OB/GYN and Other Common Documentation Tips ICD 10 Documentation Specificity Needed based on Conifer...
-
Upload
oscar-wheeler -
Category
Documents
-
view
249 -
download
0
Transcript of OB/GYN and Other Common Documentation Tips ICD 10 Documentation Specificity Needed based on Conifer...
OB/GYNand Other Common Documentation TipsICD 10 Documentation Specificity Needed based on Conifer ICD 10 CDI Queries
2 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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.
3 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
Table of contents Anemia 4
BMI – high 5
BMI –low 6
Diabetes 7
Endometriosis 8
Headache/ Migraine 9
Hypertension 10
Hyponatremia 11
Metabolic—acidosis/ alkalosis 12
Mood Disorder 13
Neoplasm 14
Malnutrition 15
Pregnancy 16
Ovarian Cancer 17
Pancreatitis 18
Pneumonia-Specificity 19
Premature infant 20
Pressure Ulcer 21
Renal Failure—acute 22
Renal failure-chronic 23
Sepsis 24
Shock 25
Substance abuse 26
Testicular Torsion 27
Urosepsis 28
UTI 29
Hospital specific
Documentation Specialists contact info 30-37
4 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
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:
ICD10 Documentation Needed
Same as in ICD 9
5 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
BMI > 40 with associated diagnosis of:
[ ] Morbid (Severe) Obesity
[ ] Overweight
[ ] Obesity (unspecified)
ICD10 Documentation Needed
Morbidly Obese
[ ] Morbid (Severe) Obesity
[ ] Due to excess calories
[ ] Familial
[ ] Endocrine
[ ] with Alveolar Hypoventilation (Pickwickian syndrome)
[ ] Drug-induced (Name of drug: _____)
6 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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
ICD10 Documentation Needed
Same as ICD 9
7 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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
8 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Endometriosis
ICD10 Documentation Needed
IDENTIFY Implant Site
[ ] Uterus
[ ] Fallopian tube: [ ] Right [ ] Left
[ ] Ovary: [ ] Right [ ] Left
[ ] Other site: ____________________ (e.g. intestine, parametrium, peritoneal, rectrovaginal septum, vaginal, vulva)
9 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Migraine
ICD10 Documentation Needed
IDENTIFY SPECIFICITY
[ ] With Aura [ ] With Refractory Migraine[ ] Intractable[ ] Persistent[ ] Other __________________
[ ] With CVA [ ] Hemiplegic [ ] Intractable[ ] With Status Migrainosus[ ] Menstrual[ ] Cyclical vomiting[ ] Periodic Headache Syndrome[ ] Ophthalmologic
Headache IDENTIFY SPECIFICITY
[ ] Tension[ ] Primary thunderclap[ ] Associated with sex, cough, exertion[ ] Cluster[ ] Post-traumatic[ ] New daily persistent[ ] Vascular[ ] Drug- induced[ ] Other_________________________
10 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Hypertension
[ ] Malignant Hypertension
[ ] Accelerated Hypertension
[ ] Benign Hypertension
[ ] Unspecified Hypertension
ICD10 Documentation Needed
Same as ICD 9
11 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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
12 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Acidosis/Alkalosis
ICD10 Documentation Needed
Identify Type of Acidosis or Alkalosis
[ ] Acidosis:
[ ] Metabolic [ ] Respiratory
[ ] Lactic [ ] Renal
[ ] Alkalosis:
[ ] Metabolic [ ] Respiratory
13 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Mood Disorder
ICD10 Documentation NeededIDENTIFY Type, Status and SeverityType (check appropriate):
[ ] Manic
[ ] Bipolar [ ] Manic [ ] Depressive [ ] Mixed
[ ] 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
14 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Neoplasm
ICD10 Documentation Needed
Identify Site, Laterality, Type, Malignancy and associated conditions
Site: Identify:_______________
Laterality: [ ] Right [ ] Left [ ] Bilateral
Type: [ ] Primary [ ] Secondary
[ ] 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 ____________________________________
15 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Malnutrition
[ ] Under-nutrition / Malnutrition:
[ ] Mild [ ] Moderate
[ ] Severe [ ] Unspecified
[ ] Protein Calorie Malnutrition:
[ ] Mild [ ] Moderate [ ] Severe
[ ] Unspecified
[ ] Marasmus
[ ] Nutritional Edema
[ ] Other Malnutrition (please specify) _______________________________
ICD10 Documentation Needed
Same as ICD 9
16 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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): ________
17 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Ovarian Cancer
ICD10 Documentation Needed
Identify laterality
[ ] Ovarian Cancer
[ ] Right [ ] Left [ ] Bilateral
18 ©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
19 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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
ICD10 Documentation Needed
Similar to ICD 9
20 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Premature Infant
ICD10 Documentation Needed
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 [ ] Less than 24 completed weeks of gestation
[ ] 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
21 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Pressure Ulcer
ICD10 Documentation Needed
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)
22 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
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 ________
ICD10 Documentation Needed
Same as ICD 9
23 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 DocumentationChronic 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 GFRGFR > 90
Stage II Kidney damage with mildly decreased GFRGFR 60-89
Stage III Kidney damage with moderately decreased GFR GFR 30-59
Stage IV Kidney damage with severely decreased GFRGFR 16-29
Stage V Kidney failure GFR<15
ESRD End Stage Renal Disease On dialysis
ICD10 Documentation Needed
Same as ICD 9
24 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Sepsis
ICD10 Documentation Needed
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 [ ] without organ dysfunction
[ ] 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 [ ] without organ dysfunction
[ ] Septic shock
[ ] Sepsis related to a device (i.e. port, IV line, pacer / ICD leads, Foley, etc.) _______________________
25 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
SHOCK
[ ] Hypovolemic shock
[ ] Hemorrhagic shock
[ ] Cardiogenic shock
[ ] Septic shock (Circulatory failure associated with severe sepsis, represents organ failure)
ICD10 Documentation Needed
Same as ICD 9
26 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Substance Abuse
ICD10 Documentation Needed
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
Complications:
[ ] Intoxication [ ] Withdrawal [ ] In remission [ ] Uncomplicated
[ ] Other complication: ____________ [ ] Unspecified complication
Substance-Induced Disorders:
[ ] Psychosis: [ ] Delirium [ ] Delusions [ ] Hallucinations
[ ] Perceptual Disturbances: [ ] Anxiety Disorder [ ] Sexual Dysfunction
[ ] Sleep Disorder
[ ] Unspecified substance-induced disorder
[ ] Other substance-induced disorder: ________________________________
[ ] No substance-induced disorder
27 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Testicular Torsion
ICD10 Documentation Needed
Identify Extra or Intra vaginal and site
[ ] Extravaginal:
[ ] Epididymis
[ ] Spermatic Cord
[ ] Testicle/Testis
[ ] Intravaginal:
[ ] Epididymis
[ ] Spermatic Cord
[ ] Testicle/Testis
28 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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)
ICD10 Documentation Needed
Same as ICD 9
29 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
UTI
ICD10 Documentation Needed
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
30 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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
31 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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
Questions—contact your Clinical Documentation Specialists at your hospital
32 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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
Questions—contact your Clinical Documentation Specialists at your hospital
33 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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
Questions—contact your Clinical Documentation Specialists at your hospital
34 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
St. Joe East
Clinical Documentation Specialists Kimberly Gilbert-Morrison
Kelly Geers
Manager- Sandy Hodge- Bowman 502-409-2673
Supervisor- Kristen Boles 859-421-1542
Questions—contact your Clinical Documentation Specialists at your hospital
35 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
Flaget
Clinical Documentation Specialist Cheryl Mitchell—502-350-5247
Manager- Sandy Hodge- Bowman 502-409-2673
Supervisor- Kristen Boles 859-421-1542
Questions—contact your Clinical Documentation Specialists at your hospital
36 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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
Questions—contact your Clinical Documentation Specialists at your hospital
37 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
St. Joe Mt. Sterling
Clinical Documentation Specialists Lori Barry
Manager- Sandy Hodge- Bowman 502-409-2673
Supervisor- Kristen Boles 859-421-1542
Questions—contact your Clinical Documentation Specialists at your hospital