The Transition to What you need to know for General Surgery/Trauma 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

Anemia, Blood Loss Document, when appropriate: –Anemia due to acute blood loss –Anemia due to chronic blood loss –Postoperative anemia due to acute blood loss 8 Appendicitis Document severity: –Acute –Chronic –Recurrent –Relapsing –Subacute Document if with: –Peritoneal abscess –Peritonitis –Gangrene –Perforation

Complication of Surgery Physicians documentation must include the cause and effect relationship between the care provided and the condition that may be considered a complication. Physician documentation must indicate that condition is a complication. The physician may be asked for clarification if the complication is not clearly documented as either a complication or as an expected outcome 9

Neoplasms Document if neoplasm is benign or malignant Document site and laterality such as: –Lung –Prostate –Kidney –Breast –Colon –Other anatomic sites Differentiate between primary and secondary (metastatic) site –Document primary site and if it is still present For secondary sites: –Document suspected and final pathology results –EVEN IF RECEIVED AFTER THE PATIENT IS DISCHARGED WITH A LATE ENTRY DATED AS NEEDED 10

Obesity Document etiology: –Due to excess calories or nutritional –Due to drugs –Other, for example, due to thyroid or pituitary disorder Specify if morbidly obese Document BMI Document if: –With alveolar hypoventilation/ hypoventilation syndrome 11 Ascites Document if ascites is malignant Document neoplasm linked to malignant ascites

Crohn’s Disease Document anatomical site: –Large intestine –Small intestine –Small and large intestine Document any associated complications, such as: –Bleeding –Intestinal obstructions –Fistula –Abscess –Perforation Don’t use the term “inflammatory bowel disease.” Use of this term when your intended diagnosis is Crohn’s disease may understate severity of illness and risk of mortality 12

Encephalopathy Document acute/chronic Document type: –Metabolic –Toxic –Alcoholic –Septic –Hepatic –Anoxic Document cause: –Infection –Electrolyte imbalance –Substance abuse and resulting disease –Viral hepatitis 13 Hernia Document site and laterality: –Bilateral inguinal hernia –Femoral hernia –Umbilical hernia –Ventral hernia –Diaphragmatic/hiatal hernia Document if with: –Gangrene –Obstruction –Gangrene and obstruction

Gastritis Document severity: –Acute –Chronic Document underlying cause: –Alcohol induced –Diet deficiency –Viral –Allergic Document associated complications –bleeding 14 Pancreatitis Document severity: –Acute –Chronic Document etiology and show cause and effect: –Idiopathic cute pancreatitis –Acute pancreatitis due to alcohol abuse –Gallstones or biliary –Drug induced

Hepatic Failure Document type: –Acute –Subacute –Chronic Document if with hepatic coma Document etiology, for example: –Due to alcohol or drugs 15 Irritable Bowel Syndrome Document if with diarrhea Document if psychogenic

Peptic Ulcer Disease Document severity: –Acute –Chronic Document site: –Duodenal –Esophagus –Gastric –Other Document underlying cause: –Alcohol –Drug or chemical Document if associated with: –Perforation –Hemorrhage –Perforation and hemorrhage 16 Gastrointestinal Bleed Document etiology and show cause and effect, for example: –Acute GI bleed due to bleeding esophageal varices –Acute GI bleed due to hemorrhoids –Acute GI bleed due to gastritis Document where blood was observed: –Rectal –Hematochezia –Hematemesis

Ulcerative Colitis Use the following terms to further define the anatomical site: –Pancolitis –Proctitis –Rectosigmoiditis Document any associated complications: –Bleeding –Intestinal obstruction –Fistula –Abscess –Perforation Don’t use the term “inflammatory bowel disease.” Use of this term when your intended diagnosis is Ulcerative Colitis may understate severity of illness and risk of mortality 17

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