1

Shatondra Surulere, MBA, RHIA, CCS, CCS‐P, CHTS‐PW, AHIMA Approved Trainer and AmbassadorSenior Consultant, Revenue Cycle Consulting

ICD‐10 Documentation Preparation and Leveraging Documentation Templates and Coding Queries

2

Presentation Objectives

Identify ICD-10 documentation requirements for hospitals and physician practices

Gain an understanding of today’s documentation challenges

Review key ICD-10 documentation requirements

Review ICD-10 documentation improvement strategies

3

IF IT ISN’T DOCUMENTED, IT CANNOT BE CODED

4

In a Perfect World…

All clinical documentation would be:

Legible

Complete

Clear

Consistent

Precise

5

The Real World…

Clinical Documentation Practices

VS.

Coding Documentation Needs

6

The Role of Clinical Documentation

Clinical information for patient care

Quality/core measures Hospital profiling Physician profiling Disease reporting Compliance

Government and payor reviews

Others

7

The Connection to Coding

Clinical documentation paints a picture

Patient’s acute condition

Complicating condition(s)

Clinical, therapeutic and/or diagnostic treatment and patient responses to treatment

Translates to codes

o Billing

o Incentive payments

8

1. Billing and AR

2. Quality incentives

3. Discharged Not Final Billed (DNFB)

4. Patient status (inpatient, outpatient, observation)

5. APDRG/APRDRG/MS-DRG reimbursement

6. Compliance

The Relationship to Reimbursement

9

The Reality – For Many Health Information Management Departments

Accountability

Tools Documentation

Coding Benchmarks

Responsibility

Tools Documentation

Coding Benchmarks

10

Polling Question

In your opinion, does your facility do a good job holding physicians accountable for the quality of their documentation?

A. Yes

B. No

C. Not sure

11

From the Provider’s Point of View

12

Basic Clinical Documentation

+

Quality Requirements

+

Meaningful Use

+

Regulatory and Compliance Initiatives

+

Operational Challenges

+

EHR Template Requirements

+

ICD-10 Initiatives

Overwhelming Documentation Requirements

13

Inconsistent Tools and Requirements

Incomplete and inconsistent documentation tools Physician query questions could be addressed in

current tools Inconsistent physician query questions between

clinical documentation improvement and/or coding staff

Quality, Joint Commission, infection control, and other requirements are often not incorporated in documentation tools

14

ICD-10 Documentation Requirements

15

The Importance of Specificity

Specificity in documentation is key, because, in ICD-10, fewer “unspecified” codes exist

Specific documentation benefits

Reduces physician queries and AR delays

Reduces denials/request for medical records

More accurate quality and infection control reporting

Your documentation is, the less queries you will receive from the CDI specialist and the coders

16

ICD‐10 … A Refresher in Documentation Requirements

Below are some general documentation tips

that you can begin using now to create a

seamless transition to the new system:

Specific diagnosis

o Document the diagnosis to the

greatest level of specificity

Specific anatomy

o Document the exact body location

Document ALL conditions identified and treated during the encounter

o Secondary diagnosis ARE IMPORTANT

17

ICD‐10 … A Refresher in Documentation Requirements

Laterality

Document which side of the body- right or left

o Note: approximately 5,000+ codes have a right and left distinction

Dominant verses non-dominant side

Document dominant verses non-dominant side for all paralytic syndrome conditions

Initial verses recurrent

Document whether the condition is initial or recurrent

Combination codes for conditions and common symptoms or manifestations

o Secondary diagnosis ARE IMPORTANT

18

Cardiovascular Example

CAD (coronary arteriosclerosis) is specified as of native vessel, bypass graft, or transplanted heart.

Combination codes to include CAD with angina (unstable, with spasm, other) as well as CAD with ischemic chest pain.

Document exact date of MI New/initial MI: Occurred or diagnosed within the past four

weeks but not previously treated Old MI: Report a "healed or old MI" whether the patient is

currently experiencing problems or not Subsequent MI: subsequent, new MI occurring within the

four-week timeframe of the initial MI Document type of MI

STEMI vs. NSTEMI

19

Cardiovascular Documentation Examples

Physician office documentation: “reports history of CAD, HTN, MI, and angioplasty”

o Need additional documentation CAD is present after angioplasty of a native artery (I25.10) or of the bypass (I25.810)

o Documentation regarding the date and specifies of the MI will be required

Inpatient physician documentation: “patient has history of ESRD, CHF, and high blood pressure and

past MI”o There is conflicting documentation on this chart from another

physician, stating that the patient has HTN. HBP and HTN are coded differently, and, if the patient truly has HTN (I10), it should be documented as such, not as HBP (R03.0).

o Documentation regarding the date and specifies of the MI will be required

20

Laterality Documentation Examples

For all body parts that can be defined as left, right, or bilateral side(s), the specific “side” must be documented

Physician office documentation “patient complains of hearing

loss (right); large right cerumen impaction” – good example of laterality documentation (H61.21 –impacted cerumen, right ear)

Physician office documentation “patient presents with glaucoma

and senile cataract” – This would need specification for the glaucoma and cataract(s), are they right, left, or bilateral?

21

Fracture Documentation Requirements

More information will be required to accurately code fractures in ICD-10 type of fracture specific anatomical site whether the fracture is

displaced or not laterality routine versus delayed healing nonunion and malunions

22

Injury Documentation Requirements

Documentation for injuries should include the “encounter type”

Initial encounter

Subsequent encounter for fracture with routine healing

Subsequent encounter for fracture with delayed healing

Sequela of fracture

23

Pregnancy/Obstetrics Documentation

All diagnoses related to a patient’s pregnancy should have the trimester in which the problem began documented (1st

trimester up to 13 weeks, 6 days; 2nd trimester 14 weeks 0 days to 27 weeks 6 days; 3rd trimester 28 weeks 0 days to delivery) Inpatient physician documentation:

H&P – “patient is 29 weeks pregnant, presents with new onset of malnutrition, low weight gain since week 20, and edema of the legs which is new.”

This is an example of good documentation regarding obstetrics. The codes for this patient would be:

o O25.13 – malnutrition in pregnancy, 3rd trimester

o O12.03 – gestational edema, 3rd trimester

o O26.12 – low weight gain in pregnancy, second trimester

24

Tobacco Use/Exposure Documentation   

The medical record documentation should include information regarding the patient’s history impact to current encounter and treatment

Tobacco use/abuse codes now specify what type of tobacco (cigarettes, chewing tobacco, etc.)

Any patient with a respiratory diagnosis and/or cardiac diagnosis should have documentation of current and/or past tobacco smoke exposure/abuse

Physician office documentation – “current tobacco use”.

This example of documentation would need more clarification.

o Is patient tobacco dependent?

o Does patient smoke cigarettes (F172.10), cigars/other (F172.90), or use chewing tobacco (F172.20)?

25

Procedure Documentation

Standard terminology Example, in ICD-9, “excision” can mean different things,

depending on the body site/procedure being done. In ICD-10, excision means “cutting out or off, without replacement, a portion of a body part”

Expandability – to accommodate new procedures and technologies

Specificity – specify approach, body part and devises Example, in ICD-9, 39.31 means suture of an artery. In

ICD-10, specific codes exist for each artery.

26

27

Step 1: Develop The Plan

Identify the team

Develop a detailed plan

Specific steps and timelines

Milestones

Testing

Monitoring

Accountability

28

Collaboration is Required!

29

Build a Collaborative Team

ICD-10 governance structure Clinical documentation work

group

Physician champions

Coding specialists (hospital and physician practice)

Administration

Information technology

Physician practice management

30

Step 2: Understand Current State

Communication is Key!

31

Understand the Physician Environment

Evaluate physician perception of documentation work flow, requirements, and concerns

Identify opportunities to develop and/or expand physician champion strategyDevelop physician champion strategy

Physician champion roles and responsibilities

Engage physician leadersBy specialty

Consider physician feedback strategies

Engage physician practice managers

32

Identify your most common diagnoses and procedures and pull a sample of medical records by physician.

Conduct an ICD-10 documentation gap analysis. Identify gaps and trends

By disease

Specialty

Physician

Start with the Documentation

33

Step 3: Work Flow Optimization

Consider work flow re-design sessions

Evaluate dashboards Documentation issues by disease

Physician query trends

A/R delays due to non-specific and/or missing documentation

Identify opportunities to utilize technology Enhance tracking, trending and reporting to capture

trends and delays

34

Step 4: Develop Future State Tools

A successful conversion to ICD-10 will require a review of current tools to identify enhancements to facilitate capture documentation required for code assignment CPOE Templates EHR Templates Physician Query Forms

Identify ICD-10 specific documentation requirements Engage Physicians to identify opportunities to enhance

compliance and acceptance A few things to consider

Work flow re-design sessions Utilizing an ICD-10 Approved Trainer

Start NOW!

35

ICD‐10 Mitral Valve Disorder Code Revisions

ICD-9 Code

ICD-9 Descriptions ICD-10 Code ICD-10 Description

424.0Mitral Valve Disorders

I34.0Nonrheumatic mitral (valve) insufficiency

I34.8Other nonrheumatic mitral valve disorders

Mitral Valve DisordersDocumentation Specificity Required for Code Assignment

36

Problem List/CPOE Templates

Problem Non-Specific Documentation Specific Documentation

Hypertension, heart disease, kidney disease

1) HTN; 2) CAD; 3) CKD

Hypertensive heart and CKD, stage 4, w/out heart failure

Hypertension, heart disease, kidney disease, CHF

1) CHF; 2) CAD; 3) CKD; 4) HTN

Hypertensive heart disease; Stage 3 CKD; Primary essential hypertension; Acute/Chronic systolic heart failure

MI or Not? ACS Atherosclerotic heart disease of native coronary artery with unstable angina pectoris

MI NQWMI NSTEMI

MI STEMI STEMI involving left circumflex coronary artery

Sample Problem List and Physician Order Specificity for Reporting Cardiac Ischemia

37

EHR Documentation Templates

Review documentation templates by disease

Identify ICD-10 documentation needs

Develop future state tables and prompts to support ICD-10 documentation requirements

Coordinate physician practice and hospital templates for like diseases

Engage vendors to identify timelines and upgrade requirements

38

EHR Documentation Templates‐Obstetrics

Obstetrics Specify trimester for which condition occurs

o 1st trimester less – than 14 weeks, 0 days

o 2nd trimester – 14 weeks, 0 days to less than 28 weeks, 0 days

o 3rd trimester- 28 weeks, 0 days until delivery

Specify # weeks of pregnancy Specify pre-existing or pregnancy

induced Complications affecting pregnancy

39

Acute Myocardial Infarction (MI) MI episode of care

o Initial refers to initial episode of care for an acute MI

o Subsequent refers to care for a subsequent, new Acute MI occurring within the 4 week time frame

Type of MI

o STEMI

o NSTEMI

Site and artery (if known)

Complications of the MI

CABG Aorta to coronary artery

(aortocoronary)

Coronary artery to coronary artery

Coronary vein to coronary artery (percutaneous only)

Left internal mammary (LIMA) to coronary artery

Right internal mammary (RIMA) to coronary artery

Abdominal to coronary artery (gastroepiploic anastomosis)

Thoracic to coronary artery

EHR Documentation Templates‐MI/CABG

40

Body Part

Coronary Artery, One Site

Coronary Artery, Two Site

Coronary Artery, Three Site

Coronary Artery, Four or More Sites

Device

No Device (direct anastomosis)

Autologous Arterial Tissue

Autologous Venous Tissue

Nonautologous Tissue Substitute

EHR Documentation Templates‐MI/CABG (Continued)

41

Type

Diabetes mellitus due to underlying condition

Drug or chemical induced diabetes mellitus

Type 1 diabetes mellitus

Type 2 diabetes mellitus

Other specified diabetes mellitus

Control

ICD-10 no longer recognizes “uncontrolled”

Poorly controlled, out of control, or inadequately controlled are coded to diabetes by type with hyperglycemia

Complications of Diabetes

EHR Documentation Templates‐Diabetes

42

EHR Documentation Templates‐Acute Respiratory Failure/Asthma/Bronchitis/COPD

Respiratory Failure

Acuity

Hypercapnic/Hypoxic

Tobacco usage/exposure/history

43

EHR Documentation Templates‐Acute Respiratory Failure/Asthma/Bronchitis/COPD (Continued)

Asthma/Bronchitis/ COPD Identify the type of asthma

o Allergic extrinsic, childhood, chronic obstructive, exercise-induced, hay fever, persistent, due to other agents

Identify the type of bronchitiso Allergic, asthmatic, chemical, chronic obstructive,

smoker’s, viral, due to other agents

Identify the type of COPDo Chronic bronchitis with tracheobronchitis, emphysema,

decompensated, due to other agents

Acuity Tobacco usage/exposure/history

44

EHR Documentation Templates – Traumatic Fracture

Site Laterality Open

Gustilo classification for long bone fractures

Closed Episode of care

Initial (active phase of treatment) Subsequent (after active phase)

o With delayed healing o With malunion o With nonunion o With routine healing or aftercare

Sequela/late effect

45

Document if sepsis was present on admission

Document underlying local infection Pneumonia, UTI, and post operative infections are examples

Urosepsis-MUST specify sepsis with UTI, versus UTI only

o Urosepsis is not recognized in ICD-10

Specify causal relationship to local infection and/or procedure

Identify causative organism

Severity With septic shock

Without septic shock

Associated organ dysfunction when documenting severe sepsis

EHR Documentation Templates‐Sepsis

46

Location of insertion Atrium, right

Inferior vena cava (IVC)

Innominate vein

Subclavian vein (e.g., midline cath)

Superior vena cava (SVC)

Approach Open

Percutaneous

Percutaneous endoscopic

Radiological guidance *No guidance performed

ECG (electrocardiography)

Fluoroscopic

Ultrasonic

Contrast Used None

High osmolar

Low osmolar

Other contrast

EHR Documentation Templates PICC/CVC Placement

47

EHR Templates‐Obstetrics

48

EHR Templates‐Obstetrics

49

EHR Templates‐PICC Line

50

EHR Templates‐Orthopedics

51

Template Case Study

52

Polling Question

Do you have a clinical documentation improvement program?

A. Yes

B. No

C. Not sure

53

Physician Query Redesign

Review Trends Physician response rate

Most common queries by disease

Evaluate process and identify opportunities for improvement

Re-design physician query forms (standard vs. free text) Be clearly and concisely written

Contain precise language

Present the facts but not lead the clinician

54

Physician Query Redesign

Include

ICD-10 specific documentation needed for diagnoses

o Sepsis, urosepsis

o Obstetrics

ICD-10 specific documentation needed for procedures

o PICC/CVC insertion

o Transfusions

55

Physician Education Recommendations 

ICD-10 documentation changes

Emphasis on physician specialty

Specificity in documentation of diagnoses

Specificity in documentation of procedures

Importance of coding secondary diagnoses

More than four diagnoses (physician office)

56

Coder Education Recommendations

ICD-10 Official Coding Guidelines for Coding and Reporting

Chapters specific changes

Specificity in the coding of diagnoses

Specificity in the coding of procedures

Emphasis on secondary diagnosis coding

ICD-10 Coding Clinics

ICD-10 documentation and physician query guidelines

57

Step 5: Implement the Plan

Develop a “Roll Out Schedule” Physician queries

o By disease

o In conjunction with physician, coding, and/or CDI education

Floor coaching Hospital

Physician practice

Hotline and ongoing assistance

Monitoring and reporting

58

Step 6: Hardwiring Solution

New physician and/or staff orientation

Documentation tools maintenance

Control

Re-design

Testing

59

60

Intended for internal guidance only, and not as recommendations for specific situations. Readers should

consult a qualified attorney for specific legal guidance.

Thanks for Attending!