icd-10 documentation - peacehealth...icd-10 documentation women’s health care symposium september...
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ICD-10 documentation Women’s Health Care Symposium
September 25th, 2015Springfield, Oregon
Dr. Juanita [email protected]: 541-510-5602
• I have no relevant financial disclosures
ICD-10• October 1st is the transition date• Replaces ICD-9 which is about 30 years old• There is a significant increase in number of codes
• Increased specificity will influence:– Public health issues and research decisions– VBP and PFP and national provider profiling
What are the primary changes?• Laterality• Episode of care (initial, subsequent, sequela)• Trimester of pregnancy or weeks gestation• Detail of disease anatomy• Clinical guidance scales• Post procedural complications
What conditions are most affected by the increase in number of codes?
• Fractures• Poisoning and toxic effects• Pregnancy related conditions
What do I need to include in my documentation?
• Who• What • Where• When• Why• How • How much
Obstetrics: co-morbid conditions
• Specify whether condition is pregnancy related– Nausea with/without vomiting
• Specify if condition present before pregnancy– Pre-existing diabetes (type 1 or 2) – Gestational diabetes (diet or insulin controlled)
ICD-10 obstetrics documentation
• Document anesthesia complications• Document obstetric complications
– low weight, retained IUD, or gestational herpes• Denote which fetus is affected by a condition or
complication in multiple gestation pregnancies
Pregnancy Classification SystemICD-9 OLDAntepartumDeliveredPostpartum
ICD-10 NEW1st trimester < 14 weeks2nd trimester 14 to 28 weeks3rd trimester 28 weeks to delivery
ICD-10 NEWPregnancyChildbirthPuerperium
Abortion definition change
• Timeframe for a missed abortion (vs. fetal death) has changed from 22 to 20 weeks
• An elective abortion is now described as elective termination of pregnancy
ICD-10 gynecology documentation
• Laterality– Left, right, bilateral
• Etiology– Causative organism of infection
• Chronicity– Acute or subacute or chronic
PCS for inpatient procedures
• Only used for facility billing of inpatient procedures• Coders need to build a 7 component code
• Root operation describes intent of the procedure• Approach – open, laparoscopic, via natural opening• Device
General comments about documentation• It is ok to use a sign/symptom when you don’t know the
diagnosis• Include the cause and the outcome• It is ok to use ‘unspecified’ when you don’t know details• Avoid eponyms• Able to code for things not done
– Refusing immunization– Underdosing medications
Is it alright to use ‘unspecified’?
• Acceptable to use when more specific clinical information about a patient’s condition is not known
• Use the most specific diagnosis term that is supported by documentation and clinical knowledge
Medical Diagnoses
• Tobacco history– Exposure/history of/dependence/use
• Depression– Single episode/recurrent and mild/moderate/severe
• Anemia– Acute/chronic and specify cause
ELECTRONIC HEALTH RECORDS
• Centricity Enterprise– problem list terms will be mapped to ICD-10 codes
• CareConnect Ambulatory– already ICD-10 compliant with diagnosis calculator
• CareConnect Inpatient– includes tools that assist in choosing ICD-10 terms
CMS website includes:
• Common OB/GYN codes• Documentation primer re changes• Clinical scenarios• Education resources including webcasts
Where to find ICD-10 Information on Crossroads
WHERE TO FIND ICD-10 INFORMATION ON PHYSICIAN PORTAL
PeaceHealth - Online education modules• At My Learning on Crossroads• CME available• 40-60 minutes with a physician voiceover
Physician Introduction to ICD-10 – inpatientPhysician Introduction to ICD-10 – OutpatientGeneral SurgeryGynecologyGynecology OncologyObstetrics
Apps and website
• www.ICD10data.com/convert– Convert ICD-9 code to ICD-10 code
• Find-A-Code app– Convert ICD-9 code to ICD-10 code
• ICD-10 Doc Guide app– Clinical Documentation guide
