The Transition to What you need to know for Infectious Disease 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

AIDS AIDS or symptomatic HIV infection means the patient has in the past or is currently showing signs of the infection Identify all conditions related to AIDS –Pneumocystitis –Kaposi sarcoma 8 Document HIV positive when patient has not progressed to AIDS HIV

Central Line associate-Blood Stream Infection/ CLABSI If bacteremia is related to a central line clearly indicate this by using words such as “due to” or “secondary to” Document if Present on Admission Document type and site and laterality of central line: –Dialysis –PICC –Femoral –Subclavian Document causative organism, when known or suspected 9

Drug Resistant Infection Document all infections that are drug resistant Document name of drug they are resistant to 10

Meningitis Document type –Bacterial –Viral –Fungal Document causative organism, when known or suspected 11

Pressure Ulcer/Decubitus Ulcer Document anatomic site and laterality: –Lower leg –Foot –Heel –Other sites Document if present on admission Document stage if known 12

Non-pressure Ulcer (skin) Document site and laterality: –Lower limb –Foot –Heel Document type: –Non-healing –Chronic –Stasis –Diabetic –Atherosclerotic Document if with: –Infection –gangrene 13

Urinary Tract Infection (UTI)/CAUTI 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 14

Tuberculosis Document severity –Acute or chronic Document site –Respiratory –Nervous system 15

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