UROLOGY and Other Common Documentation Tips ICD 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  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.

3 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. Table of contents  Anemia4  BMI-high5  BMI-low6  Debridement7  Dementia8  Diabetes9  Encephalopathy10  Heart failure- acute11  Heart failure-chronic12  HIV-AIDS13  Hypertension14  Hyponatremia15  Mental Status- Altered16  Metabolic—acidosis/ alkalosis17  Neoplasm18  Non pressure ulcer19  Malnutrition20  Personal Injury21  Pneumonia-Specificity 22  Pressure Ulcer23  Prostatitis24  Renal Failure—acute25  Renal failure-chronic26  Respiratory- COPD27  Respiratory- Emphysema28  Sepsis29  Shock30  Substance abuse31  Testicular Torsion32  Urosepsis33  UTI34  Hospital specific  Documentation Specialists contact info 35-42

4 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. 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

5 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. 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: _____)

6 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. 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

7 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed 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 Needed Same as ICD 9

8 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. 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: ___________________

9 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. 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

10 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Encephalopathy ICD10 Documentation Needed IDENTIFY Acuity, Etiology and Severity Acuity: [ ] Acute [ ] Subacute [ ] Chronic Etiology: [ ] Hypertensive [ ] Metabolic [ ] Toxic[ ] Toxic Metabolic [ ] Hepatic[ ] Hypoxic [ ] Septic [ ] Alcohol [ ] Drugs (specify)_______________ [ ] Post procedural (specify)______________ Severity: [ ] with coma [ ] without coma

11 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation ACUTE 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 ICD10 Documentation Needed 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

12 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation CHRONIC HEART FAILURE [ ] Chronic Systolic Heart Failure [ ] Chronic Diastolic Heart Failure [ ] Chronic Systolic and Diastolic Heart Failure ICD10 Documentation Needed SAME as ICD 9 with the addition of etiology Etiologies: [ ] Hypertension [ ] Valvular disease [ ] Rheumatic heart disease

13 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed 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 ICD10 Documentation Needed Similar to ICD 9

14 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Hypertension [ ] Malignant Hypertension [ ] Accelerated Hypertension [ ] Benign Hypertension [ ] Unspecified Hypertension ICD10 Documentation Needed Same as ICD 9

15 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. 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

16 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. 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

17 ©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

18 ©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 ____________________________________

19 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. 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

20 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. 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

21 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Injury ICD10 Documentation Needed For this injury _________, please document the following information: How the injury occurred (i.e. fall, MVA, etc.) ___________________ Location where the injury occurred (i.e. home, work, school, etc.) ____________________________ Activity at time of injury (i.e. running, gardening, skating, etc.) ______________________________ Status at time of injury (i.e. civilian, military, volunteer, etc.) ______________________________

22 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. 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

23 ©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)

24 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Prostatitis ICD10 Documentation Needed Identify 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)

25 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. 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

26 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Chronic 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 GFR GFR > 90 Stage IIKidney damage with mildly decreased GFRGFR Stage III Kidney damage with moderately decreased GFR GFR Stage IVKidney damage with severely decreased GFR GFR Stage VKidney failureGFR<15 ESRDEnd Stage Renal DiseaseOn dialysis ICD10 Documentation Needed Same as ICD 9

27 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation COPD ICD10 Documentation Needed Identify Acuity [ ] Acute exacerbation of COPD [ ] Acute exacerbation of Asthma [ ] COPD – Chronic and stable

28 ©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

29 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Sepsis 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.) _______________________

30 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation SHOCK [ ] Hypovolemic shock [ ] Hemorrhagic shock [ ] Cardiogenic shock [ ] Septic shock (Circulatory failure associated with severe sepsis, represents organ failure) ICD10 Documentation Needed Same as ICD 9

31 ©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

32 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Testicular Torsion ICD10 Documentation Needed Identify Extra or Intra vaginal and site [ ] Extravaginal: [ ] Epididymis [ ] Spermatic Cord [ ] Testicle/Testis [ ] Intravaginal: [ ] Epididymis [ ] Spermatic Cord [ ] Testicle/Testis

33 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed 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) ICD10 Documentation Needed Same as ICD 9

34 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation UTI ICD10 Documentation Needed 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

35 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. Questions—contact your Clinical Documentation Specialists at your hospital  Jewish Hospital CDI office for all specialists  Jewish Shelbyville CDI office  Clinical Documentation Specialists --  Candy Rickard  Peggy Barlar  Charlotte Hopewell  Susan Hinkle  Dale Crosby  Becki Fudge  Sara Goff  Manager- Sandy Hodge- Bowman  Supervisor- Kristen Boles

36 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.  Sts. Mary and Elizabeth  Clinical Documentation Specialists  Mickey Decker–  Cheryl Brooks  Annette Majors  Manager- Sandy Hodge- Bowman  Supervisor- Kristen Boles Questions—contact your Clinical Documentation Specialists at your hospital

37 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.  University of Louisville  Clinical Documentation Specialists  Katie Hernandez–  Hilda Meehan—  Olga Soukhanova—  Cheryl Ward—  Peggy Fields—  Manager- Sandy Hodge- Bowman  Supervisor- Kristen Boles Questions—contact your Clinical Documentation Specialists at your hospital

38 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.  St Joe Main  Clinical Documentation Specialists  Michelle Ahady—  Tina Baker—  Lynnette Tuttle—  Ann Spero—  Teressa Cozine—  Trudy Paynter—  Karen Browning—  Manager- Sandy Hodge- Bowman  Supervisor- Kristen Boles Questions—contact your Clinical Documentation Specialists at your hospital

39 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.  St. Joe East  Clinical Documentation Specialists  Kimberly Gilbert-Morrison—  Kelly Geers—  Manager- Sandy Hodge- Bowman  Supervisor- Kristen Boles Questions—contact your Clinical Documentation Specialists at your hospital

40 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.  Flaget  Clinical Documentation Specialist  Cheryl Mitchell—  Manager- Sandy Hodge- Bowman  Supervisor- Kristen Boles Questions—contact your Clinical Documentation Specialists at your hospital

41 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.  St Joe London  Clinical Documentation Specialists  Katrina Henson—  Sherry Mills—  Manager- Sandy Hodge- Bowman  Supervisor- Kristen Boles Questions—contact your Clinical Documentation Specialists at your hospital

42 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.  St. Joe Mt. Sterling  Clinical Documentation Specialists  Lori Barry—  Manager- Sandy Hodge- Bowman  Supervisor- Kristen Boles Questions—contact your Clinical Documentation Specialists at your hospital