The Transition to What you need to know for Primary Care Date | Presenter Information

Tools Available Flat Screens in lounges AMGDoctors. com How can we reach our physicians? Intranet Blasts Physician Relations Team Website APP Newsletter Pocket Cards 2

Ongoing Support for ICD-10 Physician Advisors Clinical Informatics 3 -Public Reporting -Reimbursement -Physician Scorecards -Quality Improvement

What’s in it for me? Better reflection of the quality of the care you provided to your patient A more accurate assessment of the Severity of Illness (SOI) i.e. how sick your patient was during the hospitalization Improves your publicly reported quality measure scores Supports the improvement of your patient’s clinical outcomes and safety Enables a better capture of SOI (severity of illness) and ROM (risk of mortality) 4

What should be documented? 5 Reimbursement Admit HPI: tell “the story” PMH: all chronic conditions in as much detail as available (e.g., Chronic Systolic CHF) PSH: all surgeries (e.g., left hip arthroplasty) Assessment and Plan: Differential diagnosis Working diagnoses Other conditions being treated Daily Rule out or confirm differential diagnosis based on test results, imaging results and response to empiric treatment. Discharge All treated/resolved diagnoses should be documented. For diagnoses that are documented as suspected, possible, probable at the time of discharge should be listed in the discharge summary.

No Matter How Obvious it is to the Clinician It is not appropriate for the coder to report a diagnosis based on abnormal findings: –Laboratory –Pathology –Imaging A query must be sent to document a definitive diagnosis Only a physician can establish a cause and effect relationship between a diagnosis such as gastroparesis and diabetes Possible, probable and suspected conditions can be reported, but ONLY if documented at the time of discharge (for inpatient records) Outpatient Surgical and Observation Records: Enter as much information as known at the time. Patient with shortness of breath and lung nodule. Coded to shortness of breath and lung nodule. Patient with shortness of breath and lung nodule, suspected lung cancer with pathology pending. Coded to shortness of breath and lung nodule. We would not code a possible condition as an established diagnosis on outpatient records. What Coders are Unable to Assume 6

Key Changes Needed to Support ICD-10 Coding

Acute Coronary Syndrome (ACS) Be clear on your intended Diagnosis. Would one of the following better describe the patient’s condition? -Angina -Unstable Angina -Myocardial Infarction 8

Acute Kidney Failure/Injury Document etiology, if known, possible or suspected, such as: -Acute tubular, cortical, or medullary necrosis -Postprocedural -Posttraumatic -With transplant kidney Be clear on your intended diagnosis. Note that “acute renal insufficiency” results in an “unspecified” code. Do not use abbreviations AKI or ARF 9

Acute Myocardial Infarction (AMI) Document the severity of the signs and symptoms and the clinical findings of the patient Document Type as: - STEMI or NSTEMI Document Possible Probable Location and the clinical basis (such as your EKG interpretation) –Transmural –Anterior Wall –Inferior Wall –Subendocardial –Other site Document exact date of recent MI (one occurring within the last 4 weeks) and type: –STEMI and wall of heart affected versus NSTEMI 10

Adverse Effects and Poisoning List all complications and the substances that may cause (e.g., cardiac arrest, convulsions, arrhythmias, etc.). Supply the name of the substance causing the complications (e.g., Prednisone, shellfish, Digoxin, Latex, etc.) Specify any abuse of or dependence on the substance Specify any external causes (e.g. malfunction of insulin pump). Provide information regarding the circumstances surrounding the event as follows: –Accidental (i.e. unintentional) –Intentional (i.e. self-harm) –Assault –Undetermined (only use this when it is impossible to determine the intent) 11

Anemia Blood Loss Document, when appropriate: –Anemia due to acute blood loss –Anemia due to chronic blood loss –Acute blood loss anemia ( expected) –Postoperative anemia due to acute blood loss ( a complication) 12 Ascites Document type of ascites and known or suspected cause e.g.malignant Document neoplasm and if primary and if treated or in remission and link (“malignant ascites”)

Anemia in Chronic Disease Document the chronic disease and link it to the anemia, for example: –Anemia due to chronic kidney disease- specify stage of CKD –Anemia due to any neoplasm condition –Anemia due to chemotherapy (document drug if known/suspected) Document neoplasm and link to anemia 13

Anemia Nutritional Document iron deficiency anemia by type, such as: –Sideropenic iron deficiency anemia –Iron deficiency due to inadequate dietary iron intake Document vitamin B12 type, such as: –Due to intrinsic factor deficiency –Vitamin B12 malabsorption Document folate deficiency type: –Due to diet –Drug induced 14

Asthma Document Severity and type: –Mild intermittent –Mild persistent –Moderate persistent –Severe persistent Document Status: –Uncomplicated –w/ acute exacerbation –w/ status asthmaticus Document if present with COPD, Bronchitis other 15

Atrial Fibrillation & Atrial Flutter For atrial fibrillation, document type as: –Paroxysmal –Persistent or –Chronic For atrial flutter, document type as: –Typical or Type I or –Atypical or Type 2 16

Cardiomyopathy Document type known or suspected: –Dilated –Congestive –Ischemic –Obstructive/Non-obstructive –Hypertrophic –Alcoholic Document if due to: –Poisoning and identify if known suspected –Drug and identify if known suspected –Other Diseases i.e. gout, hypothyroidism 17

Cerebral Infarction/ “Stroke” Document etiology: –Due to embolus and source –Due to thrombus and location Document specific artery affected and right or left when appropriate: –Vertebral – Middle –Basilar – Anterior –Carotid – Posterior –Other Document residuals from current stroke: –Hemiplegia/Hemiparesis –Dysphasia –Cognitive Defects Document if TPA was given at another facility within last 24 hours Document ICD-10 PCS code if TPA administered as inpatient 18

Cerebrovascular Disease, Sequela Document cause and effect relationship –Dysphagia due to Cerebral Infarction –Hemiplegia due to traumatic brain injury Document underlying type of Cerebrovascular Disease –Cerebral infarction –Cerebral hemorrhage –Traumatic Brain injury –Other When you don’t specify side affected as dominant or non-dominant: –Right side defaults to dominant –Left side defaults to non- dominant 19 Document specific sequelae being treated Cognitive defects Speech: Aphasia Dysphasia Dysarthria Fluency disorder Monoplegia Hemiplegia Hemiparesis Document affected side as dominant or non-dominant Document laterality Use term paresis vs. weakness

Chronic Kidney Disease Document stage: –Stage 1-5 –End stage (ESRD) Document etiology, for example: –Diabetic CKD –Hypertensive CKD Document if patient is on dialysis 20

Central Line Associate-Blood Stream Infection/ CLABSI If bacteremia is related to a central line clearly indicate this by using words such as “due to” or “secondary to”. Document if Present on Admission (POA) Document type and site of central line: –Dialysis –PICC –Femoral –Subclavian Document causative organism, when known or suspected 21

Congestive Heart Failure (CHF) Document severity: –Acute –Chronic –Acute on chronic Document type: –Systolic –Diastolic –Combined systolic & diastolic Document etiology, if known or suspected, such as due to: –Dilated cardiomyopathy 22

Chronic Obstructive Pulmonary Disease (COPD) Document if present with acute lower respiratory tract infection + casual organism, when known or suspected, such as: –Pseudomonas pneumonia –Acute Bronchitis due to Hemophilus Influenzae –Chronic Bronchitis Document if present with: –Acute exacerbation Document if present with respiratory failure and severity: –Acute respiratory failure –Chronic respiratory failure –Acute on chronic respiratory failure Document if oxygen-dependent 23

Coronary Artery Disease (CAD) Document Site as: –Native artery and/or –Bypass graft Autologous vein Autologous artery Nonautologous Document if with: –Angina pectoris –Unstable angina pectoris –Angina pectoris and spasm 24

Demand Ischemia Document underlying cause: –Hypertension –Hypotension –Anemia –Tachycardia –Bradycardia Note: In coding, not equivalent to Type II MI or NSTEMI. If both diagnoses used, a query may request clarification 25

Dementia Specify cause –Alzheimer's (early or late onset) –Vascular –Lewy Body Dementia –Parkinson's –Arteriosclerotic –Alcoholic With or without behavior disturbance –Aggression –Combative behavior –Violent behavior –Wandering behavior 26

Depression Document type, such as: –Major depression (see major depression disorder below) –Adjustment disorder with or without depression and/or anxiety, e.g., grief reaction –Anxiety depression –Depressive neurosis For depression document the type (ex. Major Depression, Anxiety Depression, etc.) –“Depression” that is not specified as to the type is coded as “Major Depression” 27

Diabetes Document type as: –Type 1 –Type 2 –Secondary Document associated complications, such as: –Diabetic peripheral angiopathy –Diabetic autonomic neuropathy –Diabetic foot ulcer If control is not maintained, document insulin control status as: –Inadequate controlled –Out of control –Poorly controlled –Document if control not maintained as Present On Admission Document if insulin pump is present 28

Drug Underdosing Document –Intentional versus –Unintentional Document the drug and reason for underdosing, for example: –Financial hardship or –Age related dementia 29 Drug Resistant Infection Document all infections that are drug resistant Document name of drug they are resistant to

Encephalopathy Document if acute or chronic Document type: –Metabolic –Toxic –Alcoholic –Septic –Hepatic –Anoxic Document cause: –Infection –Electrolyte imbalance –Substance abuse and resulting disease –Viral Hepatitis and Type of known/suspected 30

Gastrointestinal Bleed Document etiology and show cause and effect, for example: –Acute GI bleed due to bleeding esophageal varices –Acute GI bleed due to hemorrhoid and type (e.g. Fourth Degree) –Acute GI bleed due to gastritis Document where blood was observed: –Rectal –Hematochezia –Hematemesis 31

Hepatic Failure Document type: –Acute –Subacute –Chronic Document if with hepatic coma Document etiology, for example: –Due to alcohol or drugs ( and if use/abuse/dependence etc.) 32 Hypotension Document type: -Idiopathic -Orthostatic -Postural -Due to drug- specify drug -Post procedural -Due to Chronic hemodialysis

Hypertensive Heart Disease Document link of cardiac and renal disease state to the cause “CKD due to Hypertension” Document type of CKD and stage: –CKD Stage 1-5 (not a range) –End Stage (ESRD) Document acuity and type of heart failure: –Systolic Heart Failure; e.g “acute systolic” –Diastolic Heart Failure –Systolic & Diastolic Heart Failure 33

Malnutrition Document type such as: –Protein calorie –Protein energy Document severity: –Mild or 1 st degree –Moderate or 2 nd degree –Sever or 3 rd degree Document BMI Document Obesity if present 34

Peripheral Vascular Disease Document site: –Aorta –Renal artery –Artery of lower extremity –Bypass graft of lower extremity Document laterality: –Right –Left –Bilateral For lower extremity, specify if present: –Pain at rest –Ulceration –Intermittent claudication –Gangrene 35

Pneumonia Document type: –Aspiration pneumonia –Ventilator associated pneumonia –Viral pneumonia –Bacterial pneumonia Document causative organism, when known or suspected: –Klebsiella pneumonia –Gram negative pneumonia –Other 36

Pressure Ulcer/Decubitus Ulcer Document site and laterality: –Lower leg –Foot –Heel Document if present on admission Document stage if known 37

Non-pressure Ulcer (skin) Document site and laterality: –Lower leg –Foot –Heel Document type: –Non-healing –Chronic –Stasis –Diabetic –Atherosclerotic Document if with: –Infection –gangrene 38

Pulmonary Edema Document severity –Acute vs. chronic Identify underlying cause: –Heart failure –Chronic Kidney Disease Flash pulmonary edema: –i.e. not codeable unless specified as acute 39

Pulmonary Embolism Document type, such as: –Saddle –Septic Document cor pulmonale if present and whether it is: –Acute or Chronic Specify if PE is: –Chronic (still present) versus –Resolved –Note that “history of PE” is ambiguous Document if anti-coagulant therapy is for active treatment or prophylactic 40

Respiratory Failure Document severity: –Acute –Chronic –Acute on chronic Document type: –Hypoxic –Hypercapnic –Hypoxic and hypercapnic –Acute or chronic respiratory acidosis/alkalosis Document if associated with COPD or other pulmonary condition Document if POA Post-procedural –Acute post-procedural Respiratory failure –Acute on chronic post-procedural respiratory failure 41

Urinary Tract Infection (UTI)/CAUTI If UTI is related to a device, such as Foley catheter or cystostomy tube, clearly indicate this by using words such as “due to” or “secondary to”. Document if Present on Admission Identify the specific site of the UTI, if known, such as: –Bladder –Ureter (laterality, anatomic site, presence of calculi and type) –Urethra –Kidney Document causative organism, when known or suspected, such as E. coli or Candida 42

Venous Embolism Thrombosis Document location : –Portal vein –Hepatic vein –Vena cava, superior, inferior –Thoracic vein –Renal vein –Deep vein of lower extremity –Femoral vein –Iliac vein –Tibial vein –Superficial vessel of upper extremity –Deep vein of upper extremity –Antecubital vein –Basilic vein –Cephalic vein –Radial vein –Ulnar vein –Axillary vein –Subclavian vein –Inner jugular 43 Document laterality Right Left Bilateral Document location continued: –Radial vein –Ulnar vein –Axillary vein –Subclavian vein –Inner jugular Document severity: Acute chronic Document device if underlying cause PICC Central line AV Graft

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