ob/gyn and other common documentation tips icd 10 documentation specificity needed based on conifer...

OB/GYNand 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.


Table of contents Anemia 4

BMI – high 5

BMI –low 6

Diabetes 7

Endometriosis 8

Headache/ Migraine 9

Hypertension 10

Hyponatremia 11

Metabolic—acidosis/ alkalosis 12

Mood Disorder 13

Neoplasm 14

Malnutrition 15

Pregnancy 16

Ovarian Cancer 17

Pancreatitis 18

Pneumonia-Specificity 19

Premature infant 20

Pressure Ulcer 21

Renal Failure—acute 22

Renal failure-chronic 23

Sepsis 24

Shock 25

Substance abuse 26

Testicular Torsion 27

Urosepsis 28

UTI 29

Hospital specific

Documentation Specialists contact info 30-37


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 Documentation

BMI > 40 with associated diagnosis of:

[ ] Morbid (Severe) Obesity

[ ] Overweight

[ ] Obesity (unspecified)


Morbidly Obese

[ ] Morbid (Severe) Obesity

[ ] Due to excess calories

[ ] Familial

[ ] Endocrine

[ ] with Alveolar Hypoventilation (Pickwickian syndrome)

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



ICD9 Documentation

BMI < 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 Documentation

Diabetes


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



ICD9 Documentation

Endometriosis


IDENTIFY Implant Site

[ ] Uterus

[ ] Fallopian tube: [ ] Right [ ] Left

[ ] Ovary: [ ] Right [ ] Left

[ ] Other site: ____________________ (e.g. intestine, parametrium, peritoneal, rectrovaginal septum, vaginal, vulva)



ICD9 Documentation

Migraine


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_________________________



ICD9 Documentation

Hypertension

[ ] Malignant Hypertension

[ ] Accelerated Hypertension

[ ] Benign Hypertension

[ ] Unspecified Hypertension


Same as ICD 9



ICD9 Documentation

Hyponatremia


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

Acidosis/Alkalosis


Identify 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


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 ____________________________________



ICD9 Documentation

Malnutrition

[ ] Under-nutrition / Malnutrition:

[ ] Mild [ ] Moderate

[ ] Severe [ ] Unspecified

[ ] Protein Calorie Malnutrition:

[ ] Mild [ ] Moderate [ ] Severe

[ ] Unspecified

[ ] Marasmus

[ ] Nutritional Edema

[ ] Other Malnutrition (please specify) _______________________________


Same as ICD 9



ICD9 Documentation

Pregnancy


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): ________



ICD9 Documentation

Ovarian Cancer


Identify laterality

[ ] Ovarian Cancer

[ ] Right [ ] Left [ ] Bilateral



ICD9 Documentation

Pancreatitis


Identify acuity, cause, gangrenous and alcohol induced

[ ] Acute:

[ ] Gallstone [ ] Biliary [ ] Idiopathic

[ ] Other

[ ] Chronic:

[ ] Cystic [ ] Infectious [ ] Interstitial

[ ] Recurrent

[ ] Gangrenous

[ ] Alcohol-induced: [ ] Abuse [ ] Dependence



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


Similar to ICD 9



ICD9 Documentation

Premature Infant


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





[ ] 37 or more completed weeks of gestation



ICD9 Documentation

Pressure Ulcer


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)



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 ________


Same as ICD 9



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


Same as ICD 9



ICD9 Documentation

Sepsis


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 Documentation

SHOCK

[ ] Hypovolemic shock

[ ] Hemorrhagic shock

[ ] Cardiogenic shock

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


Same as ICD 9



ICD9 Documentation

Substance Abuse


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



ICD9 Documentation

Testicular Torsion


Identify Extra or Intra vaginal and site

[ ] Extravaginal:

[ ] Epididymis

[ ] Spermatic Cord

[ ] Testicle/Testis

[ ] Intravaginal:

[ ] Epididymis

[ ] Spermatic Cord

[ ] Testicle/Testis



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)


Same as ICD 9



ICD9 Documentation

UTI


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


Questions—contact your Clinical Documentation Specialists at your hospital Jewish Hospital---502-587-2833 CDI office

Jewish Shelbyville --

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

Cheryl Brooks

Annette Majors



Questions—contact your Clinical Documentation Specialists at your hospital


University of Louisville

Clinical Documentation Specialists Katie Hernandez

Hilda Meehan

Olga Soukhanova

Cheryl Ward

Peggy Fields





St Joe Main

Clinical Documentation Specialists Michelle Ahady

Tina Baker

Lynnette Tuttle

Ann Spero

Teressa Cozine

Trudy Paynter

Karen Mitchell







St. Joe East

Clinical Documentation Specialists Kimberly Gilbert-Morrison

Kelly Geers





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




ob/gyn and other common documentation tips icd 10 documentation specificity needed based on conifer...

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