Transcript ConiferHealth_PowerPoint Template

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.
1
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Table of contents
2

Anemia
3

Neoplasm
29

Atrial Fib
4

Non pressure ulcer
30

BMI – high
5

Malnutrition
31

BMI –low
6

Pancreatitis
32

Cellulitis
7


Personal Injury
33
Cirrhosis of Liver
8

Colitis
9

Pneumonia- Aspiration
34

Coma
10

Pneumonia- Hypostatic /passive/ stasis
35

Crohn’s Disease / Regional Enteritis
11

Pneumonia-Specificity
36

Debridement
12

Pressure Ulcer
37

Dementia
13

Pulmonary embolism
38

Diabetes
14

Renal Failure—acute
39

Diverticulitis
15

Renal failure-chronic
40

Dysphasia
16

Encephalopathy
17

Respiratory- COPD
41

Functional Quadriplegia
18

Respiratory- Emphysema
42

Gastroparesis
19

Respiratory failure
43

Gastrointestinal Ulcer- Upper
20

Respiratory failure post op
44

GERD
21

Sepsis
45

Heart failure- acute
22

Shock
46

Heart failure-chronic
23

Substance abuse
47

HIV-AIDS
24


Urosepsis
48
Hypertension
25

Hyponatremia
26

UTI
49

Mental Status- Altered
27

Hospital specific

Metabolic—acidosis/ alkalosis
28

Documentation Specialists contact info
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50-57
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:
3
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Same as in ICD 9
ICD10 documentation specificity needed
ICD9 Documentation
A fib
ICD10 Documentation Needed
IDENTIFY TYPE
[ ] Paroxysmal Atrial Fibrillation
[ ] Persistent Atrial Fibrillation
[ ] Chronic Atrial Fibrillation (includes permanent
Atrial Fibrillation)
[ ] Unspecified Atrial Fibrillation
4
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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: _____)
5
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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
6
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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
7
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ICD10 documentation specificity needed
ICD9 Documentation
Cirrhosis of Liver
ICD10 Documentation Needed
Identify if alcoholic or non-alcoholic, if
congenital, biliary obstructive, laennec’s
and if portal
[ ] Alcoholic [ ] Non-alcoholic
[ ] Congenital ____ (underlying disease)
[ ] Biliary / Obstructive:
[ ] Primary [ ] Secondary
[ ] Laennec’s:
[ ] Alcoholic with: [ ] dependence
[ ] non-dependence
[ ] Non-alcoholic
[ ] Portal: [ ] Alcoholic [ ] Non-alcoholic
8
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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
9
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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_________
10
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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: ___________________
13
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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
14
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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
Dysphagia
ICD10 Documentation Needed
IDENTIFY PHASE, TYPE and ACUITY
Phase: [ ] Oral [ ] Oropharyngeal
[ ] Pharyngeal [ ] Pharyngoesophageal
Type:
[ ] Cervical [ ] Functional
[ ] Hysterical [ ] Nervous [ ] Neurogenic
[ ] Siderpenic
[ ] Spastica
Following Non-Traumatic:
[ ] SAH
[ ] Intracerebral Hemorrhage
[ ] Intracranial Hemorrhage
[ ] CVA
Acuity: [ ] Acute
[ ] Chronic
[ ] Acute on Chronic
[ ] Other specified Dysphagia:___________
[ ] Unspecified Dysphagia
16
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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
17
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ICD10 documentation specificity needed
ICD9 Documentation
ICD10 Documentation Needed
Functional Quadriplegia
Same as ICD 9
[ ] Functional quadriplegia (complete
immobility)
[ ] Immobilization syndrome (impaired
mobility)
18
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ICD10 documentation specificity needed
ICD9 Documentation
ICD10 Documentation Needed
Gastroparesis
Identify if related to diabetes and if
underlying disease
[ ] Gastroparesis related to Diabetes
[ ] Gastroparesis in underlying disease/process
(please state: ______________)
19
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ICD10 documentation specificity needed
ICD9 Documentation
ICD10 Documentation Needed
Upper Gastrointestinal
Ulcer
Identify acuity, type and any related or
contributing disease
Acuity:
[ ] Acute
[ ] Chronic
[ ] Hemorrhage -or- [ ] No Hemorrhage
[ ] Perforation -or- [ ] No Perforation
Type:
[ ] Gastric Ulcer
[ ] Esophageal Ulcer
[ ] Duodenal, Duodenum
[ ] Other location ________________
[ ] Any related or contributing disease(s) Alcohol
or drugs: _________________
20
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ICD10 documentation specificity needed
ICD9 Documentation
ICD10 Documentation Needed
GERD
IDENTIFY GERD WITH OR WITHOUT
ESOPHAGITIS
Gastro esophageal reflux disease (GERD)
with Esophagitis
Gastro esophageal reflux disease (GERD)
without Esophagitis
21
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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
22
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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
23
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Etiologies:
[ ] Hypertension
[ ] Valvular disease
[ ] Rheumatic heart disease
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
24
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ICD10 Documentation Needed
Similar to ICD 9
ICD10 documentation specificity needed
ICD9 Documentation
Hypertension
[ ] Malignant Hypertension
[ ] Accelerated Hypertension
[ ] Benign Hypertension
[ ] Unspecified Hypertension
25
©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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
26
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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
27
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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
28
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[ ] Respiratory
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
____________________________________
29
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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
30
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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)
_______________________________
31
ICD10 Documentation Needed
©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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
32
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ICD10 documentation specificity needed
ICD9 Documentation
ICD10 Documentation Needed
Injury
For this injury _________, please
document the following information:
How the injury occurred (i.e. fall, MVA,
etc.) ___________________
Location where the injury occurred (i.e.
home, work, school, etc.)
____________________________
Activity at time of injury (i.e. running,
gardening, skating, etc.)
______________________________
Status at time of injury (i.e. civilian,
military, volunteer, etc.)
______________________________
33
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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
34
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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)________________
35
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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
36
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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)
37
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ICD10 documentation specificity needed
ICD9 Documentation
ICD10 Documentation Needed
Pulmonary Embolism
Identify acuity, type and if associated
acute cor pulmonale
Acuity:
[ ] Acute
[ ] Chronic
Type:
[ ] Saddle
[ ] Septic
[ ] Other___
[ ] Pulmonary Embolism with associated
Acute Cor Pulmonale
38
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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 ________
39
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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
40
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
COPD
Identify Acuity
[ ] Acute exacerbation of COPD
[ ] Acute exacerbation of Asthma
[ ] COPD – Chronic and stable
41
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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
42
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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
43
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ICD10 documentation specificity needed
ICD9 Documentation
ICD10 Documentation Needed
Post op Respiratory Issues
Identify Acuity and surgery type
[ ] Post-op Acute pulmonary insufficiency
[ ] Thoracic surgery [ ] Non-Thoracic surgery
[ ] Post-op Acute respiratory failure
[ ] Thoracic surgery [ ] Non-Thoracic surgery
[ ] Post-op Chronic pulmonary insufficiency
[ ] Post-op Chronic respiratory failure
[ ] Hypoxia
[ ] Respiratory failure not related to surgical
procedure
[ ] Acute
44
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[ ] Chronic
[ ] Acute on Chronic
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.) _______________________
45
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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)
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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
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)
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©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 for all specialists
 Jewish Shelbyville -- 502-587-2833 CDI office
 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
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Questions—contact your Clinical Documentation
Specialists at your hospital
 Sts. Mary and Elizabeth
 Clinical Documentation Specialists
 Mickey Decker– 502-361-6125
 Cheryl Brooks-502-361-6549
 Annette Majors- 502-361-6495
 Manager- Sandy Hodge- Bowman 502-409-2673
 Supervisor- Kristen Boles 859-421-1542
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Questions—contact your Clinical Documentation
Specialists at your hospital
 University of Louisville
 Clinical Documentation Specialists
 Katie Hernandez– 502-562-2895
 Hilda Meehan—502-562-3801
 Olga Soukhanova—502-562-3152
 Cheryl Ward—502-562-3539
 Peggy Fields—502-562-3730
 Manager- Sandy Hodge- Bowman 502-409-2673
 Supervisor- Kristen Boles 859-421-1542
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Questions—contact your Clinical Documentation
Specialists at your hospital
 St Joe Main
 Clinical Documentation Specialists
 Michelle Ahady—859-313-2178
 Tina Baker—859-313-2254
 Lynnette Tuttle—859-313-1925
 Ann Spero—859-313-2254
 Teressa Cozine—859-313-2178
 Trudy Paynter—859-313-1927
 Karen Browning—859-313-1925
 Manager- Sandy Hodge- Bowman 502-409-2673
 Supervisor- Kristen Boles 859-421-1542
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Questions—contact your Clinical Documentation
Specialists at your hospital
 St. Joe East
 Clinical Documentation Specialists
 Kimberly Gilbert-Morrison—502-316-5220
 Kelly Geers—502-750-2329
 Manager- Sandy Hodge- Bowman 502-409-2673
 Supervisor- Kristen Boles 859-421-1542
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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
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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
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Questions—contact your Clinical Documentation
Specialists at your hospital
 St. Joe Mt. Sterling
 Clinical Documentation Specialists
 Lori Barry—859-497-5458
 Manager- Sandy Hodge- Bowman 502-409-2673
 Supervisor- Kristen Boles 859-421-1542
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