anesthesiology and other common documentation tips icd 10 documentation specificity needed based on...
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ANESTHESIOLOGYand Other Common Documentation TipsICD 10 Documentation Specificity Needed based on Conifer ICD 10 CDI Queries
2 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD 10 Documentation Specialty Introduction
ICD 10 is being mandated by CMS. Compliance date is set at October 2015. ICD-9 Diagnosis Codes = 14,000
ICD-10 Diagnosis Codes = 69,000
ICD-9 Procedure Codes = 3,800
ICD-10 Procedure Codes = 71,000
The CDI team is here to help with inpatient provider documentation specificity needed in I-10.
Based on Conifer ICD 10 Updated queries, the attached pages will assist with the documentation needed in I-10.
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Table of Contents Alzheimer's 4
Anemia 5
Aplastic Anemia 6
Atrial Fib 7
BMI – high 8
BMI –low 9
Cardiac Arrest 10
Cellulitis 11
Degenerative Disc Disease 12
Dementia 13
Diabetes 14
Diverticulitis 15
Dysphasia 16
Hypertension 17
Hyponatremia 18
Level of consciousness 19
Lung Cancer 20
Lymphoma 21
Mental Status- Altered 22
Metabolic -acidosis/ alkalosis 23
Neoplasm 24
Non pressure ulcer 25
Malnutrition 26
Pregnancy 27
Pain 28
Pneumonia- Aspiration 29
Pneumonia-Specificity 30
Pressure Ulcer 31
Pulmonary embolism 32
Renal Failure—acute 33
Renal failure-chronic 34
Respiratory-asthma 35
Respiratory- Bronchitis 36
Respiratory- COPD 37
Respiratory- Emphysema 38
Respiratory failure 39
Respiratory failure post op 40
Substance abuse 41
Hospital specific
Documentation Specialists contact info 42-49
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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
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
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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
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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
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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
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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
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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
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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
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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
23 ©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
24 ©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 ____________________________________
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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
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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
27 ©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): ________
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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
29 ©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
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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
31 ©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)
32 ©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
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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
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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
35 ©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
36 ©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____________
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ICD10 documentation specificity needed
ICD9 Documentation
COPD
ICD10 Documentation Needed
Identify Acuity
[ ] Acute exacerbation of COPD
[ ] Acute exacerbation of Asthma
[ ] COPD – Chronic and stable
38 ©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
39 ©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
40 ©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
41 ©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
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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
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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
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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
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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
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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
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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
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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
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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