The Transition to What you need to know for Emergency Medicine 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

Abdominal Pain Link symptoms to diagnostic term: -Small Bowel Obstruction “SBO” -Pancreatitis: acute vs. chronic -Peptic Ulcer Disease -Pelvic Inflammatory Disease -Gastroenteritis -Other 8

Acute Coronary Syndrome (ACS) Be clear on your intended Diagnosis. Would one of the following better describe the patient’s condition? -Angina -Unstable Angina -Myocardial Infarction 9

Acute Kidney Failure/Injury Document etiology, if known or suspected, such as: -Acute tubular, cortical, or medullary necrosis -Post procedural -Posttraumatic -With transplant kidney Be clear on your intended diagnosis. Note that “acute renal insufficiency” results in an “unspecified” code. Do not use abbreviations AKI or ARF 10

Acute Myocardial Infarction (AMI) Document Type as: - STEMI or NSTEMI Document Location: –Transmural –Anterior Wall –Inferior Wall –Subendocardial –Other site Document exact date of recent MI (one occurring within the last 4 weeks) and type: –STEMI and wall of heart affected versus NSTEMI 11

Alcohol/ Drug Abuse and Dependence Document if alcohol or drug use is: –Abuse –Dependence For dependence, document if in remission/withdrawal based on your clinical judgment Document any associated manifestations, for example: –Anxiety –Delirium –Delusions –Hallucinations –Psychoses 12

Asthma Document Severity and Type: –Mild intermittent –Mild persistent –Moderate persistent –Severe persistent Document Status: –Uncomplicated –w/ acute exacerbation –w/ status asthmaticus Document if present with COPD, bronchitis/other 13

Atrial Fibrillation & Atrial Flutter For atrial fibrillation, document type as: –Paroxysmal –Persistent or –Chronic For atrial flutter, document type as: –Typical or Type I or –Atypical or Type 2 14

Cardiac Arrest Document cause as due to: –Underlying cardiac or non-cardiac condition –Show cause and effect by using words such as “due to” or “secondary to” 15 Document the underlying cause Cardiogenic Shock

Congestive Heart Failure (CHF) Document severity: –Acute –Chronic –Acute on chronic Document type: –Systolic –Diastolic –Combined systolic & diastolic Document etiology, if known, such as due to: –Dilated cardiomyopathy 16

Chronic Obstructive Pulmonary Disease (COPD) Document if present with acute lower respiratory tract infection + casual organism, when known, such as: –Pseudomonas pneumonia –Acute Bronchitis Document if present with: –Acute exacerbation Document if present with respiratory failure and severity and if POA: –Acute respiratory failure –Chronic respiratory failure –Acute on chronic respiratory failure Document if oxygen-dependent 17

Encephalopathy Document type: –Metabolic –Toxic –Alcoholic –Septic –Hepatic –Anoxic Document cause: –Infection –Electrolyte imbalance –Substance abuse and resulting disease –Viral Hepatitis 18 Document type –Idiopathic –Orthostatic –Postural –Due to drug- specify drug –Post procedural –Due to hemodialysis –Chronic Hypotension

Fractures Pathological Vertebr al Specify whether etiology is: –Osteoporosis (senile vs. disuse) –Osteopenia –Neoplastic –Some other disease Document site and laterality If COMPRESSION fracture, clarify if traumatic or pathological 19

Fractures Traumatic Vertebral Document: –Level of vertebral column, for example L1 –Displaced versus non-displaced –Part of vertebra fractured, for example, posterior arch Document type of fracture, for example: –Type II dens fracture of the 2 nd cervical vertebra –Type III spondylolisthesis of 2 nd cervical vertebra –Stable versus unstable burst fracture –Zone I-III or Type 1-4 sacral fracture 20 Document the healing process –Routine –Delayed –Nonunion –Malunion Indicate the encounter type –Initial –Subsequent –Sequela

Fractures Traumatic Document: –Open versus closed –Displaced versus nondisplaced –Name of specific bone and specific site on bone –Orientation of fractures, such as transverse, oblique, spiral and ‒ Laterality For open fractures of the forearm, femur, and lower leg, document type as –Type I, II, IIIA, IIIB, or IIIC according to Gustilo classification For physeal fractures, Document –Type I, II, III, IV according to Salter Harris classification 21 For sacral fractures, document: –Zone I, II, III and ‒ Minimally versus severely displaced or ‒ Type 1, 2, 3, 4 Document the healing process –Routine (D) –Delayed –Malunion Indicate the encounter type ‒ Initial ‒ Subsequent Sequela

Gastrointestinal Bleed Document etiology and link 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 22

Respiratory Failure Document severity: –Acute –Chronic –Acute on chronic Document type: –Hypoxic –Hypercapnic –Hypoxic and hypercapnic Document if associated with COPD Post-procedural –Acute post-procedural Respiratory failure –Acute on chronic post-procedural respiratory failure 23

Urinary Tract Infection (UTI) If UTI is related to a device, such as Foley catheter or cystostomy tube, clearly indicate this by using words such as “due to” or “secondary to.” Document if Present on Admission Identify the specific site of the UTI, if known, such as: –Bladder –Urethra –Ureter (laterality) –Kidney (laterality) Document causative organism, when known or suspected, such as E. coli or Candida 24

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