Post on 25-Dec-2015
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Advocate CondellSurgery Trauma Neurosurgery Orthopedics v 2
Thomas C Kravis MD
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Clinical Documentation Improvement Goals and Objectives
Clear concise accurate documentation
Across the continuum of care: inpatient and outpatient
Capture the severity of illness (SOI) and the Risk of Mortality (ROM)
Support hospital and physician reimbursement
Improve quality report cards and clinical outcomes
Reduce denials and queries
Prepare for ICD-10
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Value of Accurate and Complete Documentation MD and Hospital Quality Reports
Care Coordination
Team Medical Necessity
Value Base
Purchasing
PSIs
Core Measures
ComplianceFraud Abuse
RAC
2 MIDNIGHTRULE
E&M Pro feesDenial related
claims
ICD-9-CMICD-10
POAHACs
Preventable ReadmissionComplications
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Impact of DocumentationMS-DRG 330 2.4981
Bowel Procedurewith CC
PDx: Colon cancer
SDx:
Dehydration
Post-op ileus(codes to 997.4 + 560.1)
“Ulcer/Wound” noted by RN
PPx: Left hemicolectomy
MS-DRG 329 5.1396
Bowel Procedurewith MCC
PDx: Colon cancer
SDx:
Acute Renal Failure – ATN
Expected ileus(560.1)
Pressure Ulcer, site unspecific
PPx: Left hemicolectomy
APR DRG: 221SOI Level: 2APR Weight: 1.7681ROM Level: 1Peer Group 0.0%
APR DRG: 221SOI Level: 3APR Weight: 2.9531ROM Level: 3Peer Group 2.5%
Highest MS-DRG paymentHighest MS-
DRG payment
MS-DRG 329 5.1396
Bowel Procedurewith MCC
PDx: Colon cancer
SDx:
Acute Renal Failure – ATN
Expected ileus(560.1)
Pressure Ulcer Stage IV on Sacrum
PPx: Left hemicolectomy
APR DRG: 221SOI Level: 4APR Weight: 6.3732ROM Level: 4Peer Group 24.2%
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© 3M 2011. All Rights Reserved.Copy Right 3M 2013 All Rights Reserved
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California Statewide Health Planning and Development
Copy Right 3M 2015 All Rights Reserved
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General guidelines for Documentation Document all diagnoses and procedures Licensed hands-on treating practitioner in the body of the EMR
and discharge summary All medications, treatments and diagnostic studies and the
corresponding medical diagnoses for each and the clinical significance
Conditions cannot be coded from lab, x-ray, other diagnostic test results or symbols (↑, ↓) without practitioner documentation.
‘Cut and pasted’ documentation must accurately reflect the clinical condition of the patient at the time of the documentation
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When should I document a condition?
To assign an appropriate code and capture the severity of illness and risk of mortality in the inpatient setting a condition must meet at least one of the following criteria:
Clinical evaluation Therapeutic treatment Diagnostic procedures Extended length of hospital stay Increased nursing care and/or monitoring
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Documentation & Coding Issues at Advocate
Physician Document in
CLINICAL terms
Documentation for coding, profiling &
compliance requires specificity in
DIAGNOSIS terms
This gap will be increased with ICD-10This gap will be increased with ICD-10
Two separate languages
Documentation Improvement can help bridge the gap
Documentation Improvement can help bridge the gap
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Liver failure, renal failure, resp failure
Respiratory failure : acute, acute on chronic
Hypotension, shock-cardiogenic/septic
Dehydration, hypovolemia
Simple UTI
Hypokalemia
Pneumonia Left Lower Lobe
Acute/Chronic Blood Loss Anemia
Coma, Encephalopathy
Protein Calorie Malnutrition
Able to CodeUnable to Code
Multi-system organ failure
Severe respiratory distress
Hemodynamically unstable
Will rehydrate
“Urosepsis”
↓ K = 2.0, will give KCL
Chest X infiltrate
↓ HgB 5.2, Transfuse
Altered Mental Status
Emaciated,Total Protein/Albumin Low
Clinical Diagnostic
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Unknown Dx and if evaluated treated : “Probable”
“Possible”
“Suspected”
Coded as if condition exists until condition has been excluded
The Key Elements : Chief Complaint History Examination Medical Decision Making
Chief Complaint: Symptom, problem, condition,
diagnosis
Physician Inpatient E&M DRG Assurance
Two Midnight RuleSigns Symptoms Expectation of 2 Midnight
Risk of Adverse Event Exception INPATIENT ONLY
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ICD-10 Consists of 2 Components
12ICD-10-PCS Procedure Classification
System for Inpatient Hospital Use
ICD-10-CM Diagnosis Classification System
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ICD-9 vs. ICD-10 Structural Changes
ICD-9 (Diagnoses)
3-7 charactersaa ## a/#a/# a/#a/# a/#a/#
Category etiology, site,manifestation
extension
a/#a/# a/#a/#
ICD-10 (Diagnoses)
## ## ## ## ##
CategoryCategory etiology, site,manifestationetiology, site,manifestation
3-5 characters3-5 characters
Encounter
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ICD-10-CM requirements
Laterality Neoplasm e.g malignant neoplasm of upper lobe of right lungInjuries e.g laceration of left subclavian veinBody Part - e.g. DVT of left iliac vein
Acuity:AcuteChronicAcute on Chronic
Etiology or Cause Encounter ( treatment status) Specificity:
Initial- patient receiving active treatment for a condition e.g. injuries,Subsequent- patient has received active treatment and is receiving routine care
during the recovery period Sequela-recovered
Note: “visit” in CPT = patient type (new or established).
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ICD-10 Diagnosis Code example Fracture Femur
SS 77 22 00 44 22 KK
Fracture of the femur
Fracture of the femur
Head &Neck
Head &Neck
Base ofNeck
Base ofNeck
Displacedfracture leftDisplaced
fracture leftSubsequent encounter for
closed fx with nonunionSubsequent encounter for
closed fx with nonunion
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Physician role Clinical Documentation
Focus remains on patient care Real time 3M 360 :Natural Language Processing Respond to query and document in the EMR Do not need to learn coding Minimal impact on day-to-day routine Clinical Documentation Specialists – a resource to
the physician
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Concurrent Query Process
Doc. Spec. Identifies
Query Opportunity
Query Posed to Physician
Physician Agrees?
Yes
Write Diagnosis inProgress Note
No No Response
Write “NO” on the Query Form
360
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Impact of Responding to Query
Impact w/ Response to Query RW = 2.9797 GLOS = 8.98 SOI = 3 Major ROM = 2 Moderate
Impact w/o Response to Query RW = 2.9797 GLOS = 8.98 SOI = 2 Moderate ROM = 2 Moderate
Query: “The magnesium level is 1.6 and the patient is receiving magnesium sulfate” “Please provide a corresponding diagnosis ” Physician documents: “hypomagnesemia”
Cardiac Procedure
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Probable, Possible, Suspected Diagnosis Uncertain Diagnosis
Inpatient application only: These conditions may be coded as though they exist Applies to hospital setting only If condition is ruled out, it may not be coded
Outpatient application:Must code signs/symptoms, not the suspected conditionSupports appropriate E&M professional component
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Clinical example
66 year old male admitted with nausea, abdominal and chest pain and “AMS” altered mental status; history of elevated triglycerides
and daily alcohol use.
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Possible probable suspected alternatives
Cardiac CathMS-DRGs 286/287
RW = 1.9634
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Abdominal Pain ICD-10
What Stays the Same?― Specifies abdominal pain,
tenderness and rigidtiy by anatomic locations :• All four quadrants• Epigastric• Periumbilical• Generalized
What’s New?― rebound tenderness
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Hemorrhoids Document the degree/grade/stage of hemorrhoids:
• First degreeo Hemorrhoids (bleeding) without prolapse outside of anal canal
• Second degreeo Hemorrhoids (bleeding) that prolapse with straining, but retract spontaneously
• Third degreeo Hemorrhoids (bleeding) that prolapse with straining and require manual replacement
back inside anal canal• Fourth degreeo Hemorrhoids (bleeding) with prolapsed tissue that cannot be manually replaced
Document presence of any associated complications:• Prolapsed• Strangulated• Thrombosed• Ulcerated
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Documentation of Pancreatitis
Lab: Elevated bilirubin lipase and amylase
Treatment: IVF, NPO, pain control, electrolyte correction.
Final Diagnosis: Acute pancreatitis due to alcohol dependence
Current Documentation Improved Documentation
Final Diagnosis: Pancreatitis, alcohol abuse
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Barrett’s Esophagus & Barrett’s Ulcer Barrett’s esophagus,
disease, syndrome― Document presence of
dysplasia• High grade dysplasia• Low grade dysplasia
Barrett’s ulcer― Document presence of
bleeding
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Respiratory Failure Acute/chronic/acute on chronic
Cause or etiology (pneumonia,COPD,drug,trauma;
If following surgery was it POA ( PSI) or due to underlying pulmonary condition, failure to wean
Signs :RR> 26, accessory muscles use, altered mental status
Arterial blood gas and pH:
pH of <7.30 or >7.50
pCO2 of >50
pO2 of <60 (impacted by hemoglobin level)
Type I Hypoxemic : pO2 60 mm Hg normal or low pCO2
Type II Hypercapnic: pH < 7.30 and increased bicarbonate;pCO2 >50 Chronic : As above and low flow 02 at home; polycythemia ;cor pulmonale; heart
failure
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Postoperative Respiratory Failure
Respiratory failure in a postsurgical patient, clarify if: The surgery caused the failure The patient failed weaning off vent The patient has underlying respiratory problems that could have been the
cause of the failure Quality Concepts
Respiratory failure not present on admission and occurs after an operative episode is considered a patient safety indicator (PSI 11)
Important to get confirmation of the following: POA status (present on admission vs. occurs after admission) Confirmation of diagnosis if condition documented without corresponding clinical
picture Cause of the respiratory failure following surgery (related or unrelated to surgery)
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Altered Mental Status Alternatives
ComaMS-DRGs 080/081
RW = 1.2252
Encephalopathy and Metabolic
EncephalopathyMS-DRGs 070/071/072
RW = 1.6593
SeizuresMS-DRGs 100/101
RW = 1.5185
Hepatic Encephalopathy
MS-DRGs 441/442/443RW = 1.8534
Hypertensive Encephalopathy
MS-DRGs 077/078/079RW = 1.6290
TIAMS-DRG 069RW = 0.6948
CVAMS-DRGs
064/065/066RW = 1.7417
Acute Confusional State
MS-DRGs 880 RW = 0.6388
Diabetic Ketoacidosis
MS-DRGs 637/638/639RW = 1.3888
Drug-Induced and Alcoholic Delirium
and DementiaMS-DRGs 896/897
RW = 1.5146
UTIMS-DRGs 689/690
RW = 1.1300
Altered Mental Status
MS-DRGs 947/948RW = 1.1324
Alzheimer’s Disease
Parkinson’s Disease
MS-DRGs 056/557RW = 1.7368
Toxic and Anoxic Encephalopathy
MS-DRGs 091/092/093RW = 1.5851
Dementia and Vascular Dementia
MS-DRG 884RW = 1.0060
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Cerebral Infarction Specify etiology or cause of the infarct:
― Thrombosis― Embolism― Occlusion or stenosis
Document specific artery involved and laterality:― Precerebral arteries which include:
• Carotid artery• Basilar artery• Vertebral artery
― Cerebral arteries which include:• Anterior cerebral artery• Cerebellar artery• Middle cerebral artery• Posterior cerebral artery
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Document etiology of cerebral infarction:― Embolism― Thrombosis― Occlusion― Stenosis
Specify artery involved:― Anterior cerebral artery― Basilar artery― Carotid artery― Cerebellar artery― Middle cerebral artery― Posterior cerebral artery― Vertebral artery
Document the link between the occluded vessel and the CVA, if appropriate
Requires laterality distinction (left vs. right)
Intraoperative or postprocedural cerebral infarction occurring during cardiac or other type of surgery
Cerebral Infarction Following Surgery
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Documentation of Encounter Specificity Initial – patient is receiving active treatment for the condition such as:
Surgical treatment Emergency department encounter, and Evaluation and treatment by a new physician
Subsequent – patient has received active treatment of the condition and is currently receiving routine care for the condition during the healing or recovery phase. Cast change or removal Removal of external or internal fixation device Adjustment of medication Other aftercare and follow-up visits following treatment of the injury or condition
Sequela – used for complications or conditions – late effects that arise as a direct result of a condition.
Documentation Requirements for Injuries
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Injury of Spleen
Specify type of injury― Contusion
• Minor – contusion of spleen less than 2 cm
• Major – contusion of spleen greater than 2 cm
― Laceration• Superficial/minor – laceration of spleen less than 1 cm
• Moderate – laceration of spleen 1 to 3 cm
• Major/massive – laceration of spleen greater than 3 cm; multiple lacerations of spleen
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Injury of Liver
Specify type of injury― Contusion
― Laceration• Minor – laceration involving capsule only, or, without significant
involvement of hepatic parenchyma (i.e., less than 1 cm deep)
• Moderate – laceration involving parenchyma but without major disruption of parenchyma (i.e., less than 10 cm long and less than 3 cm deep)
• Major – laceration with significant disruption of hepatic parenchyma (i.e., greater than 10 cm long and 3 cm deep); multiple moderate lacerations, with or without hematoma
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ICD-10 documentation for pneumothorax will need to include:
Spontaneous – primary, secondary or tension
• Also note underlying cause such as due to underlying lung disease or connective tissue disorder
Postprocedural Traumatic Chronic
If postoperative pneumothorax, please specify the significance or that it is an insignificant finding not impacting the patient.
Pneumothorax
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Injury of Heart
Specify type of injury― Contusion (EKG changes, elevated troponin)
― Laceration
• Mild – laceration of heart without penetration of heart chamber
• Moderate – laceration of heart with penetration of heart chamber
• Major – laceration of heart with penetration of multiple heart chambers
Document presence of hemopericardium
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Document the underlying cause or etiology if known or suspected
Indicate a linkage to the known or suspected etiology by selecting words such as “due to” or “secondary to”
Cardiac Arrest
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Many of the following terms may be considered nonspecific: Closed head injury (CHI) Traumatic brain injury (TBI) - diffuse or focal Intracranial injury
Please document the specific type of injury: Cerebral edema Compression of brain/brain herniation – diffuse or focal injury Concussion Contusion of brain Hemorrhage of brain Laceration of brain
Also specify if any loss of consciousness and the time duration
Head Injury
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Traumatic Brain Hemorrhage Specify site
― Left or right cerebrum
― Cerebellum
― Brainstem
― Epidural
― Subdural
― Subarachnoid
Specify if with LOC and for how long in order to accurately report time.
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Spinal Cord Injury Document by specific type of injury:
― Anterior cord syndrome― Brown-Séquard syndrome ― Central cord syndrome― Complete lesion― Spinal concussion― Spinal edema
Specific level for each vertebral segment (C1), rather than a range (C1-C4)
Encounter: initial, subsequent or sequela Example: “C4 and C5 spinal cord injury with closed nondisplaced
fracture of C4 & C5 vertebrae, initial encounter"
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Glasgow Coma Scale (GCS) Based on 3 categories of responsiveness: eye opening, best motor response,
and best verbal response.
Lower the GCS, the deeper the level of unconsciousness.
90% with a score < or equal to 8 are in a coma
50% with score < than or equal to 8 at six hours die
Head injury classification:
Severe – GCS 8 or less
Moderate – GCS 9 to 12
Mild – GCS 13 to 15
Coma
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Gustilo Open Fracture Classification The following is required for open fractures of the forearm, femur, lower leg or
ankle: Type I: clean wound less than 1 cm with minimal soft tissue injury. Bone fracture is simple with
minimal comminution. Type II: moderately contaminated wound greater than 1 cm with moderate soft tissue injury.
Fracture contains moderate comminution. Type III: extensive skin damage involving muscle or nerves. Type III is further subdivided as
follows: Type III A: extensive laceration of soft tissues with bone fragments from severe
comminution or segmental fractures Type III B: extensive lesion of soft tissues with periosteal stripping and contamination
which usually requires a flap to cover the exposed bone Type III C: exposed fracture with major vascular injury requiring repair for limb salvage
Documentation Requirements for Fractures
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Salter-Harris Classification The following is required on growth plate fractures
Type I – transverse fracture through the hypertrophic zone of the physis
Type II – fracture through the physis and metaphysis, but does not involve the epiphysis. This is the most common type and may cause minimal shortening, but rarely results in functional limitations
Type III – fracture though the hypertrophic layer of the physis extending to split the epiphysis thereby damaging the reproductive layer of the physis
Type IV – fracture through epiphysis, physis and metaphysis
Type V – fracture involving only the physis which results in a compressive deformity of the growth plate
Documentation Requirements for Fractures
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Examples of specificity: Nondisplaced intertrochanteric fracture of right femur, initial encounter for open
fracture type II (S72.144B)
Torus fracture of lower end of left humerus, subsequent encounter for fracture with delayed healing (S42.482G)
Displaced oblique fracture of shaft of right tibia, initial encounter for closed fracture (S82.231A)
Documentation Examples for Fractures
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Traumatic Vertebral Fractures
Document: Level of vertebral column
― For example, L1
Part of vertebra fractured― For example, posterior arch
Displaced versus nondisplaced
Specify: Type of fracture
― For example:
• Type II dens fracture of the 2nd cervical vertebra
• Type III spondylolisthesis of the 2nd cervical vertebra
• Stable or unstable burst fracture of L1
• Traumatic wedge compression fracture
• Zone I-III or Type 1-4 sacral fracture
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Documentation Requirements for Pathological Fractures Specify:
― Exact location of fracture Site Laterality
― Etiology of fracture Bone disease/lesion Neoplastic disease Osteoporosis (age related or disuse)
― Encounter type Initial encounter for fracture Subsequent encounter for fracture Sequela
― Cause of fracture• A fracture will default to traumatic unless otherwise documented
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Blood Loss Anemia
Blood loss anemia may be due to trauma, gastrointestinal conditions, obstetrical delivery or surgery or other causes
Document:― Anemia due to acute blood loss― Anemia due to chronic blood loss― Postoperative anemia due to blood loss
Link anemia to the blood loss, when appropriate Anemia following surgery with an expected amount of blood
loss may be documented as acute blood loss anemia.
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Adult Malnutrition Classification of adult malnutrition is based on the documented
known or suspected etiology:― Starvation-related ― Chronic disease-related ― Acute disease or injury-related
Two or more of the following six characteristics required:*― Insufficient energy intake ― Weight loss ― Loss of muscle mass― Loss of subcutaneous fat― Localized or generalized fluid accumulation that may mask weight loss― Diminished functional status as measured by hand grip strength
*May 2012, the Academy of Nutrition and Dietetics (Academy) and the American Society for Parenteral and Enteral Nutrition (ASPEN)
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Neoplasms Document specific site and laterality:
― Example: Malignant neoplasm of right upper lobe of the lung
― Example: Benign neoplasm of splenic flexure
Document primary and all secondary sites In the case of admission for treatment of secondary malignancy,
specify if the primary site is still present
It’s perfectly acceptable to state a diagnosis or anatomical site as probable or suspected
― Example: Probable osteosarcoma of left femur
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Sepsis Urosepsis imprecise No IDD-10 a code for urosepsis
Sepsis is classified by the bacteria causing the infection― Streptococcal sepsis (group A, group B,
Streptococcus pneumoniae, other streptococcal) or
― Other sepsis (e.g., MRSA, pseudomonas)
Severe sepsis is associated with organ dysfunction/failure― Document the specific associated organ
dysfunction (not MOD) and
― Document presence of septic shock
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“Postoperative” Diagnosis: Two Definitions
Clinical Definition
“A condition occurring in the postoperative period”.
Coder Definition
“A diagnosis related to the surgical procedure” Complication-900 code
“Coder cannot make the determination if it is a complication or an expected outcome”
(Coding Clinic 4/27/2011)
.
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Examples
Complication Postop ileus (997.4 + 560.1) Ileus secondary to surgery
(997.4 + 560.1)
Post op atelectasis (997.39 + 518.0)
Post op anemia (998.11 + 285.1)
Non-Complication Ileus
Prolonged ileus
Expected ileus
Incidental atelectasis
Atelectasis
Acute blood loss anemia
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ICD-10 Documentation Requirements for Procedures Laterality of site
― Left― Right― Bilateral
Specificity of approach• Open • Percutaneous • Percutaneous endoscopic • Via natural or artificial opening• Via natural or artificial opening- endoscopic • Open with percutaneous endoscopic assistance • External
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00 22 77 BB 33 44 ZZ
Med/SurgMed/Surg
Heart & Great Vessels
Heart & Great Vessels
DilatationDilatation
Coronary Artery
Coronary Artery
PercutaneousPercutaneous
Transluminal Device, Drug
Eluting
Transluminal Device, Drug
Eluting
NoneNone
SectionSectionBody
SystemBody
SystemRoot
OperationRoot
OperationBodyPart
BodyPart ApproachApproach DeviceDevice QualifierQualifier
Documentation of a procedure: Example stent ICD-10-PCS
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Reduction: open vs. closed Fixation: internal vs. external vs. no fixation device Reduction = “reposition” in ICD-10-PCS
― Example “Closed reduction with percutaneous internal fixation of right femoral neck fracture”
Fracture Treatment
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Amputation Status
ICD-9-CM ICD-10-CM
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Joint Replacement Status
ICD-9-CM ICD-10-CM
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Specific location of both bypass attachmentsCoronary to coronaryCoronary to thoracic artery or abdominal arteryCoronary to aorta Internal mammary, right or left
Specific graft usedAutologous venous tissue/Autologous arterial tissueSynthetic substituteNonautologous tissue substitute
Number of bypass grafts Approach
OpenPercutaneous endoscopic
Specific vein harvested for graft (greater/lesser saphenous vein: left/right)
Coronary Artery Bypass Graft (CABG)
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Coronary Angioplasty Specify the number of sites If stent inserted, drug-eluting versus non-drug eluting
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Objective of the procedure ― Root operation “dilation” is defined as “expanding an orifice
or the lumen of a tubular body part”
Coronary artery and the number of sites receiving treatment (e.g., one, two, three or four more sites)
Approach is open, percutaneous, or percutaneous endoscopic Drug-eluting or non-drug-eluting device
Coronary Angioplasty
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Heart Biopsy Specific site of heart from which tissue is taken
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Mechanical Ventilation
Root operation: Performance (Completely taking over a physiological function by extracorporeal means)
Body system: Respiratory Duration:
• Less than 24 consecutive hours• 24-96 consecutive hours• Greater than 96 consecutive hours
Document durationcharacter 1 character 2 character 3 character 4 character 5 character 6 character 7
Section Body System Operation Body System Duration Function Qualifier5 A 1 9 4 5 Z
Extracorporeal Assistance & Performance
Physiological systems Performance Respiratory24-96
Consecutive Hours
Ventilation No Qualifier
Mechanical Ventilation 36 Hours5A1945Z
Mechanical Ventilation 36 Hours5A1945Z
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Document the type of debridement:― Excisional debridement or “cutting away or excision of tissue”
― Non-excisional debridement or “minor removal of loose fragments”
Specify the depth of debridement: ― Skin
― Subcutaneous tissue
― Fascia
― Muscle
― Bone
Document instruments used during procedure
Wound Debridement
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Suture of Laceration Example: Suture of 6x2 cm, left supraorbital deep facial laceration.
Closure was performed of subcutaneous tissue with #5-0 Vicryl followed by skin closure with #5-0 nylon.
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Use of flexible material that stabilizes the vertebrae
Device is used in conjunction with surgery or separately
Surgical approach― Open― Percutaneous― Percutaneous endoscopic
Spinal Stabilization Device Specific device used to accomplish the
stabilization― Interspinous process― Pedicle-based― Facet Replacement
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Excision of Intervertebral Disc
Example: “removal of some adjacent disc material”
Since only a portion of the disc was removed, a code for excision will be assigned