Transcript Infectious Disease ICD 10 Speciality 7-17-15x

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
3

Anemia
4

Osteomyelitis
28

Aplastic Anemia
5

Pancreatitis
29

BMI – high
6

Pneumonia- Aspiration
30

BMI –low
7

Pneumonia- Hypostatic /passive/ stasis
31

Cellulitis
8


Pneumonia-Specificity
32
Colitis
9

Coma
10

Pressure Ulcer
33

Crohn’s Disease / Regional Enteritis
11

Prostatitis
34

Debridement
12

Purpera
35

Dementia
13

Renal Failure—acute
36

Diabetes
14

Renal failure-chronic
37

Diverticulitis
15

Respiratory- Bronchitis
38

Encephalopathy
16

Respiratory- COPD
39

Heart failure- acute
17

Respiratory- Emphysema
40

Heart failure-chronic
18

Respiratory failure
41

Hepatitis
19

Sepsis
42

HIV-AIDS
20

Shock
43

Influenza
21

Substance abuse
44

Meningitis
22

Urosepsis
45

Mental Status- Altered
23

UTI
46

Metabolic—acidosis/ alkalosis
24

Hospital specific

Neutropenia
25

Documentation Specialists contact info

Non pressure ulcer
26

Malnutrition
27
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47-54
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:
4
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Same as in ICD 9
ICD10 documentation specificity needed
ICD9 Documentation
Aplastic Anemia
ICD10 Documentation Needed
Identify Specificity
[ ] Acquired pure red cell aplasia:
[ ] Chronic [ ] on Treatment
[ ] Transient [ ] Other
[ ] Constitutional: [ ] Congenital
[ ] Idiopathic [ ] Acquired
[ ] Drug Induced (please specify drug): ________
[ ] Due to other external causes (please specify cause,
i.e. radiation, etc): _______________________
[ ] Idiopathic
[ ] Unspecified
[ ] Sideroblastic Anemia: [ ] Hereditary
[ ] Due to disease
[ ] Due to drugs/toxins
[ ] Congenital
[ ] Anemia in Neoplastic Disease
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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
7
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ICD10 Documentation Needed
Same as ICD 9
ICD10 documentation specificity needed
ICD9 Documentation
Cellulitis
ICD10 Documentation Needed
Identify location, laterality and if related to
Location: _________________
Laterality:
[ ] Left
[ ] Right [ ] Bilateral [ ] Upper
[ ] Lower [ ] Cheek-internal [ ] Cheek-external
[ ] N/A_____
[ ] Bacterial - Causative Agent (if known): ____
[ ] Viral
[ ] R/T Lymphangitis (chronic / subacute)
[ ] R/T Venous Stasis ulcer with PVD
[ ] Manifestation of Diabetes
[ ] Does not apply to this patient – no cellulitis
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ICD10 documentation specificity needed
ICD9 Documentation
Colitis
ICD10 Documentation Needed
Identify Site, Type and Complications
Site (if applicable):
[ ] Small Intestine [ ] Large Intestine
[ ] Other site __
Type:
[ ] Colitis due to radiation
[ ] Ulcerative Colitis
[ ] Infectious Colitis
[ ] Toxic Colitis
[ ] Ischemic Colitis
[ ] Colitis due to ___________________
[ ] Chronic Colitis
Complications:
[ ] Rectal Bleeding
[ ] Intestinal Obstruction
[ ] Fistula
[ ] Abscess
[ ] Other complication _________________
[ ] Unspecified complication
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ICD10 documentation specificity needed
ICD9 Documentation
Coma
ICD10 Documentation Needed
Identify specificity
[ ] Coma / Comatose
[ ] Persistent vegetative state
[ ] Stupor
[ ] Drowsiness
[ ] Somnolence
[ ] Catatonic stupor
[ ] Semicoma
[ ] Associated injury (skull fracture, intracranial injury)
_________________________________
[ ] Glasgow coma score_____________
Eye opening describe ________
Verbal response describe _________
Motor functioning describe_________
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ICD10 documentation specificity needed
ICD9 Documentation
Crohn’s Disease / Regional
Enteritis
ICD10 Documentation Needed
Identify specificity, site and associated
diagnosis
[ ] Abscess
[ ] Fistula
[ ] Intestinal obstruction
[ ] Rectal bleeding
[ ] Other (specify) _______________
Site:
[ ] Small Intestine
[ ] Large Intestine
[ ] both small and large intestines
Associated diagnoses / conditions (specify)________
11
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ICD10 documentation specificity needed
ICD9 Documentation
Debridement
[ ] Excisional Debridement:
[ ] Excised
[ ] Removed [ ] Cut away
[ ] Other: ________
Depth / layer: (deepest layer of debridement):
[ ] Skin/SubQ [ ] Fascia [ ] Muscle
[ ] Bone
Margins: (please specify): ___ / __ x __ x ___
Instruments used: [ ] Scissors [ ] Scalpel
[ ] Curette [ ] Tweezers/forceps
[ ] Soft tissue clipper [ ] Other: _____
[ ] Non-excisional Debridement - Removal by
flushing, brushing, or washing
[ ] Incision and Drainage only (No Debridement):
Depth: [ ] Skin & Sub Q only [ ] Into soft tissue
[ ] Escharectomy
12
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ICD10 Documentation Needed
Same as ICD 9
ICD10 documentation specificity needed
ICD9 Documentation
Dementia
ICD10 Documentation Needed
Identify type and accompanying behaviors
Type of Dementia (check all appropriate):
[ ] Vascular (due to cerebrovascular infarct or HTN)
[ ] Frontotemporal [ ] Pick’s Disease
[ ] In Substance Use/Abuse/Dependence
Specify substance: ____________________
[ ] With Lewy Bodies (in Parkinson’s Disease)
[ ] In other specified diseases (such as Alzheimer’s,, Parkinson’s, or other
degenerative nervous system disease)
[ ] Unspecified (such as Senile or Pre-senile)
[ ] Unable to determine type of Dementia
Accompanying Behaviors (check all appropriate):
[ ] Behavioral disturbances (aggressive, combative, violent)
[ ] Psychosis [ ] Delirium [ ] Delusions [ ] Hallucinations
[ ] Depression
[ ] Wandering
[ ] Other behaviors: ___________________
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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
ICD10 Documentation Needed
Diverticulitis
IDENTIFY Acuity, Severity, Site and
Type
Acuity:
[ ] Acute [ ] Chronic [ ] Acute on Chronic
Severity:
[ ] Bleeding
[ ] No bleeding
[ ] Abscess
[ ] No abscess
[ ] Perforation [ ] No perforation
Site:
[ ] Ileum
[ ] Small Intestine
[ ] Large Intestine
[ ] Unspecified Intestine
Type:
[ ] Meckel’s diverticulum with diverticulitis
[ ] Meckel’s diverticulum without diverticulitis
15
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ICD10 documentation specificity needed
ICD9 Documentation
ICD10 Documentation Needed
Encephalopathy
IDENTIFY Acuity, Etiology and Severity
Acuity: [ ] Acute [ ] Subacute [ ] Chronic
Etiology:
[ ] Hypertensive
[ ] Metabolic
[ ] Toxic
[ ] Toxic Metabolic
[ ] Hepatic
[ ] Hypoxic
[ ] Septic
[ ] Alcohol
[ ] Drugs (specify)_______________
[ ] Post procedural (specify)______________
Severity: [ ] with coma [ ] without coma
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ICD10 documentation specificity needed
ICD9 Documentation
ACUTE HEART FAILURE
[ ] Acute Systolic Heart Failure
[ ] Acute Diastolic Heart Failure
ICD10 Documentation Needed
SAME as ICD 9 with the addition
OTHER ETIOLOGIES OF HEART FAILURE
[ ] Heart Failure Due To Valvular Disease
[ ] Acute Systolic and Diastolic Heart Failure
[ ] Right Heart Failure / Acute Cor Pulmonale
[ ] Right Heart Failure / Chronic Cor Pulmonale
[ ] Rheumatic Heart Disease
ACUTE ON CHRONIC HEART
FAILURE
[ ] Endocarditis (valvular)
[ ] Acute On Chronic Systolic Heart Failure
[ ] Myocarditis
[ ] Pericarditis
[ ] Acute On Chronic Diastolic Heart Failure
[ ] Acute On Chronic Systolic and Diastolic
Heart Failure
17
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ICD10 documentation specificity needed
ICD9 Documentation
ICD10 Documentation Needed
CHRONIC HEART FAILURE
SAME as ICD 9 with the addition of
etiology
[ ] Chronic Systolic Heart Failure
[ ] Chronic Diastolic Heart Failure
[ ] Chronic Systolic and Diastolic
Heart Failure
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Etiologies:
[ ] Hypertension
[ ] Valvular disease
[ ] Rheumatic heart disease
ICD10 documentation specificity needed
ICD9 Documentation
Hepatitis
ICD10 Documentation Needed
IDENTIFY Acuity, Etiology and
associated diagnosis
Acuity: [ ] Acute
[ ] Chronic
Etiology:
[ ] Alcoholic
[ ] Drug induced (specify)____
[ ] Viral (type A,B,C,E)_______
Associated Diagnosis:
[ ] with hepatic coma
[ ] without hepatic coma
[ ] with delta agent
[ ] without delta agent
19
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ICD10 documentation specificity needed
ICD9 Documentation
HIV-AIDS
[ ] HIV infection/disease symptomatic
related condition
[ ] AIDS
[ ] Non-HIV related condition
[ ] Asymptomatic HIV infection status
[ ] Non-specific serologic evidence of HIV
20
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ICD10 Documentation Needed
Similar to ICD 9
ICD10 documentation specificity needed
ICD9 Documentation
Influenza
ICD10 Documentation Needed
IDENTIFY Organism and associated
factors
[ ] Influenza caused by ______ (specify
organism)
[ ] Influenza-associated Encephalopathy
[ ] Influenza-associated Pneumonia
21
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ICD10 documentation specificity needed
ICD9 Documentation
Meningitis
ICD10 Documentation Needed
Identify Type, Organism and Present on
Admission
[ ] Viral Meningitis
[ ] Specify organism (i.e. adenovirus,
enterovirus, measles, etc.) ___________
[ ] Bacterial Meningitis - Acute
[ ] Specify organism (i.e. gram negative,
staph, strep, e coli, etc.)___________
[ ] Due to (please specify cause) _________
[ ] Aseptic - Acute
[ ] Late effect
[ ] Septic
[ ] Present on Admission [ ] Yes
[ ] Unable to determine
22
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[ ] No
ICD10 documentation specificity needed
ICD9 Documentation
ICD10 Documentation Needed
Altered Mental Status
IDENTIFY SPECIFICITY
Altered Mental Status:
[ ] Delirium
[ ] Mild Cognitive Impairment
[ ] Drug-Induced Delirium
[ ] Mental Disorder (Specify): __________
[ ] Other (Specify): ________
Altered Level of Consciousness:
[ ] Coma [ ] Somnolence
[ ] Persistent Vegetative State
[ ] Stupor (Catatonic)
[ ] Transient Alteration of Awareness
Encephalopathy:
[ ] Alcoholic [ ] Due to Drugs [ ] Hepatic
[ ] Hypertensive
[ ] Anoxic / hypoxic
[ ] Other (Specify): ___________
[ ] Metabolic / Septic
[ ] Traumatic
[ ] Hypoglycemic
23
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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
24
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[ ] Respiratory
ICD10 documentation specificity needed
ICD9 Documentation
Neutropenia
ICD10 Documentation Needed
Identify Cause
[ ] Congenital
[ ] Secondary to chemotherapy (list
chemotherapeutic drug: __________)
[ ] Drug induced (list drug: ________________)
[ ] Due to infection (infection site: _______
Organism: _________________________)
[ ] Cyclic
[ ] Does not apply to this patient
[ ] Unspecified
25
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ICD10 documentation specificity needed
ICD9 Documentation
Non Pressure Ulcer
ICD10 Documentation Needed
Identify Location, laterality, depth, type and
gangrenous
Location
[ ] Back [ ] Buttock
[ ] Lower limb
[ ] Ankle [ ] Calf
[ ] Heel/ midfoot
[ ] Thigh [ ] Other__________
Laterality
[ ] Left
[ ] Right
[ ] Bilateral [ ] Upper
[ ] Lower [ ] N/A
Depth
[ ] Skin only [ ] Fat exposed
[ ] Muscle Necrosis
[ ] Bone Necrosis
Type
[ ] Diabetic
[ ] Vascular r/t PVD
[ ] Varicose
[ ] Atherosclerosis of lower limb
[ ] Postphlebitic syndrome
[ ] Postthrombotic syndrome
[ ]Chronic venous hypertension [ ] Other (specify) ______
Gangrene [ ] Yes
26
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[ ] No
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)
_______________________________
27
ICD10 Documentation Needed
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ICD10 documentation specificity needed
ICD9 Documentation
Osteomyelitis
ICD10 Documentation Needed
Identify site, acuity and if related to diabetes
Osteomyelitis site: ____________
[ ] Acute osteomyelitis directly related to diabetes
mellitus
[ ] Acute osteomyelitis unrelated to diabetes mellitus
[ ] Chronic osteomyelitis directly related to diabetes
mellitus
[ ] Chronic osteomyelitis unrelated to diabetes
mellitus
28
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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
29
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ICD10 documentation specificity needed
ICD9 Documentation
ICD10 Documentation Needed
Aspiration Pneumonia
IDENTIFY SPECIFICITY and any
associated illnesses
[ ] Aspiration Bronchitis
[ ] Pneumonia secondary to______ (specify organism
/ underlying disease)
[ ] Community Acquired (simple) Pneumonia
[ ] Healthcare / Hospital Acquired Pneumonia
(outside facility / prior hospitalization)
[ ] Ventilator associated
[ ] Radiation induced
[ ] Associated illness:
[ ] Respiratory failure
[ ] Sepsis
[ ] Underlying lung disease
[ ] Other specify)_____
[ ] Pneumonia of unknown etiology
[ ] Infiltrates without evidence of Pneumonia
30
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ICD10 documentation specificity needed
ICD9 Documentation
Hypostatic Passive/ Stasis Pneumonia
[ ] Hypostatic Passive/ Stasis Pneumonia
[ ] Pneumonia due to (specify organism/
underlying disease)_____________
[ ] Ventilator-associated
[ ] Radiation induced
[ ] Associated illness:
[ ] Respiratory Failure
[ ] Underlying lung disease
[ ] Other (specify)________________
31
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ICD10 Documentation Needed
Same as ICD 9
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
32
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ICD10 Documentation Needed
Similar to ICD 9
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)
33
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ICD10 documentation specificity needed
ICD9 Documentation
ICD10 Documentation Needed
Prostatitis
Identify acuity, bacterial vs viral and
organism if know
[ ] Acute Prostatitis:
[ ] Bacterial (organism __________ if known)
[ ] Viral (organism ______________if known)
[ ] Chronic Prostatitis:
[ ] Bacterial (organism ________ if known)
[ ] Viral (organism ____________if known)
34
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ICD10 documentation specificity needed
ICD9 Documentation
ICD10 Documentation Needed
Purpura
[ ] Allergic Purpura:
[ ] Hemorrhagic [ ] Idiopathic
[ ] Type (specify)__________________
[ ] Site__________________
[ ] Related process_________________
[ ] Causal organism__________________
[ ] Immune thrombocytopenic purpura
[ ] Post-transfusion purpura
[ ] Secondary thrombocytopenia
[ ] Hereditary
35
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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 ________
36
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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
37
Stage V
Kidney failure GFR<15
ESRD
End Stage Renal Disease
On dialysis
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Same as ICD 9
ICD10 documentation specificity needed
ICD9 Documentation
ICD10 Documentation Needed
Bronchitis
Identify acuity and due to
[ ] Acute exacerbation of Bronchitis
[ ] Acute on Chronic Bronchitis
[ ] Chronic Bronchitis obstructive
[ ] Bronchitis due to:
[ ] Fumes
[ ] Radiation
[ ] Viral or Bacterial Organism____________
38
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ICD10 documentation specificity needed
ICD9 Documentation
ICD10 Documentation Needed
COPD
Identify Acuity
[ ] Acute exacerbation of COPD
[ ] Acute exacerbation of Asthma
[ ] COPD – Chronic and stable
39
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ICD10 documentation specificity needed
ICD9 Documentation
Emphysema
ICD10 Documentation Needed
Identify Acuity and Type
Acuity:
[ ] Acute exacerbation of Emphysema
[ ] Chronic and stable Emphysema
Type:
[ ] Unilateral:
[ ] Sawyer-James Syndrome
[ ] Unilateral Hyper-Lucent Lung
[ ] Unilateral Pulmonary Artery Functional
Hypoplasia
[ ] Pan lobular
[ ] Centrilobar
40
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ICD10 documentation specificity needed
ICD9 Documentation
ICD10 Documentation Needed
Respiratory Failure
IDENTIFY TYPE, ACUITY and
ETIOLOGY
Acute Respiratory Failure:
[ ] with Hypoxia
[ ] with Hypercapnia
Acute On Chronic Respiratory Failure:
[ ] with Hypoxia
[ ] with Hypercapnia
Acute Respiratory Failure caused by: _____
(etiology)
[ ] Acute Respiratory Insufficiency
following [ ] trauma [ ] other
41
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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.) _______________________
42
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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)
43
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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
44
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[ ] Hallucinations
[ ]
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)
45
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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
46
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[
Questions—contact your Clinical Documentation
Specialists at your hospital
 Jewish Hospital---502-587-2833 CDI office
 Jewish Shelbyville –502-587-2833
 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
47
©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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
48
©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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
49
©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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
50
©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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
51
©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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
52
©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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
53
©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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
54
©2015 Conifer Health Solutions, LLC. All Rights Reserved.