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Radiology INSTEAD OF PLEASE CONSIDER

Low or No Severity Diagnosis—NO

High Severity Diagnosis---YES

ICD 10 Themes: e.g. Acute on Chronic Systolic Heart Failure

Acuity/Severity/Type/Staging

Acute/Chronic/Acute on Chronic

Mild, Moderate, Severe

Systolic, Diastolic, Combined

Stage I, II, III, IV

e.g. Malignant neoplasm of lower lobe right bronchus

Anatomy/Site Specificity

Location of tumor

Bone/Joint/Muscle involved

e.g. Decubitus Ulcer, Stage 3, Right Buttocks, Present on Admission

Laterality

Right/Left/Bilateral/Overlapping (see Neoplasm re overlaps two or more contiguous (next to each other) sites)

e.g. Hypertensive heart disease with chronic systolic heart failure

Manifestations – LINK IT!

Associated or Related Conditions

‘With’/‘Secondary’ to/’Due to’

‘Evidence of’ and causative organism

Use ‘no organism isolated’, instead of ‘negative culture’

e.g. Likely Sepsis secondary to UTI; Evidence of Bacterial Pneumonia (‘Evidence of’ in outpt setting can be captured as a diagnosis)

Etiology – ‘DUE TO’ WhAt?

‘LIKELY’ suspects….Who dun it?

Possible, Probable, Suspected (Inpt Only)

Evidence of, As Evidenced by (Outpt Setting and Inpt Setting)

e.g. Drug Poisoning/Adverse Effect Episode of Care/Incidence of Encounter (Trauma/Fractures/Medication.Chemical Event(Drug Poisoning))

Initial/Subsequent/Sequela

Radiology Related Diagnoses

Radiologic Findings Antatomical Specificity

Note: A primary malignant neoplasm that overlaps two or more contiguous (next to each other) sites should be classified 'overlapping lesion', unless the combination is specifically indexed elsewhere. For multiple neoplasms of the same site that are not contiguous, such as tumors in different quadrants of the same breast, codes for each site should be assigned.

Laterality – Right; Left; Bilateral; Overlapping lesion (re Primary malignant neoplasm that overlap two or more contiguous

Severity

Complications or Manifestations

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Nature of Injury: Site/Type/Etiology/Place of Occurrence

Encounter Type/Episode of Care Episode of Care:

Initial (receiving active treatment);

Subsequent (encounters AFTER the patient

has received active treatment of the condition

and is receiving routine care):

o Routine Healing or Delayed Healing

o Non-Union or Mal-union:

If non union: State if delayed

Tx, (it’s Initial Encounter,

otherwise it’s ‘Subsequent’)

Sequela (Use for complications or conditions/residual effect that arise as a direct result of a condition (after the acute phase)…no time limit….i.e. Neuropathy of lower leg, ankle and foot due to previous crush injury)

Orthopedic Related:

Traumatic Musculoskeletal Injuries Specify injury i.e. Sprain; Strain; Contusion

Anatomical Site as specifically as possible: e.g. for ligament injuried in an ankle sprain: Calcaneofibular; Deltoid; Internal collateral; Talofibular; Tibiofibular

Traumatic Fractures (Fracture Tib/Fib, Femur, Hip) Location: Specific Part of Body - Name of specific bone and specific site on bone

Laterality

LEO C. FAUR

(acronym to remember elements of fracture documentation)

Zupko and Associates

Episode of Care:

Initial (receiving active treatment);

Subsequent (encounters AFTER the patient

has received active treatment of the condition

and is receiving routine care):

o Routine Healing or Delayed Healing

o Non-Union or Mal-union:

If non union: State if delayed

Tx, (it’s Initial Encounter,

otherwise it’s ‘Subsequent’)

Sequela (Use for complications or

conditions/residual effect that arise as a

direct result of a condition (after the acute

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phase)…no time limit….i.e. Neuropathy of

lower leg, ankle and foot due to previous crush

injury)

Open or Closed

Classifications: Open use Gustilo Classification: Type I, II, IIIA, IIIB, or IIIC (used for soft tissue classification); Salter; Physeal etc

Fracture Pattern/Type/Orientation, i.e.:

Greenstick Comminuted Torus

Spiral Segmental

Transverse Avulsed

Oblique Torus

Alignment: Displaced or Nondisplaced

Underlying Bone Diseases: i.e. Fragility (Pathologic), Stress, Traumatic in healthy etc

Results: Routine or Delayed Healing; Non union or Malunion

Pathological Fracture/Fragility Fracture (fyi: any ground level fall of 50 yr old or greater is usually a pathological fracture) -When the fracture is out of proportion to the degree of the trauma (weakening of the bone structure by pathologic processes i.e. Osteoporosis)

Site and Laterality Etiology:

Age related

Osteoporosis or Osteopenia

Neoplastic

Some other disease Episode of Care: Initial/Subsequent/Sequela For Subsequent: Routine or Delayed Healing; Non union or Malunion Current Fracture and/or personal history

Open Fractures Reference: Clin Orthop Relat Res. 201 November; 470(11): 3270 - 3274

Gustilo Classification: (used for soft tissue classification) Type 1

Wound is less than 1cm with minimal soft tissue injury Wound bed is clean Bone Injury is simple with minimal comminution

Type 2 Wound is greater than 1 cm with moderate soft tissue injury Wound bed is moderately contaminated Fracture contains moderate comminution

Type 3 Wound is longer than 1 cm, with significant soft tissue disruption Mechanism often involves high-energy

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trauma, is unstable. Grade IIIA

Adequate periosteal coverage of bone despite extensive soft-tissue laceration or damage Soft tissue coverage of bone is usually possible

Grade IIIB Extensive soft-tissue loss and periosteal stripping and bone damage

Usually associated with massive contamination Will often need further soft-tissue coverage procedure (i.e. free or rotational flap)

Grade IIIC Fracture in which there is a major vascular injury requiring repair for limb salvage In some cases it will be necessary to consider amputation.

Growth Plate (Physeal ) Fracture Salter mneumonic referes to the fracture line and its relationship to the growth plate.

Use Salter Harris Classification:

S (straight across) Type I – disrupt the physis A (above) Type II – involve a break from the growth plate up into the metaphysis, with the periosteum usually remaining intact.

L (Lower or BeLow) Type III – intraarticular fractures through the epiphysis that extend across the physis

T (Two or Through) Type IV – cross the epiphysis, physis, and metaphysis

E R (ERasure of growth plate or cRush) Type V – compression injuries to the physis.

Sacral Fracture

Vertical Fx: State if minimally vs severely displaced Zone 1: fracture involves the sacral ala lateral to the neural foramina Zone 2: fracture involves the neural foramina, but does not involve the spinal canal Zone 3: fracture is medial to the neural foramen, involving the spinal canal; these may be transverse or longitudinal, and can be sub-classified into 4 types: Transverse Fx: Type 1: only kyphotic angulation at the fracture site (no translation) Type 2: kyphotic angulation with anterior translation of the distal sacrum

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Type 3: kyphotic angulation with complete offset of the fracture fragments Type 4: comminuted S1 segment, usually due to axial compression

Complication/Infection of Internal Joint Prosthesis or Device

Laterality

Anatomical Site: Hip/Knee/Humerus/Radius/Ulna/Femur/Tibia/Fibula/ Spine/Other

Complication: Infection/Inflammation/Embolism/Fibrosis/Hemorrhage/Pain/Stenosis/Thrombosis/Other

Episode of Care: Initial/Subsequent/Sequela

Mechanical Complications with Internal Joint Prosthesis

Laterality

Anatomical Site: Hip/Knee/Other

Type: Mechanical Loosening; Dislocation; Broken; Periprosthetic Fracture; Periprosthetic Osteolysis; Wear of articular bearing surface; Other

Episode of Care: Initial/Subsequent/Sequela

Osteoarthritis Type: Primary/Secondary/Post traumatic

Anatomical Site: Hip/Knee/First Carpometacarpal joint/Shoulder/Elbow/Wrist/Hand/Ankle and Foot

Laterality: Unilateral /Bilateral Right/Left

Aseptic Necrosis Site and Laterality

Idiopathic or Non-idiopathic

Manifestations: With or Without Major Osseous Defect

If with, What is the Site?

Complications of Surgery/Procedures Affected Body System

Specific Condition

Timeframe: Intra operatively or Post operatively

(Punctures or lacerations that are unavoidable or inherent to the procedure are not complications. When NOT a complication…include the medical decision making and characterize the event as ‘intentional’, ‘unavoidable’, or ‘inherent’ to the procedure)

Link Complication to Diagnosis: ‘due to’/’secondary to’ etc… There is no timeframe/deadline for a Postoperatiave Complication (current condition due to previous surgery or procedure)

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NOT Complications Document: Inherent, Expected, Intended

Avoid ‘Accidental/Complication/Unavoidable/Slip/ Iatrogenic/Unintended’ etc when it is not a complication. Avoid using ‘Post operative’ when not a complication; if used, include that it was ‘intended, expected, inherent’ etc.

Additional Terms that suggest non-accidental: to facilitate; necessary; required; intentional; integral; routinely expected

Procedure Coding System (PCS) – New with ICD 10

Pre-Procedural/Post Procedural Diagnosis State difference b/w pre and post dx, as applicable

Link ‘findings’ with post operative diagnosis

Procedure Performed Be Explicit, including unplanned

Post op drains/tubes – Specify type of drain/tube

Be specific re ‘intent’ of surgery i.e. Excision/Biopsy etc

Types of Anesthesia/Estimated Blood Loss (EBL)/Transfusions

-Site infused (Central/Peripheral) - Type & Volume of Fluid (Fresh/Frozen/Autologous)

Procedure – Coder needs ALL elements addressed in order to be able to assign a code…..physician can use their own language for coder to translate, yet all information needs to be available. Coders must have a clear understanding of the ‘intent’ of the procedure..it will help the coder properly assign the appropriate code.

-Intent of the Procedure - Excision (partial removal i.e. biopsy)/Resection (total removal)/Drain fluid/Inspect i.e. endoscopy etc. -Approach—Specify technique used to reach the site i.e. open, percutaneous, use of scopes etc -Prose for steps and technique, not the name of procedure -Laterality of incision/Relative Location -Anatomical site – Be specific re site/Body Cavity (instead of quadrants)/How much of body part removed (all, partial, or measurements) - Devices Used Intraoperatively – material or appliance that remains in the body after the procedure is completed. i.e. Biological or synthetic material (i.e. joint prosthesis, intrauterine device; Therapeutic material (i.e. radioactive implant); Mechanical or electronic appliances ( i.e. orthopedic pin, pacemaker) etc. -Intraoperative Grafting – source and destination site -Modality of Guidance -Specimens – specify if sent to pathology are intended

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to diagnose and help treatment decisions following the procedure. -Medications applied at Surgical Site -Closure – type/area -Complications

Procedure Documentation: Imaging Categories Categories of Imaging: Plain Radiography; Fluroscopy;

Computerized Tomography (CT); Magnetic Resonance Imaging (MRI); Ultrasound (US) Type of Contrast Used: High; Low; Other i.e. Low Osmolar Contrast Enhanced or Non-enhanced for CT and MRI Scans:

Nuclear Medicine Categories Categories of Nuc Med: Planar nuclear medicine imaging; Tomographic nuclear medicine imaging; Positron emission tomorgraphic imaging; Non-imagin nuclear medicine uptake; Non-imaging nuclear medicine probe; Systemic nuclear medicine therapy Type of Radionuclide

Secondary Conditions:

Emphysema Type: Unilateral; Paniobular; Centriobular; Other Type

Intestinal or Peritoneal Adhesions With Obstruction/Without Obstruction

Intestinal Obstruction Type/Etiology: Paralytic ileus, Intussusceptions, Volvulus, Gallstone ileus impaction, Adhesions (other).

Cholecystitis with or without Cholelithiasis Acuity: Acute/Chronic/Acute on Chronic

Anatomical Site: Gallbladder/Bile Duct/Gallbladder & Bile Duct

With Obstruction/Without Obstruction

Diverticulitis Anatomical Site: Small, Large or Both Intestines, e.g. sigmoid colon

With or Without Bleeding

With or Without Hemorrhage

With or Without Perforation/Abscess

Appendicitis Acuity: Acute/Chronic/Acute on Chronic/Recurrent

With or Without Rupture

If rupture: With Localized or Generalized Peritonitis

With or Without Perforation

With or Without (Peritoneal) Abscess

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Traumatic Pneumothorax/Hemothorax Type: Traumatic, Traumatic Hemothorax, Traumatic Hemopneumothorax, Other (Specify)

With or Without Open wound into Thorax; Open; Closed

Encounter: Initial/Subsequent/Sequela

Pleural Effusion Type: Malignant (Specify site and morphology of tumor if possible); Influenzal; Tuburculous; In heart failure

Neoplasm Type: Malignant (Primary; Secondary/Metastatic); Benign; In-Situ; Uncertain Behavior (include cell type)

(Uncertain behavior is a specific pathologic diagnosis indicating behavior that cannot be predicted, as opposed to a diagnosis of unknown pathology)

Morphology: Adenocarcinoma; Sarcoma; Lymphoma etc

Note: A primary malignant neoplasm that overlaps two or more contiguous (next to each other) sites should be classified 'overlapping lesion', unless the combination is specifically indexed elsewhere. For multiple neoplasms of the same site that are not contiguous, such as tumors in different quadrants of the same breast, codes for each site should be assigned.

Behavior: Primary or Secondary Site; Designate if Overlapping

For Secondary Site…document if primary site still exists

Gender: Male or Female

Laterality: Right; Left; Bilateral

Anatomical Site: Breast: Upper-Outer; Upper-Inner; Lower Outer; Lower-Inner; Midline; Central; Nipple; Areola; Axillary tail; Colon: Ascending; Descending; Sigmoid, Transverse; Cecum; Hepatic Flexure; Splenic Flexure; With Rectum; Regional Lymph Node involvement; etc

Volvulus Anatomical Site: Intestinal; Ileal; Jejunal; Ascending Colon; Descending Colon etc

With or Without Perforation

Abscess Anatomical Site: Abdominal/Lung/Wound/Teeth/Extremity, etc

Laterality: Right/Left/Bilateral

Manifestations: i.e. Febrile Neutrophilic Dermatosis/Lymphangitis

Causative Agent: Viral or Bacterial

Causative Organism (if known)

Episode of Care: Initial/Subsequent/Sequela (if

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‘Wound’ related)

Kidney Failure Note: Re Chronic: ‘insufficiency’ and no ‘stage’ codes to ‘unspecified’ code and does not reflect the severity of the patient

Acuity: Acute/Chronic/Acute on Chronic If Chronic:

Stage 1 (GFR ≥ 90) – Kidney Damage with normal or ↑ GFR

Stage 2 (mild) (GFR 60 – 90) + Kidney Damage

Stage 3 (moderate) (GFR 30-59)

Stage 4 (severe) (GFR 15-29)

Stage 5 (GFR ‹ 15) End Stage Renal Disease

Above per KDIGO 2012 Clinical Practice Guidelines

Re Acute: ‘insufficiency’ and ‘kidney disease’ do not report ‘failure, acute renal’

If Acute: due to traumatic injury or non trauma event

Manifestations: With-Acute Tubular Necrosis (ATN)/Acute Cortical Necrosis/Medullary Necrosis

Etiology: Pre-renal AKI/ ATN/Post-Renal Obstructive AKI/Diabetic/Hypertensive

Incidental to Pregnant State vs. Impacting Pregnancy

State “Does not affect or complicate the pregnancy” if incidental, otherwise will code as ‘impacting the pregnancy’

e.g. Pregnant patient with burn of hand, “Burn of hand does not affect or complicate the pregnancy”

Obesity BMI 19 or less = Indicates Malnutrition

BMI 25 – 29.9 = Overweight

(BMI can be taken from Nursing Documentation; MD needs to document the diagnosis and etiology/manifestation correlating to BMI)

BMI 30.0 – 39.9 = Obesity

BMI ≥ 40 = Morbid Obesity (state Etiology: Excess Calories ; Other and Manifestation: Alveolar Hypoventilation, as applicable)

Etiology: Excess Calories (for Morbid Obesity); Drug Induced; Endocrine; Familial; Constitutional; etc

Manifestation: Alveolar Hypoventilation (for Morbid Obesity)

Malnutrition BMI 19 or less = Indicates Malnutrition

Acuity: Acute (< 3 mo); Chronic (>3 mo)

Severity: Mild/Moderate/Severe

(BMI can be taken from Nursing Documentation; MD needs to document the diagnosis and etiology/manifestation correlating to BMI)

Type: Protein Calorie; Protein Energy

Etiology: Renal Disease; Pregnancy Related; Diabetes; Following Gastrointestinal Surgery, etc

Utilize Dietician’s Assessment to assist you with Manifestations: Insufficient Energy Intake;

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diagnosis. To review MNT Nutrition Evaluation in CPSI, Go to

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Hyperglycemia instead. Or if used, stipulate if not hyperglycemic.

Insulin Use

Associated Diagnosis/Conditions: i.e. ulcers

Manifestations or Secondary related problems (document LINK to Diabetes): i.e. neuropathy; nephropathy; retinopathy; ketoacidosis

Pneumonia Type: Healthcare Associated/Aspiration/Ventilator Associated/Radiation Induced

CAUTION: CAP-Community Acquired PNA- defaults to a ‘simple pna’ with low severity; if documented, please also include if it is Viral or Bacterial (and other items listed from list on right, as applicable) to capture the true severity.

Causative Agent: Viral or Bacterial

Causative Organism (if known)

Associated Illnesses: influenza/ lung abscess/Sepsis

Common Secondary Conditions: Acute Respiratory Failure; Exacerbation of COPD, etc.

Clinically significant diagnostic results from Lab and Radiology in the medical record. i.e. if elevated white count; infiltrate on CXR

History of Tobacco Use, Present or Past

COPD Acute Exacerbation or Decompensated

(Chronic RF is very common in pt with severe COPD) CAUTION: ‘Respiratory Distress’ and ‘Respiratory Insufficiency’ are vague and symptomatic of underlying condition – is the intended diagnosis Respiratory Failure OR what is other underlying condition?

If with acute lower respiratory infection, as applicable (also include causative organism, if known)

IF Oxygen Dependent

Common Secondary Conditions: Acute, Chronic, Acute on Chronic Respiratory Failure; Pneumonia, etc.

History of Tobacco Use, Present or Past

Respiratory Failure Acuity: Acute/Chronic/Acute on Chronic

(Chronic RF is very common in pt with severe COPD) CAUTION: ‘Respiratory Distress’ and ‘Respiratory Insufficiency’ are vague and symptomatic of underlying condition – is the intended diagnosis Respiratory Failure OR what is other underlying condition?

Manifestation: With Hypoxia or With Hypercapnia, or both

Etiology: if known (i.e. due to COPD Exacerbation; Pneumonia; Surgery, Trauma, etc)

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Osteomyelitis Acuity: Acute/Subacute/Chronic

Anatomic Site: Body part (i.e. thigh); Specific bone (i.e. femur); Joint (i.e. shoulder)

Laterality: Right/Left/Bilateral

Causative Agent: Viral or Bacterial

Causative Organism (if known)

Etiology/’Due to’: i.e. Acute osteomyelitis, left humerus, ‘due to’ infect hip

Complications: Abscess/Amputation/Avascular necrosis/Gangrene/Meningitis etc.

Non Pressure Ulcer Wound Acuity: Chronic

Laterality

Severity/Depth of Tissue Involved: Skin Breakdown; Fat Layer Exposed; Muscle Necrosis; Bone Necrosis; Unspecified Severity

Etiology: Diabetes; Infection (specify); Other (specify)

Present on Admission, if applicable

Pressure Ulcer Anatomical Site

Laterality

Stage: 1, 2, 3, 4 (Staging can be taken from wound care RN )

Associated Illnesses: i.e. Diabetes

Gangrene, if applicable

Present on Admission, if applicable

CVA/Cerebral Infarction Etiology: Thrombus or Embolism

When you don’t specify side affected as dominant or nondominant: Rt Side defaults to dominant/Lt side defaults to nondominant

Artery Site: Precerebral – Vertebral, basilar, carotid, or other Cerebral – Middle, anterior, or posterior Cerebellar arteries

Laterality, When Appropriate

Dominant or Non-Dominant Side Affected

Associated Conditions i.e. aphasia, hemiplegia, dysphasia

Atrial Flutter Type: Typical (Type 1) or Atypical (Type 2)

Alcohol Dependence with or without Alcohol Withdrawal

Frequency of Usage: Use/Abuse/Dependence/In Remission

Type of Dependence: Uncomplicated; In Remission, Current Intoxication

Manifestations: Delirium, Delusions, Hallucinations, Anxiety, etc;

Specify intoxication/withdrawal as: Uncomplicated or

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With Delirium

Underdosing Intentional vs. Unintentional

Reason for Underdosing i.e. financial hardship or Age related dementia

Episode of Care: Initial/Subsequent/Sequeala

Tobacco Use Use/Dependence/Contact with Second Hand Exposure (Acute or Chronic)

Current/No longer Use Tobacco/Never

Type of Tobacco Product: Cigarette/Chewing Tobacco/Nicotine

If Dependence: Uncomplicated/In remission/With withdrawal/With other Nicotine induced disorder

ADDITIONAL DOCUMENTATION TIPS

Radiology Tests Ordered

‘Better info given →Better outcome on Report’

Reason for Exam –Be Specific as to what looking for - Anatomical Site Specificity/Where specifically the

problem is…i.e. ‘tender over T9’ instead of ‘back pain’

- Indication for Xray, i.e. Lt Pleuritic Chest Pain; Orthopnea; SOB at rest

- Why doing exam/What are you looking for? i.e. re Cancer…’Looking for Metastasis

- AVOID: R/O, Pre –Op, Vague terms i.e. cough, dizzy. Instead state, fever, shakes, chills so Radiologist can help you capture Pneumonia if present.

- Example of Reason for Exam: ‘Pt fell of ladder, pain medial aspect Lt ankle x 3 days’ instead of ‘ankle pain’; OR, ‘Pt with fever, chills, productive cough green sputum x 2 days’ instead of, ‘cough’.

Chronic Conditions/Secondary Diagnosis Capture the Severity!!!

Avoid stating ‘History of’ ……Instead document what you are doing for Chronic Conditions now! Examples of documentation showing link between the additional disease and this admission’s evaluation, treatment, or monitoring:

Hypertensive Heart Disease and Chronic Kidney Disease (CKD), stage 3 (Strict I & O, Monitor BP)

Chronic Systolic Heart Failure (Echo, Lasix 40 mg)

Hypokalemia (K+ repleted)

Acute Blood Loss Anemia (2 U PRBC’s)

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Indicate “Present on Admission” (POA) status, as applicable

A diagnosis without documentation of being present on admission could be inadvertently considered a hospital-acquired condition (HAC). Example: Pneumonia not definitively diagnosed until hospital day two but suspected, probable, or likely on admission should be noted as such. This allows coders to most accurately report the condition as being POA as opposed to hospital-acquired.

AVOID Signs and Symptoms as Diagnosis Definitive diagnoses are preferred in the inpatient setting and support a higher evaluation and management (E/M) fee. In the inpatient setting, coders can capture ‘probable’, ‘likely’, ‘suspected’, or presumed diagnoses when patients present with the signs and symptoms of the diagnoses being ruled out…. as long as those diagnoses are restated in the discharge summary and have not been ruled out during the stay.

References: 3M physician video; CMS Road to 10; Coding Guidelines; 3M Doc tips; AHIMA ACDIS ICD 10 Webinar 12.2014; ACDIS ICD 10 CDI Bootcamp 2014; ICD 10 CM for Hospitals; Precyse Doc Talks; Exc Debridement: Docu prompter…CMS; Coding Clinic, Second Quarter 2004 Page 5; ACDIS Annual Conference 2015; TFHS P & P.

Check out www.tfhd.com/icd10

http://www.tfhd.com/icd10