ICD 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.
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Table of contents Alzheimer's 6
Anemia 7
Aplastic Anemia 8
Atrial Fib 9
BMI – high 10
BMI –low 11
Cardiac Arrest 12
Cellulitis 13
Cerebral Edema 14
Chest pain 15
Cirrhosis of Liver 16
Cleft Palate 17
Factor VII 18
Colitis 19
Coma 20
Cor Pulmonale 21
Crohn’s Disease / Regional Enteritis 22
CVA 23
Debridement 24
Degenerative Disc Disease 25
Dementia 26
Diabetes 27
Diverticulitis 28
Dysphasia 29
Encephalopathy 30
Endometriosis 31
Epidymitis 32
Esophagitis 33
Foot deformity 34
Fracture- Bone 35
Functional Quadriplegia 36
Gastroparesis 37
Gastrointestinal Ulcer- Upper 38
GERD 39
Gout 40
Headache/ Migraine 41
Heart failure- acute 42
Heart failure-chronic 43
Hepatitis 44
HIV-AIDS 45
Hypertension 46
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Hyponatremia 47
Influenza 48
Joint complication 49
Leukemia 50
Level of consciousness 51
Lung Cancer 52
Lymphoma 53
Meningitis 54
Mental Status- Altered 55
Metabolic—acidosis/ alkalosis 56
Mood Disorder 57
Myocardial Infarction 58
Neoplasm 59
Neutropenia 60
Non pressure ulcer 61
Malnutrition 62
Pregnancy 63
Open Fracture 64
Osteomyelitis 65
Ovarian Cancer 66
Table of Contents Pain 67
Pancreatitis 68
Personal Injury 69
Pleurodesis 70
Pneumonia- Aspiration 71
Pneumonia- Hypostatic /passive/ stasis 72
Pneumonia-Specificity 73
Premature infant 74
Pressure Ulcer 75
Prostatitis 76
Pulmonary embolism 77
Purpera 78
Renal Failure—acute 79
Renal failure-chronic 80
Respiratory-asthma 81
Respiratory- Bronchitis 82
Respiratory- COPD 83
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Table of Contents
Respiratory- Emphysema 84
Respiratory failure 85
Respiratory failure post op 86
Schatzki Ring 87
Scoliosis 88
Sepsis 89
Shock 90
Sickle Cell Disease 91
Substance abuse 92
Testicular Torsion 93
TIA 94
Tumor Lysis Syndrome 95
Urosepsis 96
UTI 97
Weakness 98
Hospital specific
Documentation Specialists contact info 99-106
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ICD10 documentation specificity needed
ICD9 Documentation
Alzheimer’s
ICD10 Documentation Needed
Identify onset, behavior disturbances and with dementia or associated delirium
[ ] Alzheimer’s disease
[ ] Early onset [ ] Late onset [ ] Unspecified [ ] Other
[ ] Alzheimer’s disease with behavioral disturbances
[ ] Aggressive [ ] Combative [ ] Violent [ ] Unspecified
[ ] Other_______
[ ] Alzheimer’s disease with dementia
[ ] Acute [ ] Sub acute [ ] With wandering
[ ] Alzheimer’s disease with associated delirium
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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
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ICD10 documentation specificity needed
ICD9 Documentation
Aplastic Anemia
ICD10 Documentation Needed
Identify Specificity
[ ] Acquired pure red cell aplasia:
[ ] Chronic [ ] on Treatment
[ ] Transient [ ] Other
[ ] Constitutional: [ ] Congenital
[ ] Idiopathic [ ] Acquired
[ ] Drug Induced (please specify drug): ________
[ ] Due to other external causes (please specify cause, i.e. radiation, etc): _______________________
[ ] Idiopathic
[ ] Unspecified
[ ] Sideroblastic Anemia: [ ] Hereditary
[ ] Due to disease
[ ] Due to drugs/toxins
[ ] Congenital
[ ] Anemia in Neoplastic Disease
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ICD10 documentation specificity needed
ICD9 Documentation
A fib
ICD10 Documentation Needed
IDENTIFY TYPE
[ ] Paroxysmal Atrial Fibrillation
[ ] Persistent Atrial Fibrillation
[ ] Chronic Atrial Fibrillation (includes permanent Atrial Fibrillation)
[ ] Unspecified Atrial Fibrillation
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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: _____)
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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
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ICD10 documentation specificity needed
ICD9 Documentation
Cardiac Arrest
ICD10 Documentation Needed
Identify underlying cause, post procedure or intra-op arrest
[ ] Underlying cardiac condition (specify)___________
[ ] Underlying other condition (specify)______
[ ] Cause unspecified
[ ] Post procedural cardiac arrest following cardiac surgery
[ ] Post procedural cardiac arrest following other surgery
[ ] Intra-operative cardiac arrest during cardiac surgery
[ ] Intra-operative cardiac arrest during other surgery
[ ] Any associated diagnoses / conditions________
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ICD10 documentation specificity needed
ICD9 Documentation
Cellulitis
ICD10 Documentation Needed
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
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ICD10 documentation specificity needed
ICD9 Documentation
Cerebral edema
[ ] Cerebral edema / Vasogenic edema
[ ] Compression of brain
[ ] Findings not significant
[ ] Radiologic finding only
[ ] Does not apply to this patient
ICD10 Documentation Needed
Same as ICD 9
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ICD10 documentation specificity needed
ICD9 Documentation
Chest Pain[ ] Costochronditis
[ ] Pleurisy
[ ] Pleuritic pain
[ ] Angina with known coronary artery disease
[ ] Angina: [ ] Stable [ ] Unstable
[ ] Psychogenic cardiovascular disorder
[ ] Chest wall pain
[ ] Cholelithiasis / Cholecystitis
[ ] GERD
[ ] Esophagitis
[ ] Does not apply to this patient
ICD10 Documentation Needed
Same as ICD 9
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ICD10 documentation specificity needed
ICD9 Documentation
Cirrhosis of Liver
ICD10 Documentation Needed
Identify if alcoholic or non-alcoholic, if congenital, biliary obstructive, laennec’s and if portal
[ ] Alcoholic [ ] Non-alcoholic
[ ] Congenital ____ (underlying disease)
[ ] Biliary / Obstructive:
[ ] Primary [ ] Secondary
[ ] Laennec’s:
[ ] Alcoholic with: [ ] dependence
[ ] non-dependence
[ ] Non-alcoholic
[ ] Portal: [ ] Alcoholic [ ] Non-alcoholic
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ICD10 documentation specificity needed
ICD9 Documentation
Cleft Palate
ICD10 Documentation Needed
Identify Type, Laterality and any associated diagnosis
[ ] Hard [ ] Medial [ ] Soft [ ] Uvula
[ ] Hard with Soft
[ ] Cleft Lip Involvement
[ ] Unilateral Cleft Lip
[ ] Bilateral Cleft Lip
[ ] Median Cleft Lip
[ ] Associated diagnosis/conditions (please specify): ___________________
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ICD10 documentation specificity needed
ICD9 Documentation
Factor VII
ICD10 Documentation Needed
Identify for Reason for Factor VII administration
[ ] Idiopathic acquired coagulation defect
[ ] Surgical acquired coagulation defect (Bleeding related to a coagulopathy after surgery, not correctable by surgery)
[ ] Unspecified coagulation defect
[ ] Congenital coagulation defect
[ ] Acquired coagulation defect secondary to: _______
[ ] Disseminated intravascular coagulation
[ ] Hereditary Factor VIII deficiency
[ ] VII [ ] IX [ ] XI
[ ] Primary Thrombophilia: [ ] Von Willebrand’s disease [ ] Lupus anticoagulant
[ ] Hemorrhagic Disorder: [ ] circulating anticoagulants [ ] Intrinsic [ ] Extrinsic
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ICD10 documentation specificity needed
ICD9 Documentation
Colitis
ICD10 Documentation Needed
Identify Site, Type and ComplicationsSite (if applicable):
[ ] Small Intestine [ ] Large Intestine [ ] Other site __
Type:
[ ] Colitis due to radiation
[ ] Ulcerative Colitis
[ ] Infectious Colitis
[ ] Toxic Colitis
[ ] Ischemic Colitis
[ ] Colitis due to ___________________
[ ] Chronic Colitis
Complications:
[ ] Rectal Bleeding
[ ] Intestinal Obstruction
[ ] Fistula
[ ] Abscess
[ ] Other complication _________________
[ ] Unspecified complication
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ICD10 documentation specificity needed
ICD9 Documentation
Coma
ICD10 Documentation Needed
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_________
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ICD10 documentation specificity needed
ICD9 Documentation
Cor Pulmonale
[ ] Acute Cor Pulmonale
[ ] Chronic Cor Pulmonale
[ ] Pulmonary Hypertension
[ ] Does not apply to this patient
ICD10 Documentation Needed
Same as ICD 9
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ICD10 documentation specificity needed
ICD9 Documentation
Crohn’s Disease / Regional Enteritis
ICD10 Documentation Needed
Identify specificity, site and associated diagnosis[ ] Abscess
[ ] Fistula
[ ] Intestinal obstruction
[ ] Rectal bleeding
[ ] Other (specify) _______________
Site:
[ ] Small Intestine
[ ] Large Intestine
[ ] both small and large intestines
Associated diagnoses / conditions (specify)________
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ICD10 documentation specificity needed
ICD9 Documentation
CVA
ICD10 Documentation Needed
Identify Laterality, type, location and manifestations
[ ] CVA -- Laterality: [ ] Right [ ] Left [ ] Bilateral [ ] Unspecified
[ ] Hemorrhage (non-traumatic): Please specify Artery: _____________________[ ] Subarachnoid[ ] Intracerebral[ ] Extradural[ ] Subdural: [ ] Acute [ ] Subacute [ ] Chronic
[ ] Cerebral Infarction [ ] Cerebral [ ] Pre-Cerebral Please specify Artery: ___________
[ ] Thrombosis[ ] Embolism[ ] Unspecified occlusion or stenosis[ ] Venous Thrombosis[ ] Other Cerebral Infarction[ ] Cerebral Infarction Unspecified (Stroke NOS)
[ ] Occlusion / Stenosis without Cerebral Infarction[ ] Pre-Cerebral Artery: [ ] Vertebral [ ] Carotid [ ] Other Pre-Cerebral
Artery[ ] Cerebral Artery: [ ] Middle [ ] Anterior [ ] Posterior[ ] Cerebellar [ ] Other Cerebral Artery [ ] Unspecified Cerebral Artery
[ ] Manifestations / Residual Effects[ ] Hemiplegia [ ] Right [ ] Left [ ] Unspecified[ ] Dysphagia
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ICD10 documentation specificity needed
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
ICD10 Documentation Needed
Same as ICD 9
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ICD10 documentation specificity needed
ICD9 Documentation
Degenerative Disc Disease
ICD10 Documentation Needed
Identify Location and if with Myelopathy/Neuritis/Radiculopathy/Radiulitis
[ ] Degenerative Cervical Disc Disease
Specify level of spine: ___________
[ ] With Myelopathy [ ] With Neuritis, Radiculopathy, Radiculitis
[ ] Other/Unspecified
[ ] Degenerative Sacrococcygeal Disc Disease
[ ] Degenerative Lumbar Disc Disease
[ ] With Myelopathy [ ] With Neuritis, Radiculopathy, Radiculitis
[ ] Other/Unspecified
[ ] Degenerative Thoracic Disc Disease
[ ] With Myelopathy [ ] With Neuritis, Radiculopathy, Radiculitis
[ ] Other/Unspecified
[ ] Degenerative Thoraco-Lumbar Disc Disease
[ ] With Myelopathy [ ] With Neuritis, Radiculopathy, Radiculitis
[ ] Other/Unspecified
[ ] Degenerative Lumbosacral Disc Disease
[ ] With Myelopathy [ ] With Neuritis, Radiculopathy, Radiculitis
[ ] Other/Unspecified
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ICD10 documentation specificity needed
ICD9 Documentation
Dementia
ICD10 Documentation Needed
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: ___________________
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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
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ICD10 documentation specificity needed
ICD9 Documentation
Diverticulitis
ICD10 Documentation Needed
IDENTIFY Acuity, Severity, Site and Type
Acuity:
[ ] Acute [ ] Chronic [ ] Acute on Chronic
Severity:
[ ] Bleeding [ ] No bleeding
[ ] Abscess [ ] No abscess
[ ] Perforation [ ] No perforation
Site:
[ ] Ileum [ ] Small Intestine
[ ] Large Intestine
[ ] Unspecified Intestine
Type:
[ ] Meckel’s diverticulum with diverticulitis
[ ] Meckel’s diverticulum without diverticulitis
29 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Dysphagia
ICD10 Documentation Needed
IDENTIFY PHASE, TYPE and ACUITY
Phase: [ ] Oral [ ] Oropharyngeal [ ] Pharyngeal [ ] Pharyngoesophageal
Type: [ ] Cervical [ ] Functional[ ] Hysterical [ ] Nervous [ ] Neurogenic[ ] Siderpenic [ ] Spastica
Following Non-Traumatic: [ ] SAH [ ] Intracerebral Hemorrhage[ ] Intracranial Hemorrhage[ ] CVA
Acuity: [ ] Acute [ ] Chronic [ ] Acute on Chronic
[ ] Other specified Dysphagia:___________
[ ] Unspecified Dysphagia
30 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Encephalopathy
ICD10 Documentation Needed
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
31 ©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)
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ICD10 documentation specificity needed
ICD9 Documentation
Epididymitis
ICD10 Documentation Needed
IDENTIFY Organism and With/Without Abscess
[ ] Bacterial (specify organism if known: ____________)
[ ] Viral (specify organism if known: _______________)
[ ] With abscess [ ] Without abscess
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ICD10 documentation specificity needed
ICD9 Documentation
Esophagitis
ICD10 Documentation Needed
IDENTIFY SPECIFICITY
[ ] Eosinophilic Esophagitis[ ] Esophagitis with GERD / Reflux[ ] Candida Esophagitis[ ] Ulcerative Esophagitis[ ] Esophagitis Unspecified[ ] Other Esophagitis
34 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Foot Deformity
ICD10 Documentation Needed
IDENTIFY SPECIFICITY
(for any deformity marked below specify):
[ ] Congenital [ ] Acquired
[ ] Talipes equinovarus [ ] left [ ] right [ ] bilateral
[ ] Talipes calcaneovarus [ ] left [ ] right [ ] bilateral
[ ] Metatarsus varus [ ] left [ ] right [ ] bilateral
[ ] Talipes calcaneovalgus [ ] left [ ] right [ ] bilateral
[ ] Pes planus [ ] left [ ] right [ ] bilateral
[ ] Pes cavus [ ] left [ ] right [ ] bilateral
[ ] Vertical talus deformity [ ] left [ ] right [ ] bilateral
[ ] Other foot deformity (please specify): _________
[ ] Associated diagnosis/conditions (please specify): __
35 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Bone fracture
ICD10 Documentation Needed
IDENTIFY Site, Laterality, Type, Cause and EncounterSite: ________ Laterality: [ ] Right [ ] Left
Type of fracture: Check all that apply
[ ] Traumatic fracture [ ] Pathologic fracture
[ ] Osteoporosis fracture---
[ ] Disuse [ ] Drug- induced
[ ] Postmenopausal
[ ] Idiopathic [ ] Post-surgical
malabsorption [ ] Other (specify)___________
[ ] Stress or fatigue fracture
[ ] Neoplastic fracture
Other type of fracture: Check all that apply
[ ] Non-displaced [ ] Displaced
[ ] Open (Gustilo) [ ] Closed (greenstick, spiral)
[ ]Salter-Harris—specify type_________
External cause of fracture (fall, skiing) _________________________
Encounter type:
[ ] Initial encounter
[ ] Subsequent encounter---
[ ] Routine healing [ ] Delayed healing [ ] Nonunion
[ ] Malunion [ ] Sequela
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ICD10 documentation specificity needed
ICD9 Documentation
Functional Quadriplegia
[ ] Functional quadriplegia (complete immobility)
[ ] Immobilization syndrome (impaired mobility)
ICD10 Documentation Needed
Same as ICD 9
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ICD10 documentation specificity needed
ICD9 Documentation
Gastroparesis
ICD10 Documentation Needed
Identify if related to diabetes and if underlying disease
[ ] Gastroparesis related to Diabetes
[ ] Gastroparesis in underlying disease/process (please state: ______________)
38 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Upper Gastrointestinal Ulcer
ICD10 Documentation Needed
Identify acuity, type and any related or contributing disease
Acuity:
[ ] Acute [ ] Chronic
[ ] Hemorrhage -or- [ ] No Hemorrhage
[ ] Perforation -or- [ ] No Perforation
Type:
[ ] Gastric Ulcer
[ ] Esophageal Ulcer
[ ] Duodenal, Duodenum
[ ] Other location ________________
[ ] Any related or contributing disease(s) Alcohol or drugs: _________________
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ICD10 documentation specificity needed
ICD9 Documentation
GERD
ICD10 Documentation Needed
IDENTIFY GERD WITH OR WITHOUT ESOPHAGITIS
Gastro esophageal reflux disease (GERD) with Esophagitis
Gastro esophageal reflux disease (GERD) without Esophagitis
40 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Gout
ICD10 Documentation Needed
IDENTIFY Type, joint involved and acuity
Specify the type/cause of gout:
[ ] Drug-induced [ ] Secondary
[ ] Idiopathic [ ] Syphilitic
[ ] Lead-induced [ ] Primary
[ ] With renal impairment (specify the specific renal disease/disorder, including acuity and/or state)____
Specify the specific joint involved _ [ ] Right [ ] Left
Specificity acuity of gout:
[ ] Acute
[ ] Chronic – with or without tophus
[ ] Gout attack
[ ] Gout flare
41 ©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_________________________
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ICD10 documentation specificity needed
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
ICD10 Documentation Needed
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
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ICD10 documentation specificity needed
ICD9 Documentation
CHRONIC HEART FAILURE
[ ] Chronic Systolic Heart Failure
[ ] Chronic Diastolic Heart Failure
[ ] Chronic Systolic and Diastolic Heart Failure
ICD10 Documentation Needed
SAME as ICD 9 with the addition of etiology
Etiologies:
[ ] Hypertension
[ ] Valvular disease
[ ] Rheumatic heart disease
44 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Hepatitis
ICD10 Documentation Needed
IDENTIFY Acuity, Etiology and associated diagnosis
Acuity: [ ] Acute [ ] Chronic
Etiology:
[ ] Alcoholic
[ ] Drug induced (specify)____
[ ] Viral (type A,B,C,E)_______
Associated Diagnosis:
[ ] with hepatic coma
[ ] without hepatic coma
[ ] with delta agent
[ ] without delta agent
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ICD10 documentation specificity needed
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
ICD10 Documentation Needed
Similar to ICD 9
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ICD10 documentation specificity needed
ICD9 Documentation
Hypertension
[ ] Malignant Hypertension
[ ] Accelerated Hypertension
[ ] Benign Hypertension
[ ] Unspecified Hypertension
ICD10 Documentation Needed
Same as ICD 9
47 ©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
48 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Influenza
ICD10 Documentation Needed
IDENTIFY Organism and associated factors
[ ] Influenza caused by ______ (specify organism)
[ ] Influenza-associated Encephalopathy
[ ] Influenza-associated Pneumonia
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ICD10 documentation specificity needed
ICD9 Documentation
Complication of Joint
ICD10 Documentation Needed
IDENTIFY Location, Laterality and Due to
Location of joint with prosthesis: ___
[ ] Right [ ] Left
Complication of internal joint prosthesis due to:
[ ] Infection (if known, specify organism______)
[ ] Mechanical:
[ ] Broken specify organism: prosthesis
[ ] Dislocation
[ ] Loosening
[ ] Osteolysis
[ ] Breakdown of prosthesis
[ ] Displacement of prosthesis
[ ] Wear of articular bearing
[ ] Peri-prosthetic Fracture (specify site: ____
[ ] Other mechanical complication: ________
[ ] Pain
[ ] Hemorrhage
50 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Leukemia
ICD10 Documentation Needed
IDENTIFY Acuity, Type and Status
Acuity: [ ] Acute [ ] Chronic
Type: [ ] Lymphoid (Cell type: _______)
[ ] Myeloid (Cell type: ___________) [ ] Monocytic (Cell type: ________) [ ] Other Leukemias of specified cell type: ____________
[ ] Leukemia of unspecified cell type
Status:
[ ] Has not achieved remission
[ ] In Remission
[ ] In Relapse
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ICD10 documentation specificity needed
ICD9 Documentation
Level of Consciousness[ ] Coma / Comatose
[ ] Encephalopathy, type: ____________________________
[ ] Persistent vegetative state
[ ] Stupor
ICD10 Documentation Needed
Same as ICD 9
52 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Lung CA
ICD10 Documentation Needed
IDENTIFY Site, Laterality, Type and Malignancy
Site:
[ ] Carina [ ] Main bronchus
[ ] Upper lobe [ ] Middle Lobe
[ ] Lower Lobe [ ] Other ___________
Laterality: [ ] Right [ ] Left
Type:
[ ] Primary [ ] Secondary
[ ] In situ [ ] Overlapping primary
[ ] Malignant [ ] Benign
[ ] Kaposi’s Sarcoma [ ] Other___________
Malignancy:
[ ] Excised [ ] Eradicated
[ ] Treatment still provided for primary and/or metastatic site
[ ] Evidence of remaining malignancy at primary site
53 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Lymphoma
ICD10 Documentation Needed
IDENTIFY Anatomical Site, Type and Cell Type
Anatomical Site: _______________________)
Type:
[ ] Hodgkins (Cell type: _________)
[ ] Follicular (Cell type: _________)
[ ] Non-Follicular (Cell type: _________)
[ ] Mature T/NK Cell (Cell type: _________)
[ ] Other Specified/ Unspecified Non-Hodgkin’s (Cell type: ___________________)
[ ] Other Specified T/NK Cell (Cell type: _____)
[ ] Unspecified
54 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Meningitis
ICD10 Documentation Needed
Identify Type, Organism and Present on Admission
[ ] Viral Meningitis
[ ] Specify organism (i.e. adenovirus, enterovirus, measles, etc.) ___________
[ ] Bacterial Meningitis - Acute
[ ] Specify organism (i.e. gram negative, staph, strep, e coli, etc.)___________
[ ] Due to (please specify cause) _________
[ ] Aseptic - Acute
[ ] Late effect
[ ] Septic
[ ] Present on Admission [ ] Yes [ ] No
[ ] Unable to determine
55 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Altered Mental Status
ICD10 Documentation Needed
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
56 ©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
57 ©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
58 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Myocardial Infarction
ICD10 Documentation NeededIdentify Type, Age of Infarction, Encounter,
Site and ArteryMI TYPE:
[ ] Acute Coronary Syndrome (ACS) without Acute MI (Per coding guidelines, ACS equates to Unstable Angina)
[ ] STEMI (please also specify site and artery—see below)
[ ] NSTEMI
AGE OF INFARCTION:
[ ] Less than 4 weeks of admission
[ ] Greater than 4 weeks of admission
[ ] Less than 8 weeks
[ ] Greater than 8 weeks
[ ] Unable to determine
ENCOUNTER:
[ ] Initial [ ] Subsequent
If STEMI, SITE:
[ ] Anterior [ ] Apical
[ ] Lateral [ ] Inferior
[ ] Posterior [ ] Q Wave [ ] Septal
[ ] Unspecified [ ] Other _____________________
SPECIFIC ARTERY (Based on site)
[ ] Left Main Coronary [ ] Diagonal
[ ] Left Anterior Descending [ ] Oblique Marginal
[ ] Right Coronary Artery [ ] Other ___________________
[ ] Left Circumflex [ ] Unspecified
59 ©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 ____________________________________
60 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Neutropenia
ICD10 Documentation Needed
Identify Cause
[ ] Congenital
[ ] Secondary to chemotherapy (list chemotherapeutic drug: __________)
[ ] Drug induced (list drug: ________________)
[ ] Due to infection (infection site: _______ Organism: _________________________)
[ ] Cyclic
[ ] Does not apply to this patient
[ ] Unspecified
61 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Non Pressure Ulcer
ICD10 Documentation Needed
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
Depth
[ ] Skin only [ ] Fat exposed [ ] Muscle Necrosis
[ ] Bone Necrosis
Type
[ ] Diabetic [ ] Vascular r/t PVD [ ] Varicose
[ ] Atherosclerosis of lower limb
[ ] Postphlebitic syndrome
[ ] Postthrombotic syndrome
[ ]Chronic venous hypertension [ ] Other (specify) ______
Gangrene [ ] Yes [ ] No
62 ©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
63 ©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): ________
64 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Open Fraction
ICD10 Documentation Needed
Specificity for open fractures of the forearm, femur, and lower leg require documentation to Specify Gustilo Type I through Type IIIC.
OPEN Fracture(s): ___________________________
Site: __Laterality: [ ] Right [ ] Left Gustilo type:___
GUSTILO CLASSIFICATION
Type I: Wound < 1cm, clean, generally caused by a fracture fragment that pierces the skin
Type II: Wound > 1cm, not contaminated, without mod soft tissue injury or defect.
Type III: Wound > 1 cm. with significant soft tissue disruption, severely unstable fracture with varying degrees of fragmentation
Type IIIA: Wound < 10 cm, crush injury and contamination, sufficient soft tissue to cover the bone without the need for local or distant flap coverage
Type IIIB: Disruption of the soft tissue is extensive, such that local or distant flap coverage is necessary to cover the bone. The wound maybe contaminated and serial irrigation and debridement procedures are necessary to ensure a clean surgical wound >10 cm, crushed tissue
Type IIIC: Any open Fracture associated with an arterial injury that requires repair.
65 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Osteomyelitis
ICD10 Documentation Needed
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
66 ©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
67 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Pain
ICD10 Documentation Needed
Identify acuity and cause
[ ] Acute Pain
[ ] Trauma
[ ] Post- Thoracotomy
[ ] Post- operative / post-procedural
[ ] Other __________________
[ ] Chronic pain
[ ] Trauma
[ ] Post-Thoracotomy
[ ] Post-operative / post-procedural
[ ] Other __________________
[ ] Neoplasm pain
68 ©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
69 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Injury
ICD10 Documentation Needed
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.) ______________________________
70 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Pleurodesis
[ ] Talc Pleurodesis and scarification of the pleura
[ ] Talc Pleurodesis only
[ ] Scarification of pleura (mechanical without talc)
ICD10 Documentation Needed
Same as ICD 9
71 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Aspiration Pneumonia
ICD10 Documentation Needed
IDENTIFY SPECIFICITY and any associated illnesses
[ ] Aspiration Bronchitis[ ] Pneumonia secondary to______ (specify organism / underlying disease)[ ] Community Acquired (simple) Pneumonia[ ] Healthcare / Hospital Acquired Pneumonia (outside facility / prior hospitalization) [ ] Ventilator associated[ ] Radiation induced
[ ] Associated illness: [ ] Respiratory failure [ ] Sepsis [ ] Underlying lung disease [ ] Other specify)_____
[ ] Pneumonia of unknown etiology[ ] Infiltrates without evidence of Pneumonia
72 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
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)________________
ICD10 Documentation Needed
Same as ICD 9
73 ©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
74 ©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
75 ©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)
76 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Prostatitis
ICD10 Documentation Needed
Identify acuity, bacterial vs viral and organism if know
[ ] Acute Prostatitis:
[ ] Bacterial (organism __________ if known)
[ ] Viral (organism ______________if known)
[ ] Chronic Prostatitis:
[ ] Bacterial (organism ________ if known)
[ ] Viral (organism ____________if known)
77 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Pulmonary Embolism
ICD10 Documentation Needed
Identify acuity, type and if associated acute cor pulmonale
Acuity:
[ ] Acute [ ] Chronic
Type:
[ ] Saddle [ ] Septic [ ] Other___
[ ] Pulmonary Embolism with associated Acute Cor Pulmonale
78 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Purpura
ICD10 Documentation Needed
[ ] Allergic Purpura:
[ ] Hemorrhagic [ ] Idiopathic
[ ] Type (specify)__________________
[ ] Site__________________
[ ] Related process_________________
[ ] Causal organism__________________
[ ] Immune thrombocytopenic purpura
[ ] Post-transfusion purpura
[ ] Secondary thrombocytopenia
[ ] Hereditary
79 ©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
80 ©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
81 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Asthma
ICD10 Documentation Needed
Identify acuity and type[ ] Acute exacerbation of Asthma
[ ] Status Asthmaticus
[ ] Acute exacerbation of Allergic Bronchitis
[ ] Asthma:
[ ] Mild intermittent
[ ] Mild persistent
[ ] Moderate persistent
[ ] Severe Persistent
Type:
[ ] Childhood [ ] Exercise induced
[ ] Late onset [ ] Mixed
[ ] Other (specify)________________
[ ] COPD
[ ] Chronic obstructive bronchitis
[ ] Acute lower respiratory infection
82 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Bronchitis
ICD10 Documentation Needed
Identify acuity and due to
[ ] Acute exacerbation of Bronchitis
[ ] Acute on Chronic Bronchitis
[ ] Chronic Bronchitis obstructive
[ ] Bronchitis due to:
[ ] Fumes
[ ] Radiation
[ ] Viral or Bacterial Organism____________
83 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
COPD
ICD10 Documentation Needed
Identify Acuity
[ ] Acute exacerbation of COPD
[ ] Acute exacerbation of Asthma
[ ] COPD – Chronic and stable
84 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Emphysema
ICD10 Documentation Needed
Identify Acuity and Type
Acuity:
[ ] Acute exacerbation of Emphysema
[ ] Chronic and stable Emphysema
Type:
[ ] Unilateral:
[ ] Sawyer-James Syndrome
[ ] Unilateral Hyper-Lucent Lung
[ ] Unilateral Pulmonary Artery Functional Hypoplasia
[ ] Pan lobular
[ ] Centrilobar
85 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Respiratory Failure
ICD10 Documentation Needed
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
86 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Post op Respiratory Issues
ICD10 Documentation Needed
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
87 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Schatzki Ring
[ ] Schatzki Ring - Congenital
[ ] Schatzki Ring - Acquired
[ ] Schatzki Ring - unable to determine / unspecified
ICD10 Documentation Needed
Same as ICD 9
88 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
SCOLIOSIS
ICD10 Documentation Needed
Identify Type, Acuity and SiteType:
[ ] Infantile Idiopathic [ ] Juvenile Idiopathic
[ ] Adolescent [ ] Other idiopathic
[ ] Thoracogenic [ ] Neuromuscular
[ ] Other secondary
Acuity:
[ ] PROGRESSIVE
[ ] RESOLVING
Site:
[ ] Occipito-atlanto-axial [ ] Cervical
[ ] Cervicothoracic [ ] Thoracic
[ ] Thoracolumbar [ ] Lumbar
[ ] Lumbosacral [ ] Sacral
[ ] Sacrococcygeal
89 ©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.) _______________________
90 ©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
91 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Sickle Cell Disease
ICD10 Documentation Needed
Identify Type and Acuity
Type:
[ ] Hb-C
[ ] Hb-ss
[ ] Hb-SD / Hb-SE / Specified NEC / Spherocytosis
[ ] Thalassemia
Acuity:
[ ] With Crisis:
[ ] Acute Chest Syndrome
[ ] Splenic Sequestration
[ ] Without Crisis
92 ©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
93 ©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
94 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
TIA
ICD10 Documentation Needed
Identify TIA TYPE
[ ] TIA Stenosis / Syndrome related to:
[ ] Vertebro-Basilar Artery
[ ] Carotid Artery
[ ] Multiple / Bilateral Pre-Cerebral Artery
[ ] Cerebral / Pre-cerebral occlusion / stenosis
[ ] Small vessel disease of the brain / cerebral vascular disease
[ ] Transient Global amnesia
[ ] Amaurosis Fugax
[ ] Other TIA
[ ] Unspecified TIA (spasm of cerebral artery, transient cerebral ischemia)
95 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Tumor Lysis Syndrome
[ ] Tumor Lysis Syndrome following anti-neoplastic drug chemotherapy
[ ] Spontaneous Tumor Lysis Syndrome
ICD10 Documentation Needed
Same as ICD 9
96 ©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
97 ©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
98 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Weakness
ICD10 Documentation Needed
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
99 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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
100 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
Sts. Mary and Elizabeth
Clinical Documentation Specialists Mickey Decker– 502-361-6125
Cheryl Brooks-502-361-6549
Annette Majors- 502-361-6495
Manager- Sandy Hodge- Bowman 502-409-2673
Supervisor- Kristen Boles 859-421-1542
Questions—contact your Clinical Documentation Specialists at your hospital
101 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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
Manager- Sandy Hodge- Bowman 502-409-2673
Supervisor- Kristen Boles 859-421-1542
Questions—contact your Clinical Documentation Specialists at your hospital
102 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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
Manager- Sandy Hodge- Bowman 502-409-2673
Supervisor- Kristen Boles 859-421-1542
Questions—contact your Clinical Documentation Specialists at your hospital
103 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
St. Joe East
Clinical Documentation Specialists Kimberly Gilbert-Morrison—502-316-5220
Kelly Geers—502-750-2329
Manager- Sandy Hodge- Bowman 502-409-2673
Supervisor- Kristen Boles 859-421-1542
Questions—contact your Clinical Documentation Specialists at your hospital
104 ©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
105 ©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
106 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
St. Joe Mt. Sterling
Clinical Documentation Specialists Lori Barry—859-497-5458
Manager- Sandy Hodge- Bowman 502-409-2673
Supervisor- Kristen Boles 859-421-1542
Questions—contact your Clinical Documentation Specialists at your hospital