icd 10 documentation specificity – nephrology and common documentation tips -- based on conifer...

ICD 10 Documentation Specificity –Nephrology and Common Documentation Tips -- 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.


Table of contents Anemia 4

BMI – high 5

BMI –low 6

Cirrhosis of Liver 7

Coma 8

Debridement 9

Dementia 10

Diabetes 11

Encephalopathy 12

Functional Quadriplegia 13

Gout 14

Heart failure- acute 15

Heart failure-chronic 16

HIV-AIDS 17

Hypertension 18

Hyponatremia 19

Lymphoma 20

Mental Status- Altered 21

Metabolic—acidosis/ alkalosis 22

Mood Disorder 23

Neoplasm 24

Non pressure ulcer 25

Malnutrition 26

Pain 27

Pneumonia- Aspiration 28

Pneumonia-Specificity 29

Pressure Ulcer 30

Prostatitis 31

Renal Failure—acute 32

Renal failure-chronic 33

Respiratory failure 34

Respiratory failure post op 35

Sepsis 36

Shock 37

Substance abuse 38

Testicular Torsion 39

Urosepsis 40

UTI 41

Hospital specific

Documentation Specialists contact info 42-49


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



ICD9 DocumentationBMI > 40 with associated diagnosis

of:

[ ] Morbid (Severe) Obesity

[ ] Overweight

[ ] Obesity (unspecified)

ICD10 Documentation NeededMorbidly Obese

[ ] Morbid (Severe) Obesity

[ ] Due to excess calories

[ ] Familial

[ ] Endocrine

[ ] with Alveolar Hypoventilation (Pickwickian syndrome)

[ ] Drug-induced (Name of drug: _____)



ICD9 DocumentationBMI < 19 with associated

diagnosis of: (check one) [ ] Underweight

[ ] Protein Calorie Malnutrition:

[ ] Mild [ ] Moderate [ ] Severe

[ ] Unspecified

[ ] Cachexia

[ ] Emaciation due to malnutrition


Same as ICD 9



ICD9 DocumentationCirrhosis of Liver

ICD10 Documentation NeededIdentify 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



ICD9 DocumentationComa

ICD10 Documentation NeededIdentify 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_________



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 NeededSame as ICD 9



ICD9 Documentation Dementia

ICD10 Documentation NeededIdentify type and accompanying behaviorsType 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: ___________________



ICD9 DocumentationDiabetes

ICD10 Documentation NeededIDENTIFY TYPE, ETIOLOGY, CONTROL and any MANIFESTATIONSTYPE: [ ] 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



ICD9 DocumentationEncephalopathy

ICD10 Documentation NeededIDENTIFY Acuity, Etiology and SeverityAcuity: [ ] Acute [ ] Subacute [ ] Chronic

Etiology:

[ ] Hypertensive [ ] Metabolic

[ ] Toxic [ ] Toxic Metabolic

[ ] Hepatic[ ] Hypoxic

[ ] Septic [ ] Alcohol

[ ] Drugs (specify)_______________

[ ] Post procedural (specify)______________

Severity: [ ] with coma [ ] without coma



ICD9 DocumentationFunctional Quadriplegia[ ] Functional quadriplegia (complete

immobility)

[ ] Immobilization syndrome (impaired mobility)




ICD9 Documentation

Gout


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



ICD9 DocumentationACUTE 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


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



ICD9 DocumentationCHRONIC HEART FAILURE[ ] Chronic Systolic Heart Failure

[ ] Chronic Diastolic Heart Failure

[ ] Chronic Systolic and Diastolic Heart Failure


SAME as ICD 9 with the addition of etiology

Etiologies: [ ] Hypertension [ ] Valvular disease [ ] Rheumatic heart disease



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


Similar to ICD 9



ICD9 DocumentationHypertension[ ] Malignant Hypertension

[ ] Accelerated Hypertension

[ ] Benign Hypertension

[ ] Unspecified Hypertension


Same as ICD 9



ICD9 DocumentationHyponatremia


Identify specificity

[ ] Hyponatremia, unknown cause

[ ] Hyponatremia due to Sodium Deficiency

[ ] Hyponatremia due to SIADH (Syndrome of Inappropriate Secretion of Antidiuretic Hormone)

[ ] Insignificant lab value



ICD9 Documentation

Lymphoma

ICD10 Documentation NeededIDENTIFY Anatomical Site, Type and

Cell TypeAnatomical 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



ICD9 DocumentationAltered Mental Status

ICD10 Documentation NeededIDENTIFY 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



ICD9 Documentation

Acidosis/Alkalosis

ICD10 Documentation NeededIdentify Type of Acidosis or Alkalosis[ ] Acidosis:

[ ] Metabolic [ ] Respiratory

[ ] Lactic [ ] Renal

[ ] Alkalosis:

[ ] Metabolic [ ] Respiratory



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



ICD9 Documentation Neoplasm

ICD10 Documentation NeededIdentify Site, Laterality, Type, Malignancy

and associated conditionsSite: 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 ____________________________________



ICD9 DocumentationNon Pressure Ulcer

ICD10 Documentation NeededIdentify Location, laterality, depth, type

and gangrenousLocation

[ ] 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



ICD9 DocumentationMalnutrition[ ] Under-nutrition / Malnutrition:

[ ] Mild [ ] Moderate

[ ] Severe [ ] Unspecified

[ ] Protein Calorie Malnutrition:

[ ] Mild [ ] Moderate [ ] Severe

[ ] Unspecified

[ ] Marasmus

[ ] Nutritional Edema

[ ] Other Malnutrition (please specify) _______________________________




ICD9 DocumentationPain

ICD10 Documentation NeededIdentify 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



ICD9 DocumentationAspiration Pneumonia

ICD10 Documentation NeededIDENTIFY 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



ICD9 DocumentationPneumonia- 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 NeededSimilar to ICD 9



ICD9 DocumentationPressure Ulcer

ICD10 Documentation NeededIdentify Location, stage, laterality, POA and gangrene presentDecubitus 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)



ICD9 DocumentationProstatitis

ICD10 Documentation NeededIdentify 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)



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 ________




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 StagingStage I Kidney damage with normal or increased GFR

GFR > 90

Stage II Kidney damage with mildly decreased GFRGFR 60-89

Stage III Kidney damage with moderately decreased GFRGFR 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




ICD9 DocumentationRespiratory Failure

ICD10 Documentation NeededIDENTIFY 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



ICD9 DocumentationPost op Respiratory Issues

ICD10 Documentation NeededIdentify 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



ICD9 DocumentationSepsis

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.) _______________________



ICD9 DocumentationSHOCK[ ] Hypovolemic shock

[ ] Hemorrhagic shock

[ ] Cardiogenic shock

[ ] Septic shock (Circulatory failure associated with severe sepsis, represents organ failure)




ICD9 DocumentationSubstance Abuse

ICD10 Documentation Needed Identify substance, status, complication

and any induced disordersSubstance(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



ICD9 DocumentationTesticular Torsion

ICD10 Documentation NeededIdentify Extra or Intra vaginal and site[ ] Extravaginal:

[ ] Epididymis

[ ] Spermatic Cord

[ ] Testicle/Testis

[ ] Intravaginal:

[ ] Epididymis

[ ] Spermatic Cord

[ ] Testicle/Testis



ICD9 DocumentationUROSEPSIS- 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)




ICD9 DocumentationUTI

ICD10 Documentation NeededIdentify acuity, site and due toAcuity:

[ ] 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


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


Sts. Mary and Elizabeth Clinical Documentation Specialists

Mickey Decker– 502-361-6125 Cheryl Brooks-502-361-6549 Annette Majors- 502-361-6495


Questions—contact your Clinical Documentation Specialists at your hospital


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




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




St. Joe East Clinical Documentation Specialists

Kimberly Gilbert-Morrison—502-316-5220 Kelly Geers—502-750-2329




Flaget Clinical Documentation Specialist

Cheryl Mitchell—502-350-5247




St Joe London Clinical Documentation Specialists

Katrina Henson—606-330-6759 Sherry Mills—606-330-6000




St. Joe Mt. Sterling Clinical Documentation Specialists

Lori Barry—859-497-5458



icd 10 documentation specificity – nephrology and common documentation tips -- based on conifer...

Documents