VASCULAR SURGERY and Other Common Documentation Tips ICD 10 Documentation Specificity Needed based...

VASCULAR SURGERY and Other Common Documentation TipsICD 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.

Table of contents Anemia 4

Atrial Fib 5

BMI – high 6

BMI –low 7

Cellulitis 8

Coma 9

Debridement 10

Dementia 11

Diabetes 12

Encephalopathy 13

Heart failure- acute 14

Heart failure-chronic 15

HIV-AIDS 16

Hypertension 17

Hyponatremia 18

Mental Status- Altered 19

Metabolic—acidosis/ alkalosis 20

Non pressure ulcer 21

Malnutrition 22

Osteomyelitis 23

Personal Injury 24

Pneumonia- Hypostatic /passive/ stasis 25

Pneumonia-Specificity 26

Pressure Ulcer 27

Pulmonary embolism 28

Renal Failure—acute 29

Renal failure-chronic 30

Respiratory- COPD 31

Respiratory- Emphysema 32

Respiratory failure 33

Respiratory failure post op 34

Sepsis 35

Shock 36

Substance abuse 37

Urosepsis 38

UTI 39

Hospital specific

Documentation Specialists contact info 40-48

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

ICD9 Documentation

IDENTIFY TYPE

[ ] Paroxysmal Atrial Fibrillation

[ ] Persistent Atrial Fibrillation

[ ] Chronic Atrial Fibrillation (includes permanent Atrial Fibrillation)

[ ] Unspecified Atrial Fibrillation

ICD9 Documentation

BMI > 40 with associated diagnosis of:

[ ] Morbid (Severe) Obesity

[ ] Overweight

[ ] Obesity (unspecified)

Morbidly Obese

[ ] Morbid (Severe) Obesity

[ ] Due to excess calories

[ ] Familial

[ ] Endocrine

[ ] with Alveolar Hypoventilation (Pickwickian syndrome)

[ ] Drug-induced (Name of drug: _____)

ICD9 Documentation

BMI < 19 with associated diagnosis of: (check one)

[ ] Underweight

[ ] Protein Calorie Malnutrition:

[ ] Mild [ ] Moderate [ ] Severe

[ ] Unspecified

[ ] Cachexia

[ ] Emaciation due to malnutrition

Same as ICD 9

ICD9 Documentation

Cellulitis

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

ICD9 Documentation

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_________

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

Same as ICD 9

ICD9 Documentation

Dementia

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: ___________________

ICD9 Documentation

Diabetes

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

ICD9 Documentation

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

ICD9 Documentation

ACUTE HEART FAILURE

[ ] Acute Systolic Heart Failure

[ ] Acute Diastolic Heart Failure

[ ] Acute Systolic and Diastolic Heart Failure

ACUTE ON CHRONIC HEART FAILURE

[ ] Acute On Chronic Systolic Heart Failure

[ ] Acute On Chronic Diastolic Heart Failure

[ ] Acute On Chronic Systolic and Diastolic Heart Failure

SAME as ICD 9 with the addition

OTHER ETIOLOGIES OF HEART FAILURE

[ ] Heart Failure Due To Valvular Disease

[ ] Right Heart Failure / Acute Cor Pulmonale

[ ] Right Heart Failure / Chronic Cor Pulmonale

[ ] Rheumatic Heart Disease

[ ] Endocarditis (valvular)

[ ] Myocarditis

[ ] Pericarditis

ICD9 Documentation

CHRONIC HEART FAILURE

[ ] Chronic Systolic Heart Failure

[ ] Chronic Diastolic Heart Failure

[ ] Chronic Systolic and Diastolic Heart Failure

SAME as ICD 9 with the addition of etiology

Etiologies:

[ ] Hypertension

[ ] Valvular disease

[ ] Rheumatic heart disease

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

Similar to ICD 9

ICD9 Documentation

Hypertension

[ ] Malignant Hypertension

[ ] Accelerated Hypertension

[ ] Benign Hypertension

[ ] Unspecified Hypertension

Same as ICD 9

ICD9 Documentation

Hyponatremia

Identify specificity

[ ] Hyponatremia, unknown cause

[ ] Hyponatremia due to Sodium Deficiency

[ ] Hyponatremia due to SIADH (Syndrome of Inappropriate Secretion of Antidiuretic Hormone)

[ ] Insignificant lab value

ICD9 Documentation

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

ICD9 Documentation

Acidosis/Alkalosis

Identify Type of Acidosis or Alkalosis

[ ] Acidosis:

[ ] Metabolic [ ] Respiratory

[ ] Lactic [ ] Renal

[ ] Alkalosis:

[ ] Metabolic [ ] Respiratory

ICD9 Documentation

Non Pressure Ulcer

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

[ ] Skin only [ ] Fat exposed [ ] Muscle Necrosis

[ ] Bone Necrosis

[ ] Diabetic [ ] Vascular r/t PVD [ ] Varicose

[ ] Atherosclerosis of lower limb

[ ] Postphlebitic syndrome

[ ] Postthrombotic syndrome

[ ]Chronic venous hypertension [ ] Other (specify) ______

Gangrene [ ] Yes [ ] No

ICD9 Documentation

Malnutrition

[ ] Under-nutrition / Malnutrition:

[ ] Mild [ ] Moderate

[ ] Severe [ ] Unspecified

[ ] Protein Calorie Malnutrition:

[ ] Mild [ ] Moderate [ ] Severe

[ ] Unspecified

[ ] Marasmus

[ ] Nutritional Edema

[ ] Other Malnutrition (please specify) _______________________________

Same as ICD 9

ICD9 Documentation

Osteomyelitis

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

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)________________

Same as ICD 9

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

Similar to ICD 9

ICD9 Documentation

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)

ICD9 Documentation

Pulmonary Embolism

Identify acuity, type and if associated acute cor pulmonale

Acuity:

[ ] Acute [ ] Chronic

[ ] Saddle [ ] Septic [ ] Other___

[ ] Pulmonary Embolism with associated Acute Cor Pulmonale

ICD9 Documentation

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.) ______________________________

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 ________

Same as ICD 9

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

Same as ICD 9

ICD9 Documentation

Identify Acuity

[ ] Acute exacerbation of COPD

[ ] Acute exacerbation of Asthma

[ ] COPD – Chronic and stable

ICD9 Documentation

Emphysema

Identify Acuity and Type

Acuity:

[ ] Acute exacerbation of Emphysema

[ ] Chronic and stable Emphysema

[ ] Unilateral:

[ ] Sawyer-James Syndrome

[ ] Unilateral Hyper-Lucent Lung

[ ] Unilateral Pulmonary Artery Functional Hypoplasia

[ ] Pan lobular

[ ] Centrilobar

ICD9 Documentation

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

ICD9 Documentation

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 [ ] Chronic [ ] Acute on Chronic

ICD9 Documentation

[ ] Hypovolemic shock

[ ] Hemorrhagic shock

[ ] Cardiogenic shock

[ ] Septic shock (Circulatory failure associated with severe sepsis, represents organ failure)

Same as ICD 9

ICD9 Documentation

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 [ ] 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.) _______________________

ICD9 Documentation

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

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

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)

Same as ICD 9

ICD9 Documentation

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

ICD9 Documentation

Weakness

Identify due to and laterality

[ ] Weakness due to __________

[ ] Hemiparesis [ ] Hemiplegia

Laterality

(please check all that apply):

[ ] Right side [ ] Left side

[ ] Upper extremity [ ] Lower extremity

[ ] Dominant side [ ] Non-dominant side

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

Sts. Mary and Elizabeth

Clinical Documentation Specialists Mickey Decker– 502-361-6125

Cheryl Brooks-502-361-6549

Annette Majors- 502-361-6495

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

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

St. Joe East

Clinical Documentation Specialists Kimberly Gilbert-Morrison—502-316-5220

Kelly Geers—502-750-2329

Flaget

Clinical Documentation Specialist Cheryl Mitchell—502-350-5247

St Joe London

Clinical Documentation Specialists Katrina Henson—606-330-6759

Sherry Mills—606-330-6000

St. Joe Mt. Sterling

Clinical Documentation Specialists Lori Barry—859-497-5458

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