The Transition to What you need to know for Gastroenterology 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 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 9

Complications of Surgery Physician 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 10

Encephalopathy Document type: –Metabolic –Toxic –Alcholic –Septic –Hepatic –Anoxic Document cause: –Infection –Electrolyte imbalance –Substance abuse and resulting disease –Viral hepatitis 11 Document severity: –Acute –Chronic Document underlying cause: –Alcohol induced –Diet deficiency –Viral –Allergic Document associated complications –bleeding Gastritis

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 found: –Rectal –Hematochezia –Hematemesis 12

Irritable Bowel Syndrome Document if with diarrhea Document if psychogenic 13 Hepatic Failure Document type: –Acute –Subacute –Chronic Document if with hepatic coma Document etiology, for example: –Due to alcohol or drugs

Pancreatitis Document severity: –Acute –Chronic Document etiology and show cause and effect: –Idiopathic cute pancreatitis –Alcohol induced acute pancreatitis –Gallstones or biliary –Drug induced 14

Peptic Ulcer Disease Document severity: –Acute –Chronic Document site: –Duodenal –Esophagus –Gastric –Other 15 Document underlying cause: –Alcohol –Drug or chemical Document if associated with: –Perforation –Hemorrhage –Perforation and hemorrhage

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 16

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