CARDIOLOGY 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  Alzheimer's4  Anemia5  Aplastic Anemia6  Atrial Fib7  BMI – high8  BMI –low9  Cardiac Arrest10  Chest pain11  Coma12  Cor Pulmonale13  Dementia14  Diabetes15  Encephalopathy16  GERD17  Heart failure- acute18  Heart failure-chronic19  HIV-AIDS20  Hypertension21  Hyponatremia22  Mental Status- Altered23  Metabolic/ acidosis/alkalosis 24  Mood Disorder 25  Myocardial Infarction26  Non pressure ulcer27  Malnutrition28  Pneumonia- Aspiration29  Pneumonia-Specificity 30  Pressure Ulcer31  Pulmonary embolism32  Renal Failure—acute33  Renal failure-chronic34  Respiratory- COPD35  Respiratory- Emphysema36  Respiratory failure37  Respiratory failure post op38  Sepsis39  Shock40  Substance abuse41  Urosepsis42  UTI43  Hospital specific  Documentation Specialists contact info 44-51

4 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Alzheimer’s ICD10 Documentation Needed Identify onset, behavior disturbances and with dementia or associated delirium [ ] Alzheimer’s disease [ ] Early onset [ ] Late onset [ ] Unspecified [ ] Other [ ] Alzheimer’s disease with behavioral disturbances [ ] Aggressive [ ] Combative [ ] Violent [ ] Unspecified [ ] Other_______ [ ] Alzheimer’s disease with dementia [ ] Acute [ ] Sub acute [ ] With wandering [ ] Alzheimer’s disease with associated delirium

5 ©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

6 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Aplastic Anemia ICD10 Documentation Needed Identify Specificity [ ] Acquired pure red cell aplasia: [ ] Chronic [ ] on Treatment [ ] Transient [ ] Other [ ] Constitutional: [ ] Congenital [ ] Idiopathic [ ] Acquired [ ] Drug Induced (please specify drug): ________ [ ] Due to other external causes (please specify cause, i.e. radiation, etc): _______________________ [ ] Idiopathic [ ] Unspecified [ ] Sideroblastic Anemia: [ ] Hereditary [ ] Due to disease [ ] Due to drugs/toxins [ ] Congenital [ ] Anemia in Neoplastic Disease

7 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation A fib ICD10 Documentation Needed IDENTIFY TYPE [ ] Paroxysmal Atrial Fibrillation [ ] Persistent Atrial Fibrillation [ ] Chronic Atrial Fibrillation (includes permanent Atrial Fibrillation) [ ] Unspecified Atrial Fibrillation

8 ©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: _____)

9 ©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

10 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Cardiac Arrest ICD10 Documentation Needed Identify underlying cause, post procedure or intra-op arrest [ ] Underlying cardiac condition (specify)___________ [ ] Underlying other condition (specify)______ [ ] Cause unspecified [ ] Post procedural cardiac arrest following cardiac surgery [ ] Post procedural cardiac arrest following other surgery [ ] Intra-operative cardiac arrest during cardiac surgery [ ] Intra-operative cardiac arrest during other surgery [ ] Any associated diagnoses / conditions________

11 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Chest Pain [ ] Costochronditis [ ] Pleurisy [ ] Pleuritic pain [ ] Angina with known coronary artery disease [ ] Angina:[ ] Stable[ ] Unstable [ ] Psychogenic cardiovascular disorder [ ] Chest wall pain [ ] Cholelithiasis / Cholecystitis [ ] GERD [ ] Esophagitis [ ] Does not apply to this patient ICD10 Documentation Needed Same as ICD 9

12 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Coma ICD10 Documentation Needed 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_________

13 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Cor Pulmonale [ ] Acute Cor Pulmonale [ ] Chronic Cor Pulmonale [ ] Pulmonary Hypertension [ ] Does not apply to this patient ICD10 Documentation Needed Same as ICD 9

14 ©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: ___________________

15 ©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

16 ©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

17 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation GERD ICD10 Documentation Needed IDENTIFY GERD WITH OR WITHOUT ESOPHAGITIS Gastro esophageal reflux disease (GERD) with Esophagitis Gastro esophageal reflux disease (GERD) without Esophagitis

18 ©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

19 ©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

20 ©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

21 ©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

22 ©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

23 ©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

24 ©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

25 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Mood Disorder ICD10 Documentation Needed IDENTIFY Type, Status and Severity Type (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

26 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Myocardial Infarction ICD10 Documentation Needed Identify Type, Age of Infarction, Encounter, Site and Artery MI TYPE: [ ] Acute Coronary Syndrome (ACS) without Acute MI (Per coding guidelines, ACS equates to Unstable Angina) [ ] STEMI (please also specify site and artery—see below) [ ] NSTEMI AGE OF INFARCTION: [ ] Less than 4 weeks of admission [ ] Greater than 4 weeks of admission [ ] Less than 8 weeks [ ] Greater than 8 weeks [ ] Unable to determine ENCOUNTER: [ ] Initial [ ] Subsequent If STEMI, SITE: [ ] Anterior [ ] Apical [ ] Lateral [ ] Inferior [ ] Posterior [ ] Q Wave [ ] Septal [ ] Unspecified[ ] Other _____________________ SPECIFIC ARTERY (Based on site) [ ] Left Main Coronary[ ] Diagonal [ ] Left Anterior Descending[ ] Oblique Marginal [ ] Right Coronary Artery[ ] Other ___________________ [ ] Left Circumflex[ ] Unspecified

27 ©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

28 ©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

29 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Aspiration Pneumonia ICD10 Documentation Needed IDENTIFY 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

30 ©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

31 ©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)

32 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Pulmonary Embolism ICD10 Documentation Needed Identify acuity, type and if associated acute cor pulmonale Acuity: [ ] Acute [ ] Chronic Type: [ ] Saddle [ ] Septic [ ] Other___ [ ] Pulmonary Embolism with associated Acute Cor Pulmonale

33 ©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

34 ©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

35 ©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

36 ©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

37 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Respiratory Failure ICD10 Documentation Needed 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

38 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Post op Respiratory Issues ICD10 Documentation Needed 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

39 ©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.) _______________________

40 ©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

41 ©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

42 ©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

43 ©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

44 ©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

45 ©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

46 ©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

47 ©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

48 ©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

49 ©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

50 ©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

51 ©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