VASCULAR SURGERY and Other Common Documentation Tips ICD 10 Documentation Specificity Needed based on Conifer ICD 10 CDI Queries

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 Personal Injury 24 Atrial Fib 5 BMI – high 6 BMI –low 7 Cellulitis 8 Coma 9 Debridement 10 Dementia 11 Diabetes 12 Encephalopathy 13 Heart failure- acute 14 Heart failure-chronic 15 HIV-AIDS 16 Hypertension 17 Hyponatremia 18 Mental Status- Altered 19 Metabolic—acidosis/ alkalosis 20 Non pressure ulcer 21 Malnutrition 22 Osteomyelitis 23 Personal Injury 24 Pneumonia- Hypostatic /passive/ stasis 25 Pneumonia-Specificity 26 Pressure Ulcer 27 Pulmonary embolism 28 Renal Failure—acute 29 Renal failure-chronic 30 Respiratory- COPD 31 Respiratory- Emphysema 32 Respiratory failure 33 Respiratory failure post op 34 Sepsis 35 Shock 36 Substance abuse 37 Urosepsis 38 UTI 39 Hospital specific Documentation Specialists contact info 40-48

ICD10 documentation specificity needed ICD10 Documentation 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: Same as in ICD 9

ICD10 documentation specificity needed ICD10 Documentation Needed A fib IDENTIFY TYPE [ ] Paroxysmal Atrial Fibrillation [ ] Persistent Atrial Fibrillation [ ] Chronic Atrial Fibrillation (includes permanent Atrial Fibrillation) [ ] Unspecified Atrial Fibrillation

ICD10 documentation specificity needed ICD10 Documentation Needed 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: _____)

ICD10 documentation specificity needed ICD10 Documentation Needed 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

ICD10 documentation specificity needed ICD10 Documentation Needed Cellulitis Identify location, laterality and if related to Location: _________________ Laterality: [ ] Left [ ] Right [ ] Bilateral [ ] Upper [ ] Lower [ ] Cheek-internal [ ] Cheek-external [ ] N/A_____ [ ] Bacterial - Causative Agent (if known): ____ [ ] Viral [ ] R/T Lymphangitis (chronic / subacute) [ ] R/T Venous Stasis ulcer with PVD [ ] Manifestation of Diabetes [ ] Does not apply to this patient – no cellulitis

ICD10 documentation specificity needed ICD10 Documentation Needed Coma Identify 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_________

ICD10 documentation specificity needed ICD10 Documentation Needed 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 Same as ICD 9

ICD10 documentation specificity needed ICD10 Documentation Needed Dementia 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: ___________________

ICD10 documentation specificity needed ICD10 Documentation Needed 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

ICD10 documentation specificity needed ICD10 Documentation Needed Encephalopathy 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

ICD10 documentation specificity needed ICD10 Documentation Needed 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 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

ICD10 documentation specificity needed ICD10 Documentation Needed CHRONIC 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

ICD10 documentation specificity needed ICD10 Documentation Needed 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

ICD10 documentation specificity needed ICD10 Documentation Needed Hypertension [ ] Malignant Hypertension [ ] Accelerated Hypertension [ ] Benign Hypertension [ ] Unspecified Hypertension Same as ICD 9

ICD10 documentation specificity needed ICD10 Documentation Needed 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

ICD10 documentation specificity needed ICD10 Documentation Needed Altered Mental Status 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

ICD10 documentation specificity needed ICD10 Documentation Needed Acidosis/Alkalosis Identify Type of Acidosis or Alkalosis [ ] Acidosis: [ ] Metabolic [ ] Respiratory [ ] Lactic [ ] Renal [ ] Alkalosis: [ ] Metabolic [ ] Respiratory

ICD10 documentation specificity needed ICD10 Documentation Needed Non Pressure Ulcer 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

ICD10 documentation specificity needed ICD10 Documentation Needed 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

ICD10 documentation specificity needed ICD10 Documentation Needed Osteomyelitis Identify site, acuity and if related to diabetes Osteomyelitis site: ____________ [ ] Acute osteomyelitis directly related to diabetes mellitus [ ] Acute osteomyelitis unrelated to diabetes mellitus [ ] Chronic osteomyelitis directly related to diabetes mellitus [ ] Chronic osteomyelitis unrelated to diabetes mellitus

ICD10 documentation specificity needed ICD10 Documentation Needed Hypostatic Passive/ Stasis Pneumonia [ ] Hypostatic Passive/ Stasis Pneumonia [ ] Pneumonia due to (specify organism/ underlying disease)_____________ [ ] Ventilator-associated [ ] Radiation induced [ ] Associated illness: [ ] Respiratory Failure [ ] Underlying lung disease [ ] Other (specify)________________ Same as ICD 9

ICD10 documentation specificity needed ICD10 Documentation Needed 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

ICD10 documentation specificity needed ICD10 Documentation Needed 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)

ICD10 documentation specificity needed ICD10 Documentation Needed Pulmonary Embolism Identify acuity, type and if associated acute cor pulmonale Acuity: [ ] Acute [ ] Chronic Type: [ ] Saddle [ ] Septic [ ] Other___ [ ] Pulmonary Embolism with associated Acute Cor Pulmonale

ICD10 documentation specificity needed ICD10 Documentation Needed Injury 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.) ______________________________

ICD10 documentation specificity needed ICD10 Documentation Needed 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

ICD10 documentation specificity needed ICD10 Documentation Needed 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 II Kidney damage with mildly decreased GFR GFR 60-89 Stage III Kidney damage with moderately decreased GFR GFR 30-59 Stage IV Kidney damage with severely decreased GFR GFR 16-29 Stage V Kidney failure GFR<15 ESRD End Stage Renal Disease On dialysis   Same as ICD 9

ICD10 documentation specificity needed ICD10 Documentation Needed COPD   Identify Acuity [ ] Acute exacerbation of COPD [ ] Acute exacerbation of Asthma [ ] COPD – Chronic and stable

ICD10 documentation specificity needed ICD10 Documentation Needed  Emphysema 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

ICD10 documentation specificity needed ICD10 Documentation Needed Respiratory Failure IDENTIFY 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

ICD10 documentation specificity needed ICD10 Documentation Needed Post op Respiratory Issues Identify 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

ICD10 documentation specificity needed ICD10 Documentation Needed SHOCK [ ] Hypovolemic shock [ ] Hemorrhagic shock [ ] Cardiogenic shock [ ] Septic shock (Circulatory failure associated with severe sepsis, represents organ failure) Same as ICD 9

ICD10 documentation specificity needed ICD10 Documentation Needed 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.) _______________________

ICD10 documentation specificity needed ICD10 Documentation Needed 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

ICD10 documentation specificity needed ICD10 Documentation Needed 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

ICD10 documentation specificity needed ICD10 Documentation Needed 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

ICD10 documentation specificity needed ICD10 Documentation Needed Weakness Identify due to and laterality [ ] Weakness due to __________ [ ] Hemiparesis [ ] Hemiplegia Laterality (please check all that apply): [ ] Right side [ ] Left side [ ] Upper extremity [ ] Lower extremity [ ] Dominant side [ ] Non-dominant side

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

Questions—contact your Clinical Documentation Specialists at your hospital Sts. Mary and Elizabeth Clinical Documentation Specialists Mickey Decker– 502-361-6125 Cheryl Brooks-502-361-6549 Annette Majors- 502-361-6495 Manager- Sandy Hodge- Bowman 502-409-2673 Supervisor- Kristen Boles 859-421-1542

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 Manager- Sandy Hodge- Bowman 502-409-2673 Supervisor- Kristen Boles 859-421-1542

Questions—contact your Clinical Documentation Specialists at your hospital 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 Manager- Sandy Hodge- Bowman 502-409-2673 Supervisor- Kristen Boles 859-421-1542

Questions—contact your Clinical Documentation Specialists at your hospital St. Joe East Clinical Documentation Specialists Kimberly Gilbert-Morrison—502-316-5220 Kelly Geers—502-750-2329 Manager- Sandy Hodge- Bowman 502-409-2673 Supervisor- Kristen Boles 859-421-1542

Questions—contact your Clinical Documentation Specialists at your hospital Flaget Clinical Documentation Specialist Cheryl Mitchell—502-350-5247 Manager- Sandy Hodge- Bowman 502-409-2673 Supervisor- Kristen Boles 859-421-1542

Questions—contact your Clinical Documentation Specialists at your hospital St Joe London Clinical Documentation Specialists Katrina Henson—606-330-6759 Sherry Mills—606-330-6000 Manager- Sandy Hodge- Bowman 502-409-2673 Supervisor- Kristen Boles 859-421-1542

Questions—contact your Clinical Documentation Specialists at your hospital St. Joe Mt. Sterling Clinical Documentation Specialists Lori Barry—859-497-5458 Manager- Sandy Hodge- Bowman 502-409-2673 Supervisor- Kristen Boles 859-421-1542