Clinical Documentation ICD-10

Importance of Clinical documentation for accurate ICD-10 codingICD-10 is not the coding but its improved Patient care which is documentedDescriptive documentation to support accurate coding is the base of reimbursement from the insurancesIf physicians don't document their care, it can't be captured or codedProper documentation has the potential to improve:Patient care,Clinical data Timely and appropriate claims payment

What needs to be documented?

Basic concepts such as: Laterality (Right, Left, Bilateral, Unilateral) Anatomical locations Trimester Type of diabetes Known complications or comorbid conditionsDescription of severity, acute or chronic or other known parameters

Major ModificationsRevised diabetes mellitus codes (5th digits from ICD-9-CM will not be used)Expanded codes (e.g., injury, diabetes)Added trimesters to obstetrical codes (5th digits from ICD-9-CM will not be used)Added code extensions for injuries and external causes of injuriesLaterality Left Versus RightArea specified in cases of NeoplasmExamplesMalignant neoplasm, of central portion of breastMalignant neoplasm of central portion of right female breastMalignant neoplasm of central portion of left female breast

Most Commonly Encountered Disease/Problems taken as example

DIABETESHEART DISEASE (CAD, A-FIB, CHF etc.)PAIN (BACK, LOWER BACK, LIMBS UPPER OR LOWER)OSTEOARTHRITISCHRONIC KIDNEY DISEASEPULMONARY DISEASE

Examples on the following slides

Must/Preferable to dictate

DIABETES

Type I or Type II diabetes - Must dictate

Onset - Preferable if dictated

When did it start? - Preferable if dictatedHEART DISEASE (CAD, A-FIB, CHF etc.)

Coronary Artery Disease (CAD):

Native Artery involved Preferable if dictated

Status post bypass graft Preferable if dictated

PAIN, OSTEOARTHRITIS, OSTEOPENIA, OSTEOPROSIS, ARTHRITIS,

Anatomical location Which anatomical structure - Must dictateProximal, distal, medial, lateral, central, peripheral, superior, inferior, anterior, posterior - Preferable if dictated

Laterality Right side or left side Must dictate Severity Mild, moderate or severe Preferable if dictatedCHRONIC KIDNEY DISEASE

Stage 1 to 6 (end stage) Must dictate

Dependence on Dialysis Must dictate

Example for -PULMONARY DISEASE

Temporal Factors: Must dictateAcute / Chronic / Intermittent / Persistent

Severity: Must dictateMild / Moderate / Severe

Asthma: Must dictate

Acute / Chronic / Allergic / Exacerbation

COPD: Must dictate

With exacerbation

Bronchitis specific: Must dictate

Simple / Mucopurulent / Mixed simple and Mucopurulent / Tracheobronchitis

To be dictated by Provider

Dictated currently ICD-9To be dictated now ICD-10

Condition described : DIABETES HISTORY OF PRESENT ILLNESS: The patient is an 86 years old female with history of diabetes. At last visit, we had discussed about going up on her Lantus every three days, but it seems like the patient did not do that and she is still taking Lantus 17 to 20 units and she also continued to take NovoLog Mix 70/30 in the morning and with supper. She states that her blood sugar at suppertime is staying around 188 to 200 and fasting blood sugar is 127, but she did not bring those readings with her. Her last hemoglobin A1c was checked in January and it was high at that time. She is complaining of constipation. She has been taking over-the-counter medication, but it is not helping

ASSESSMENT:Uncontrolled diabetesConstipation.Condition described : DIABETES HISTORY OF PRESENT ILLNESS: The patient is an 86 years old female with history of diabetes. At last visit, we had discussed about going up on her Lantus every three days, but it seems like the patient did not do that and she is still taking Lantus 17 to 20 units and she also continued to take NovoLog Mix 70/30 in the morning and with supper. She states that her blood sugar at suppertime is staying around 188 to 200 and fasting blood sugar is 127, but she did not bring those readings with her. Her last hemoglobin A1c was checked in January and it was high at that time. She is complaining of constipation. She has been taking over-the-counter medication, but it is not helping

ASSESSMENT:Uncontrolled diabetes - Type I / Type II Constipation.

DXICD-9ICD-10Uncontrolled Diabetes250.02 (Uncontrolled Diabetes Type 2 / noninsulin dependent)E11.65 (Type 2 Diabetes with hyperglycemia)Uncontrolled Diabetes Type 1 / insulin-dependent250.03 (Uncontrolled Diabetes Type 1 / insulin dependent)E10.65 (Type 1 Diabetes with hyperglycemia)

Diabetes250.00 (Diabetes Type 2, not stated as uncontrolled)E11.9 (Type 2 Diabetes without complications)Diabetes - Type 1 / Insulin-dependent250.01 (Diabetes Type 1 (juvenile type) / insulin-dependent, not stated as uncontrolled)E10.9 (Type 1 Diabetes without complications)

To be dictated by Provider

Dictated currently ICD-9To be dictated now ICD-10

Condition described : HEART DISEASE (CAD)

ASSESSMENT AND PLAN:

The patient is an individual who has CAD, has dropped about 4 pounds since last time, status post multiple surgeries in the past, obesity, the patient has a history of anxiety, neuropathy, hypertension, intervertebral disk disease, hypertriglyceridemia, atrial fibrillation, GERD, and insulin-dependent diabetes mellitus.

Condition described : HEART DISEASE (CAD)

ASSESSMENT AND PLAN:

The patient is an individual who has CAD with/without - stable/unstable - other/unspecified etc angina, status post bypass graft, has dropped about 4 pounds since last time, status post multiple surgeries in the past, obesity, the patient has a history of anxiety, neuropathy, hypertension, intervertebral disk disease, hypertriglyceridemia, atrial fibrillation, GERD, and insulin-dependent diabetes mellitus.

DXICD-9 ICD-10 CAD-unspecified type of vessel, native, or graft414.00I25.10

CAD-native coronary artery

414.01125.110 (CAD-native artery with unstable angina)

I25.111 (CAD-native artery with unstable angina with documented spasm)

I25.118 (CAD-native artery with other forms of angina pectoris)

I25.119 (CAD-native artery with unspecified angina pectoris)

CAD with bypass graft - unspecified type

414.05I25.700 (Atherosclerosis of coronary artery bypass graft, unspecified, with unstable angina pectoris

I25.701 (Atherosclerosis of coronary artery bypass graft, unspecified, with angina pectoris with documented spasm)

I25.708 (Atherosclerosis of coronary artery bypass graft, unspecified, with other forms of angina pectoris)

I25.709 (Atherosclerosis of coronary artery bypass graft, unspecified, with unspecified angina pectoris

To be dictated by Provider

Dictated currently ICD-9To be dictated now ICD-10

Condition described : PAIN

ASSESSMENT: The patient has UTI and history of kidney stones. The patient has chronic kidney disease. The patient has tobacco abuse. The patient has chronic pain of leg

Condition described : OSTEOARTHRITIS

ASSESSMENT: This is an individual with chronic kidney disease, hypertension, insomnia, depression, chronic pain syndrome, knee pain, and gout. The patient is accompanied by her daughter. There is also underlying restless legs syndrome, COPD which is severe, degenerative joint disease, and osteoarthritisCondition described : PAIN

ASSESSMENT: The patient has UTI and history of kidney stones. The patient has chronic kidney disease. The patient has tobacco abuse. The patient has chronic pain of right/left upper/lower leg

Condition described : OSTEOARTHRITIS

ASSESSMENT: This is an individual with chronic kidney disease, hypertension, insomnia, depression, chronic pain syndrome, knee pain, and gout. The patient is accompanied by her daughter. There is also underlying restless legs syndrome, COPD which is severe, degenerative joint disease, and osteoarthritis of knee right/left

DXICD-9 ICD-10Pain of Leg

729.5 (Pain in Limb)M79.606 (Pain in Unspecified Leg)Pain of Right LegM79.604 (Pain in Right Leg)Pain of Left LegM79.605 (Pain in Left Leg)Pain of ThighM79.659 (Pain in Unspecified Thigh)Pain of Right ThighM79.651 (Pain in Right Thigh)Pain of Left ThighM79.652 (Pain in Left Thigh)Pain of Lower LegM79.669 (Pain in Unspecified Lower Leg)Pain of Right Lower LegM79.661 (Pain in Right Lower Leg)Pain of Left Lower LegM79.662 (Pain in Left Lower Leg)

To be dictated by Provider

Dictated currently ICD-9To be dictated now ICD-10

Condition described : CHRONIC KIDNEY DISEASE

ASSESSMENT: The patient is a 73-year-old who was recently in the hospital for volume overload, has chronic kidney disease as well as CHF, certainly does have multiple other issues including hyperlipidemia, CAD, hypertension, seasonal allergic rhinitis, is being followed by Dr. abcdef of renal. We will certainly get Dr. xyz to see him for his CHFCondition described : CHRONIC KIDNEY DISEASE

ASSESSMENT: The patient is a 73-year-old who was recently in the hospital for volume overload, has chronic kidney disease stage 3 , etc. / end-stage / on dialysis as well as CHF, certainly does have multiple other issues including hyperlipidemia, CAD, hypertension, seasonal allergic rhinitis, is being followed by Dr. abcdef of renal. We will certainly get Dr. XYZ to see him for his CHF

DXICD-9ICD-10Chronic Kidney Disease585.9 (CKD, stage unspecified)N18.9 (CKD, stage unspecified)CKD-Stage 1585.1 (CKD, stage 1)N18.1 (CKD, stage 1)CKD-Stage 2585.2 (CKD, stage 2) (mild)N18.2 (CKD, stage 2) (mild)CKD-Stage 3585.3 (CKD, stage 3) (moderate)N18.3 (CKD, stage 3) moderate)CKD-Stage 4585.4 (CKD, stage 4) (severe)N18.4 (CKD, stage 4) severe)CKD-Stage 5585.5 (CKD, stage 5)N18.5 (CKD, stage 5)CKD, end stage585.6 (End Stage Renal Disease)N18.6 (End Stage Renal disease)

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