICD9 Documentation
ICD10 Documentation Needed
Premature Infant
Prematurity
[ ] Prematurity (birth weight of 1,000 – 2,499 grams)
[ ] Extreme Immaturity (birth weight < 1,000 grams)
[ ] Slow fetal growth
[ ] Malnutrition
[ ] Unable to determine
[ ] Other __________________________________
Weeks of Gestation:
[ ] Unspecified weeks of gestation
gestation
[ ] Less than 24 completed weeks of
[ ] 24 completed weeks of gestation [ ] 25 to 26 completed weeks of
gestation
[ ] 27 to 28 completed weeks of gestation
[ ] 29 to 30 completed weeks of gestation
[ ] 31 to 32 completed weeks of gestation
[ ] 33 to 34 completed weeks of gestation
[ ] 35 to 36 completed weeks of gestation
[ ] 37 or more completed weeks of gestation
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ICD10 documentation specificity needed
ICD9 Documentation
ICD10 Documentation Needed
Pressure Ulcer
Identify Location, stage, laterality, POA
and gangrene present
Decubitus Ulcer:
Location: __________
POA: [ ] Yes [ ] No
[ ] Unable to determine
Stage (I to IV): _______
Laterality:
Left_____ Right_____
Bilateral_____ N/A_____
[ ] Gangrene present
[ ] Yes [ ] No
(Stage I: Erythema; Stage II: Partial thickness;
Stage III: Full thickness; Stage IV: Necrosis to
muscle/bone)
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ICD10 documentation specificity needed
ICD9 Documentation
ICD10 Documentation Needed
Acute Renal Failure (ARF) / Acute Kidney
Injury (AKI)
[ ] Prerenal Azotemia (dehydration, shock, CHF, renal
obstruction, creatinine responds to IV fluid)
[ ] Acute Tubular Necrosis (ATN) (nephrotoxicity, extended
decreased renal perfusion, increasing creatinine (0.5 / day) not
responding to fluids, low urine output)
[ ] Acute Interstitial Nephritis (AIN) (nephritis in which the
interstitial connective tissue is chiefly affected)
[ ] Acute cortical necrosis
[ ] Acute medullary necrosis
[ ] Acute kidney injury
[ ] traumatic injury [ ] Nontraumatic injury
[ ] Other Etiology or underlying conditions related to the
diagnosis of ARF/ AKI:________________
[ ] Acute on Chronic Renal Failure please specify Type of ARF
(above) and Stage of CKD ________
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Same as ICD 9
ICD10 documentation specificity needed
ICD9 Documentation
ICD10 Documentation Needed
Chronic Renal Failure
[
] Chronic Renal Failure (CRF) / Chronic Kidney Disease (CKD)
Stage: _______ (I to V or ESRD—see below)
Dialysis dependent [ ] Yes [ ] No
CKD- National Kidney Foundation Guidelines for CKD
Staging
Stage I
Kidney damage with normal or increased GFR
GFR > 90
Stage II
60-89
Kidney damage with mildly decreased GFR GFR
Stage III
Kidney damage with moderately decreased GFR
GFR 30-59
Stage IV Kidney damage with severely decreased GFR
GFR 16-29
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Stage V
Kidney failure GFR<15
ESRD
End Stage Renal Disease
On dialysis
©2015 Conifer Health Solutions, LLC. All Rights Reserved.
Same as ICD 9
ICD10 documentation specificity needed
ICD9 Documentation
ICD10 Documentation Needed
Sepsis
Identify causative agent, due to, name
organ dysfunction- if applicable
[ ] Sepsis (include causative agent if known) _________
Due to:
[ ] Device [ ] Implant [ ] Graft [ ] Infusion
[ ] Abortion
[ ] SIRS due to non-infectious process
[ ] with organ dysfunction
dysfunction
[ ] without organ
[ ] Severe sepsis with acute organ dysfunction of:
__________________________________________
(Examples: respiratory failure, encephalopathy, acute
kidney failure, other)
[ ] SIRS due to infection or infectious process
[ ] with organ dysfunction
dysfunction
[ ] without organ
[ ] Septic shock
[ ] Sepsis related to a device (i.e. port, IV line, pacer /
ICD leads, Foley, etc.) _______________________
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ICD10 documentation specificity needed
ICD9 Documentation
ICD10 Documentation Needed
SHOCK
Same as ICD 9
[ ] Hypovolemic shock
[ ] Hemorrhagic shock
[ ] Cardiogenic shock
[ ] Septic shock (Circulatory failure
associated with severe sepsis,
represents organ failure)
25
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ICD10 documentation specificity needed
ICD9 Documentation
ICD10 Documentation Needed
Substance Abuse
Identify substance, status, complication
and any induced disorders
Substance(s):
[ ] Alcohol
[ ] Opioid
[ ] Cannabis
[ ] Sedative, Hypnotic, Anxiolytic
[ ] Cocaine
[ ] Other stimulant
[ ] Hallucinogenic
[ ] Inhalant-related
[ ] Other psychoactive drug: __________
[ ] Unspecified drug
Status:
[ ] Use
[ ] Abuse
[ ] Dependence
[ ] Withdrawal
[ ] In remission
[ ] Uncomplicated
Complications:
[ ] Intoxication
[ ] Other complication: ____________ [ ] Unspecified complication
Substance-Induced Disorders:
[ ] Psychosis:[ ] Delirium
[ ] Delusions
[ ] Perceptual Disturbances:
Sexual Dysfunction
[ ] Anxiety Disorder
[ ] Sleep Disorder
[ ] Unspecified substance-induced disorder
[ ] Other substance-induced disorder:
________________________________
[ ] No substance-induced disorder
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[ ] Hallucinations
[ ]
ICD10 documentation specificity needed
ICD9 Documentation
ICD10 Documentation Needed
Testicular Torsion
Identify Extra or Intra vaginal and site
[ ] Extravaginal:
[ ] Epididymis
[ ] Spermatic Cord
[ ] Testicle/Testis
[ ] Intravaginal:
[ ] Epididymis
[ ] Spermatic Cord
[ ] Testicle/Testis
27
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ICD10 documentation specificity needed
ICD9 Documentation
UROSEPSIS- codes to UTI, please state if
[ ] Sepsis from a urinary source
Related to:
[ ] Urinary obstruction
[ ] Indwelling catheter
[ ] Self-catheterization
[ ] Suprapubic catheter
[ ] Localized urinary tract infection (without
sepsis)
28
©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 Documentation Needed
Same as ICD 9
ICD10 documentation specificity needed
ICD9 Documentation
ICD10 Documentation Needed
UTI
Identify acuity, site and due to
Acuity:
[ ] Acute
[ ] Chronic
[ ] Acute on Chronic
Site:
[ ] Kidney [ ] Ureter
[ ] Bladder [ ] Urethra
] Other site __________
[ ] Unable to determine
[ ] UTI due to or related to:
[ ] Indwelling catheter
[ ] Self-catheterization
[ ] Neurogenic bladder
[ ] Suprapubic catheter
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[
Questions—contact your Clinical Documentation
Specialists at your hospital
 Jewish Hospital---502-587-2833 CDI office
 Jewish Shelbyville - Clinical Documentation Specialists
 Candy Rickard
 Peggy Barlar
 Charlotte Hopewell
 Susan Hinkle
 Dale Crosby
 Becki Fudge
 Sara Goff
 Manager- Sandy Hodge- Bowman 502-409-2673
 Supervisor- Kristen Boles 859-421-1542
30
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Questions—contact your Clinical Documentation
Specialists at your hospital
 Sts. Mary and Elizabeth
 Clinical Documentation Specialists
 Mickey Decker
 Cheryl Brooks
 Annette Majors
 Manager- Sandy Hodge- Bowman 502-409-2673
 Supervisor- Kristen Boles 859-421-1542
31
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Questions—contact your Clinical Documentation
Specialists at your hospital
 University of Louisville
 Clinical Documentation Specialists
 Katie Hernandez
 Hilda Meehan
 Olga Soukhanova
 Cheryl Ward
 Peggy Fields
 Manager- Sandy Hodge- Bowman 502-409-2673
 Supervisor- Kristen Boles 859-421-1542
32
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Questions—contact your Clinical Documentation
Specialists at your hospital
 St Joe Main
 Clinical Documentation Specialists







Michelle Ahady
Tina Baker
Lynnette Tuttle
Ann Spero
Teressa Cozine
Trudy Paynter
Karen Mitchell
 Manager- Sandy Hodge- Bowman 502-409-2673
 Supervisor- Kristen Boles 859-421-1542
 Manager- Sandy Hodge- Bowman 502-409-2673
 Supervisor- Kristen Boles 859-421-1542
33
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Questions—contact your Clinical Documentation
Specialists at your hospital
 St. Joe East
 Clinical Documentation Specialists
 Kimberly Gilbert-Morrison
 Kelly Geers
 Manager- Sandy Hodge- Bowman 502-409-2673
 Supervisor- Kristen Boles 859-421-1542
34
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Questions—contact your Clinical Documentation
Specialists at your hospital
 Flaget
 Clinical Documentation Specialist
 Cheryl Mitchell—502-350-5247
 Manager- Sandy Hodge- Bowman 502-409-2673
 Supervisor- Kristen Boles 859-421-1542
35
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Questions—contact your Clinical Documentation
Specialists at your hospital
 St Joe London
 Clinical Documentation Specialists
 Katrina Henson—606-330-6759
 Sherry Mills—606-330-6000
 Manager- Sandy Hodge- Bowman 502-409-2673
 Supervisor- Kristen Boles 859-421-1542
36
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Questions—contact your Clinical Documentation
Specialists at your hospital
 St. Joe Mt. Sterling
 Clinical Documentation Specialists
 Lori Barry
 Manager- Sandy Hodge- Bowman 502-409-2673
 Supervisor- Kristen Boles 859-421-1542
37
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