CRITICAL CARE 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  Anemia5  Aplastic Anemia6  Atrial Fib7  BMI – high8  BMI –low9  Cardiac Arrest10  Cellulitis11  Cerebral Edema12  Chest pain13  Cirrhosis of Liver14  Colitis15  Coma16  Cor Pulmonale17  Crohn’s Disease / Regional Enteritis18  CVA19  Debridement20  Dementia21  Diabetes22  Divertulitis23  Dysphasia24  Encephalopathy25  Fracture-Bone26  Functional Quadriplegia27  Gastroparesis28  Gastrointestinal Ulcer- Upper29  Heart failure- acute30  Heart failure-chronic31  Hepatitis32  HIV-AIDS33  Hypertension34  Hyponatremia35  Leukemia36  Level of consciousness37  Meningitis38  Mental Status- Altered39  Metabolic—acidosis/ alkalosis40  Myocardial Infarction41  Neoplasm42  Neutropenia43  Non pressure ulcer44  Malnutrition45

4 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. Table of Contents  Respiratory- Emphysema61  Respiratory failure62  Respiratory failure post op63  Sepsis64  Shock65  Substance abuse66  TIA67  Tumor Lysis Syndrome68  Urosepsis69  UTI70  Weakness71  Hospital specific  Documentation Specialists contact info  Open Fracture46  Osteomyelitis47  Pain48  Pancreatitis49  Personal Injury50  Pneumonia- Aspiration51  Pneumonia- Hypostatic /passive/ stasis52  Pneumonia-Specificity 53  Pressure Ulcer54  Pulmonary embolism55  Renal Failure—acute56  Renal failure-chronic57  Respiratory-asthma58  Respiratory- Bronchitis59  Respiratory- COPD60

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 Cellulitis ICD10 Documentation Needed 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

12 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Cerebral edema [ ] Cerebral edema / Vasogenic edema [ ] Compression of brain [ ] Findings not significant [ ] Radiologic finding only [ ] Does not apply to this patient ICD10 Documentation Needed Same as ICD 9

13 ©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

14 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Cirrhosis of Liver ICD10 Documentation Needed Identify if alcoholic or non-alcoholic, if congenital, biliary obstructive, laennec’s and if portal [ ] Alcoholic [ ] Non-alcoholic [ ] Congenital ____ (underlying disease) [ ] Biliary / Obstructive: [ ] Primary [ ] Secondary [ ] Laennec’s: [ ] Alcoholic with: [ ] dependence [ ] non-dependence [ ] Non-alcoholic [ ] Portal: [ ] Alcoholic [ ] Non-alcoholic

15 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Colitis ICD10 Documentation Needed Identify Site, Type and Complications Site (if applicable): [ ] Small Intestine [ ] Large Intestine[ ] Other site __ Type: [ ] Colitis due to radiation [ ] Ulcerative Colitis [ ] Infectious Colitis [ ] Toxic Colitis [ ] Ischemic Colitis [ ] Colitis due to ___________________ [ ] Chronic Colitis Complications: [ ] Rectal Bleeding [ ] Intestinal Obstruction [ ] Fistula [ ] Abscess [ ] Other complication _________________ [ ] Unspecified complication

16 ©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_________

17 ©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

18 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Crohn’s Disease / Regional Enteritis ICD10 Documentation Needed Identify specificity, site and associated diagnosis [ ] Abscess [ ] Fistula [ ] Intestinal obstruction [ ] Rectal bleeding [ ] Other (specify) _______________ Site: [ ] Small Intestine [ ] Large Intestine [ ] both small and large intestines Associated diagnoses / conditions (specify)________

19 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation CVA ICD10 Documentation Needed Identify Laterality, type, location and manifestations [ ] CVA -- Laterality:[ ] Right[ ] Left[ ] Bilateral[ ] Unspecified [ ] Hemorrhage (non-traumatic):Please specify Artery: _____________________ [ ] Subarachnoid [ ] Intracerebral [ ] Extradural [ ] Subdural: [ ] Acute [ ] Subacute [ ] Chronic [ ] Cerebral Infarction[ ] Cerebral[ ] Pre-Cerebral Please specify Artery: ___________ [ ] Thrombosis [ ] Embolism [ ] Unspecified occlusion or stenosis [ ] Venous Thrombosis [ ] Other Cerebral Infarction [ ] Cerebral Infarction Unspecified (Stroke NOS) [ ] Occlusion / Stenosis without Cerebral Infarction [ ] Pre-Cerebral Artery:[ ] Vertebral [ ] Carotid[ ] Other Pre-Cerebral Artery [ ] Cerebral Artery:[ ] Middle [ ] Anterior[ ] Posterior [ ] Cerebellar [ ] Other Cerebral Artery [ ] Unspecified Cerebral Artery [ ] Manifestations / Residual Effects [ ] Hemiplegia [ ] Right [ ] Left [ ] Unspecified [ ] Dysphagia

20 ©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

21 ©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: ___________________

22 ©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

23 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Diverticulitis ICD10 Documentation Needed IDENTIFY Acuity, Severity, Site and Type Acuity: [ ] Acute [ ] Chronic[ ] Acute on Chronic Severity: [ ] Bleeding [ ] No bleeding [ ] Abscess [ ] No abscess [ ] Perforation [ ] No perforation Site: [ ] Ileum [ ] Small Intestine [ ] Large Intestine [ ] Unspecified Intestine Type: [ ] Meckel’s diverticulum with diverticulitis [ ] Meckel’s diverticulum without diverticulitis

24 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Dysphagia ICD10 Documentation Needed IDENTIFY PHASE, TYPE and ACUITY Phase: [ ] Oral [ ] Oropharyngeal [ ] Pharyngeal [ ] Pharyngoesophageal Type:[ ] Cervical[ ] Functional [ ] Hysterical[ ] Nervous[ ] Neurogenic [ ] Siderpenic[ ] Spastica Following Non-Traumatic: [ ] SAH[ ] Intracerebral Hemorrhage [ ] Intracranial Hemorrhage [ ] CVA Acuity: [ ] Acute [ ] Chronic [ ] Acute on Chronic [ ] Other specified Dysphagia:___________ [ ] Unspecified Dysphagia

25 ©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

26 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Bone fracture ICD10 Documentation Needed IDENTIFY Site, Laterality, Type, Cause and Encounter Site: ________ Laterality:[ ] Right[ ] Left Type of fracture: Check all that apply [ ] Traumatic fracture[ ] Pathologic fracture [ ] Osteoporosis fracture--- [ ] Disuse [ ] Drug- induced [ ] Postmenopausal [ ] Idiopathic [ ] Post-surgical malabsorption [ ] Other (specify)___________ [ ] Stress or fatigue fracture [ ] Neoplastic fracture Other type of fracture: Check all that apply [ ] Non-displaced[ ] Displaced [ ] Open (Gustilo) [ ] Closed (greenstick, spiral) [ ]Salter-Harris—specify type_________ External cause of fracture (fall, skiing) _________________________ Encounter type: [ ] Initial encounter [ ] Subsequent encounter--- [ ] Routine healing [ ] Delayed healing [ ] Nonunion [ ] Malunion[ ] Sequela

27 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Functional Quadriplegia [ ] Functional quadriplegia (complete immobility) [ ] Immobilization syndrome (impaired mobility) ICD10 Documentation Needed Same as ICD 9

28 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Gastroparesis ICD10 Documentation Needed Identify if related to diabetes and if underlying disease [ ] Gastroparesis related to Diabetes [ ] Gastroparesis in underlying disease/process (please state: ______________)

29 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Upper Gastrointestinal Ulcer ICD10 Documentation Needed Identify acuity, type and any related or contributing disease Acuity: [ ] Acute [ ] Chronic [ ] Hemorrhage -or-[ ] No Hemorrhage [ ] Perforation -or- [ ] No Perforation Type: [ ] Gastric Ulcer [ ] Esophageal Ulcer [ ] Duodenal, Duodenum [ ] Other location ________________ [ ] Any related or contributing disease(s) Alcohol or drugs: _________________

30 ©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

31 ©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

32 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Hepatitis ICD10 Documentation Needed IDENTIFY Acuity, Etiology and associated diagnosis Acuity: [ ] Acute [ ] Chronic Etiology: [ ] Alcoholic [ ] Drug induced (specify)____ [ ] Viral (type A,B,C,E)_______ Associated Diagnosis: [ ] with hepatic coma [ ] without hepatic coma [ ] with delta agent [ ] without delta agent

33 ©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

34 ©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

35 ©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

36 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Leukemia ICD10 Documentation Needed IDENTIFY Acuity, Type and Status Acuity: [ ] Acute[ ] Chronic Type:[ ] Lymphoid (Cell type: _______) [ ] Myeloid(Cell type: ___________) [ ] Monocytic (Cell type: ________) [ ] Other Leukemias of specified cell type: ____________ [ ] Leukemia of unspecified cell type Status: [ ] Has not achieved remission [ ] In Remission [ ] In Relapse

37 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Level of Consciousness [ ] Coma / Comatose [ ] Encephalopathy, type: ____________________________ [ ] Persistent vegetative state [ ] Stupor ICD10 Documentation Needed Same as ICD 9

38 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Meningitis ICD10 Documentation Needed Identify Type, Organism and Present on Admission [ ] Viral Meningitis [ ] Specify organism (i.e. adenovirus, enterovirus, measles, etc.) ___________ [ ] Bacterial Meningitis - Acute [ ] Specify organism (i.e. gram negative, staph, strep, e coli, etc.)___________ [ ] Due to (please specify cause) _________ [ ] Aseptic - Acute [ ] Late effect [ ] Septic [ ] Present on Admission [ ] Yes [ ] No [ ] Unable to determine

39 ©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

40 ©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

41 ©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

42 ©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 ____________________________________

43 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Neutropenia ICD10 Documentation Needed Identify Cause [ ] Congenital [ ] Secondary to chemotherapy (list chemotherapeutic drug: __________) [ ] Drug induced (list drug: ________________) [ ] Due to infection (infection site: _______ Organism: _________________________) [ ] Cyclic [ ] Does not apply to this patient [ ] Unspecified

44 ©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

45 ©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

46 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Open Fraction ICD10 Documentation Needed Specificity for open fractures of the forearm, femur, and lower leg require documentation to Specify Gustilo Type I through Type IIIC. OPEN Fracture(s): ___________________________ Site: __Laterality: [ ] Right [ ] Left Gustilo type:___ GUSTILO CLASSIFICATION Type I: Wound < 1cm, clean, generally caused by a fracture fragment that pierces the skin Type II: Wound > 1cm, not contaminated, without mod soft tissue injury or defect. Type III: Wound > 1 cm. with significant soft tissue disruption, severely unstable fracture with varying degrees of fragmentation Type IIIA: Wound < 10 cm, crush injury and contamination, sufficient soft tissue to cover the bone without the need for local or distant flap coverage Type IIIB: Disruption of the soft tissue is extensive, such that local or distant flap coverage is necessary to cover the bone. The wound maybe contaminated and serial irrigation and debridement procedures are necessary to ensure a clean surgical wound >10 cm, crushed tissue Type IIIC: Any open Fracture associated with an arterial injury that requires repair.

47 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Osteomyelitis ICD10 Documentation Needed 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

48 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Pain ICD10 Documentation Needed Identify acuity and cause [ ] Acute Pain [ ] Trauma [ ] Post- Thoracotomy [ ] Post- operative / post-procedural [ ] Other __________________ [ ] Chronic pain [ ] Trauma [ ] Post-Thoracotomy [ ] Post-operative / post-procedural [ ] Other __________________ [ ] Neoplasm pain

49 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Pancreatitis ICD10 Documentation Needed Identify acuity, cause, gangrenous and alcohol induced [ ] Acute: [ ] Gallstone [ ] Biliary [ ] Idiopathic [ ] Other [ ] Chronic: [ ] Cystic [ ] Infectious [ ] Interstitial [ ] Recurrent [ ] Gangrenous [ ] Alcohol-induced:[ ] Abuse[ ] Dependence

50 ©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.) ______________________________

51 ©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

52 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation 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)________________ ICD10 Documentation Needed Same as ICD 9

53 ©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

54 ©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)

55 ©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

56 ©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

57 ©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

58 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Asthma ICD10 Documentation Needed Identify acuity and type [ ] Acute exacerbation of Asthma [ ] Status Asthmaticus [ ] Acute exacerbation of Allergic Bronchitis [ ] Asthma: [ ] Mild intermittent [ ] Mild persistent [ ] Moderate persistent [ ] Severe Persistent Type: [ ] Childhood [ ] Exercise induced [ ] Late onset [ ] Mixed [ ] Other (specify)________________ [ ] COPD [ ] Chronic obstructive bronchitis [ ] Acute lower respiratory infection

59 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Bronchitis ICD10 Documentation Needed Identify acuity and due to [ ] Acute exacerbation of Bronchitis [ ] Acute on Chronic Bronchitis [ ] Chronic Bronchitis obstructive [ ] Bronchitis due to: [ ] Fumes [ ] Radiation [ ] Viral or Bacterial Organism____________

60 ©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

61 ©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

62 ©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

63 ©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

64 ©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.) _______________________

65 ©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

66 ©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

67 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation TIA ICD10 Documentation Needed Identify TIA TYPE [ ] TIA Stenosis / Syndrome related to: [ ] Vertebro-Basilar Artery [ ] Carotid Artery [ ] Multiple / Bilateral Pre-Cerebral Artery [ ] Cerebral / Pre-cerebral occlusion / stenosis [ ] Small vessel disease of the brain / cerebral vascular disease [ ] Transient Global amnesia [ ] Amaurosis Fugax [ ] Other TIA [ ] Unspecified TIA (spasm of cerebral artery, transient cerebral ischemia)

68 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Tumor Lysis Syndrome [ ] Tumor Lysis Syndrome following anti-neoplastic drug chemotherapy [ ] Spontaneous Tumor Lysis Syndrome ICD10 Documentation Needed Same as ICD 9

69 ©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

70 ©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

71 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Weakness ICD10 Documentation Needed 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

72 ©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

73 ©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

74 ©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

75 ©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

76 ©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

77 ©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

78 ©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

79 ©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