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Advocate Condell Surgery Trauma Neurosurgery Orthopedics v 2 Thomas C Kravis MD
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Clinical Documentation Improvement Goals and Objectives
ICD-10 General Awareness Session – Intro & Physician Leader 4/20/2017 Clinical Documentation Improvement Goals and Objectives Clear concise accurate documentation Across the continuum of care: inpatient and outpatient Capture the severity of illness (SOI) and the Risk of Mortality (ROM) Support hospital and physician reimbursement Improve quality report cards and clinical outcomes Reduce denials and queries Prepare for ICD-10

Value of Accurate and Complete Documentation
MD and Hospital Quality Reports Core Measures POA HACs ICD-9-CM ICD-10 Preventable Readmission Complications PSIs Compliance Fraud Abuse RAC Value Base Purchasing 2 MIDNIGHT RULE Care Coordination Team E&M Pro fees Denial related claims Medical Necessity

Impact of Documentation
MS-DRG Bowel Procedure with CC PDx: Colon cancer SDx: Dehydration Post-op ileus (codes to ) “Ulcer/Wound” noted by RN PPx: Left hemicolectomy MS-DRG Bowel Procedure with MCC PDx: Colon cancer SDx: Acute Renal Failure – ATN Expected ileus (560.1) Pressure Ulcer, site unspecific PPx: Left hemicolectomy MS-DRG Bowel Procedure with MCC PDx: Colon cancer SDx: Acute Renal Failure – ATN Expected ileus (560.1) Pressure Ulcer Stage IV on Sacrum PPx: Left hemicolectomy Highest MS-DRG payment APR DRG: 221 SOI Level: 2 APR Weight: ROM Level: 1 Peer Group 0.0% APR DRG: 221 SOI Level: 3 APR Weight: ROM Level: 3 Peer Group 2.5% APR DRG: 221 SOI Level: 4 APR Weight: ROM Level: 4 Peer Group 24.2%

California Statewide Health Planning and Development
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General guidelines for Documentation
Document all diagnoses and procedures Licensed hands-on treating practitioner in the body of the EMR and discharge summary All medications, treatments and diagnostic studies and the corresponding medical diagnoses for each and the clinical significance Conditions cannot be coded from lab, x-ray, other diagnostic test results or symbols (↑, ↓) without practitioner documentation. ‘Cut and pasted’ documentation must accurately reflect the clinical condition of the patient at the time of the documentation

When should I document a condition?
To assign an appropriate code and capture the severity of illness and risk of mortality in the inpatient setting a condition must meet at least one of the following criteria: Clinical evaluation Therapeutic treatment Diagnostic procedures Extended length of hospital stay Increased nursing care and/or monitoring

Documentation & Coding Issues at Advocate
Two separate languages Physician Document in CLINICAL terms Documentation for coding, profiling & compliance requires specificity in DIAGNOSIS terms This gap will be increased with ICD-10 Documentation Improvement can help bridge the gap

Clinical Diagnostic Unable to Code Able to Code
Multi-system organ failure Severe respiratory distress Hemodynamically unstable Will rehydrate “Urosepsis” ↓ K = 2.0, will give KCL Chest X infiltrate ↓ HgB 5.2, Transfuse Altered Mental Status Emaciated,Total Protein/Albumin Low Liver failure, renal failure, resp failure Respiratory failure : acute, acute on chronic Hypotension, shock-cardiogenic/septic Dehydration, hypovolemia Simple UTI Hypokalemia Pneumonia Left Lower Lobe Acute/Chronic Blood Loss Anemia Coma, Encephalopathy Protein Calorie Malnutrition On the left, is an example of documented statements that leave a coder unable to code the diagnosis. The diagnoses on the right would contribute significantly to the final assignment of severity and/or risk of mortality.

E&M DRG Assurance Inpatient Physician The Key Elements :
Chief Complaint History Examination Medical Decision Making Chief Complaint: Symptom, problem, condition, diagnosis Unknown Dx and if evaluated treated : “Probable” “Possible” “Suspected” Coded as if condition exists until condition has been excluded Two Midnight Rule Signs Symptoms Expectation of 2 Midnight Risk of Adverse Event Exception INPATIENT ONLY

ICD-10 Consists of 2 Components
ICD-10-CM Diagnosis Classification System 2 ICD-10-PCS Procedure Classification System for Inpatient Hospital Use

ICD-9 vs. ICD-10 Structural Changes
ICD-10 General Awareness Session – ICD-10 Overview 4/20/2017 ICD-9 vs. ICD-10 Structural Changes ICD-9 (Diagnoses) # Category etiology, site, manifestation 3-5 characters Here we will show the comparison of ICD-9 to ICD-10. In ICD-9 most of the characters are numeric, (exceptions are the V-codes and the E-codes). The decimal point is after the 3rd digit. Press ENTER. In comparison, in ICD-10, the first digit is always alpha, the second character is always numeric, characters 3 – 7 can be either alpha or numeric. The decimal point is also after the 3rd character, as in ICD9. You will notice in ICD-10 there’s an additional character to allow for additional specificity of the codes in the etiology, site and manifestation. (Point to this on the slide) Finally, there is the addition of the 7th character. This is new to ICD-10 which is called an extension character. This character is used in certain conditions to identify the type of encounter and status of the condition. The importance of complete, specific documentation in the medical record cannot be overemphasized. Without complete documentation, the coder will be unable to assign a code upon initial review of the chart and a query may have to be created in an effort to clarify documentation for coding purposes. You may receive query’s from both professional coders as well as from the Clinical Documentation Specialists. ICD-10 (Diagnoses) 3-7 characters a # a/# Category etiology, site, manifestation extension Encounter

ICD-10-CM requirements Laterality
Neoplasm e.g malignant neoplasm of upper lobe of right lung Injuries e.g laceration of left subclavian vein Body Part - e.g DVT of left iliac vein Acuity: Acute Chronic Acute on Chronic Etiology or Cause Encounter ( treatment status) Specificity: Initial- patient receiving active treatment for a condition e.g. injuries, Subsequent- patient has received active treatment and is receiving routine care during the recovery period Sequela-recovered Note: “visit” in CPT = patient type (new or established).

ICD-10 Diagnosis Code example Fracture Femur
ICD-10 General Awareness Session – ICD-10 Overview 4/20/2017 ICD-10 Diagnosis Code example Fracture Femur S 7 2 4 K Fracture of the femur Head & Neck Base of Neck Displaced fracture left Subsequent encounter for closed fx with nonunion To show the complexity of the new structure of ICD-10, let’s build an ICD-10 code. Press ENTER. The first three characters indicate that this is a fracture of the femur. Press ENTER. The next character indicates the anatomical section of the head and neck. Press ENTER. The next character gives further specificity of the base of neck. Press ENTER. The next character adds a new component in ICD-10 which is that the fracture is displaced in addition to the laterality. Press ENTER. The final character tells us whether it was the initial encounter or subsequent encounter. If it was a subsequent encounter we need to identify whether it was for routine healing, non-healing, nonunion, malunion or for sequela. All of this is new information and will need to be documented in the medical record in order for the chart to be coded.

Physician role Clinical Documentation
Focus remains on patient care Real time 3M 360 :Natural Language Processing Respond to query and document in the EMR Do not need to learn coding Minimal impact on day-to-day routine Clinical Documentation Specialists – a resource to the physician 17

Concurrent Query Process
360

Impact of Responding to Query
Query: “The magnesium level is 1.6 and the patient is receiving magnesium sulfate” “Please provide a corresponding diagnosis ” Physician documents: “hypomagnesemia” Cardiac Procedure Impact w/o Response to Query RW = GLOS = 8.98 SOI = 2 Moderate ROM = 2 Moderate Impact w/ Response to Query RW = GLOS = 8.98 SOI = 3 Major ROM = 2 Moderate

Probable, Possible, Suspected Diagnosis Uncertain Diagnosis
Inpatient application only: These conditions may be coded as though they exist Applies to hospital setting only If condition is ruled out, it may not be coded Outpatient application: Must code signs/symptoms, not the suspected condition Supports appropriate E&M professional component 20

Clinical example 66 year old male admitted with nausea, abdominal and chest pain and “AMS” altered mental status; history of elevated triglycerides and daily alcohol use.

Possible probable suspected alternatives
Cardiac Cath MS-DRGs 286/287 RW = GERD Gastritis MS-DRGs 391/392 RW = Chest Pain MS-DRG 313 RW = Anterior CP Pleuritic CP Chest Wall Pain MS-DRG 204 RW = Costochondritis Tietze’s Disease MS-DRGs 205/206 RW = Pulmonary Embolism MS-DRGs 175/176 RW = Cardiac Arrhythmia MS-DRGs 308/309/310 RW = Angina MS-DRG 311 RW = CAD MS-DRGs 302/303 RW = Shingles MS-DRGs 595/596 RW = Psychogenic Chest Pain MS-DRG 882 RW = Pleurisy MS-DRGs 193/194/195 RW = Psychogenic Angina Pericarditis MS-DRGs 314/315/316 RW = Anxiety MS-DRG 880 RW = Biliary Colic MS-DRGs 444/445/446 RW = 22

Abdominal Pain ICD-10 What Stays the Same? What’s New?
Specifies abdominal pain, tenderness and rigidtiy by anatomic locations : All four quadrants Epigastric Periumbilical Generalized What’s New? rebound tenderness Abdominal Pain Bullet 1: ICD-10 continues to specify abdominal pain, abdominal tenderness and abdominal rigidity by anatomic location – all four quadrants, epigastric, and periumbilical as well as generalized. Bullet 2 plus box on right: What’s new is that ICD-10 provides specific codes for abdominal rebound tenderness by anatomic location. The takeaway here is to remember to document in your note the specific location on the abdomen for these symptoms. Providing a more specific symptom code will help support medical necessity for any diagnostic tests you may order in an effort to learn the cause of this common symptom.

Hemorrhoids Document the degree/grade/stage of hemorrhoids:
First degree Hemorrhoids (bleeding) without prolapse outside of anal canal Second degree Hemorrhoids (bleeding) that prolapse with straining, but retract spontaneously Third degree Hemorrhoids (bleeding) that prolapse with straining and require manual replacement back inside anal canal Fourth degree Hemorrhoids (bleeding) with prolapsed tissue that cannot be manually replaced Document presence of any associated complications: Prolapsed Strangulated Thrombosed Ulcerated Current medical literature classifies hemorrhoids into four stages or degrees. The distinction among these stages is clear and affects the therapy given. Consequently, ICD-10 has included this new terminology in new codes. Note that bleeding, when present, is included in the code for each grade or stage of hemorrhoid. However, the source of the bleeding should be clearly documented in your notes as due to hemorrhoids or due to some other problem.

Documentation of Pancreatitis
Lab: Elevated bilirubin lipase and amylase Treatment: IVF, NPO, pain control, electrolyte correction. Current Documentation Improved Documentation Final Diagnosis: Pancreatitis, alcohol abuse Final Diagnosis: Acute pancreatitis due to alcohol dependence We see in this example of medical record documentation a final diagnosis of pancreatitis and alcohol abuse. There is no statement of acute versus chronic and there is no linkage between the pancreatitis and alcohol abuse. The final diagnosis on the right tells a better story. It clearly states the pancreatitis is acute and shows cause and effect by stating “due to alcohol dependence” which results in the reporting of “alcohol induced acute pancreatitis.” The coder is not permitted to assume the alcohol caused the pancreatitis. Only you are able to document and use words such as “caused by,” “due to,” or “secondary to.” Additionally, consider the statement in the history: “daily alcohol use.” If your intended diagnosis is alcohol dependence, state dependence rather than abuse or use. Dependence and use or abuse are two different codes.

Barrett’s Esophagus & Barrett’s Ulcer
Barrett’s esophagus, disease, syndrome Document presence of dysplasia High grade dysplasia Low grade dysplasia Barrett’s ulcer Document presence of bleeding ICD-10 K22.10 Barrett’s ulcer without bleeding K22.11 Barrett’s ulcer with bleeding K22.70 Barrett’s esophagus without dysplasia K22.710 Barrett’s esophagus with low grade dysplasia K22.711 Barrett’s esophagus with high grade dysplasia K22.719 Barrett’s esophagus with dysplasia, unspecified ICD-10 now classifies Barrett’s esophagus separately from ulcer of the esophagus and provides increased specificity and the requirement to identify with and without dysplasia. If you know the patient has associated dysplasia, and whether it is low- or high grade, document this in your notes. The coder is not permitted to assign the code based only on a path report – codes are based on what you document.

Respiratory Failure Acute/chronic/acute on chronic
Cause or etiology (pneumonia,COPD,drug,trauma; If following surgery was it POA ( PSI) or due to underlying pulmonary condition, failure to wean Signs :RR> 26, accessory muscles use, altered mental status Arterial blood gas and pH: pH of <7.30 or >7.50 pCO2 of >50 pO2 of <60 (impacted by hemoglobin level) Type I Hypoxemic : pO2 60 mm Hg normal or low pCO2 Type II Hypercapnic: pH < 7.30 and increased bicarbonate;pCO2 >50 Chronic : As above and low flow 02 at home; polycythemia ;cor pulmonale; heart failure

Postoperative Respiratory Failure
Respiratory failure in a postsurgical patient, clarify if: The surgery caused the failure The patient failed weaning off vent The patient has underlying respiratory problems that could have been the cause of the failure Quality Concepts Respiratory failure not present on admission and occurs after an operative episode is considered a patient safety indicator (PSI 11) Important to get confirmation of the following: POA status (present on admission vs. occurs after admission) Confirmation of diagnosis if condition documented without corresponding clinical picture Cause of the respiratory failure following surgery (related or unrelated to surgery)

Altered Mental Status Alternatives
Coma MS-DRGs 080/081 RW = Encephalopathy and Metabolic Encephalopathy MS-DRGs 070/071/072 RW = Seizures MS-DRGs 100/101 RW = Hepatic Encephalopathy MS-DRGs 441/442/443 RW = Hypertensive Encephalopathy MS-DRGs 077/078/079 RW = TIA MS-DRG 069 RW = CVA MS-DRGs 064/065/066 RW = Acute Confusional State MS-DRGs 880 RW = Diabetic Ketoacidosis MS-DRGs 637/638/639 RW = Drug-Induced and Alcoholic Delirium and Dementia MS-DRGs 896/897 RW = UTI MS-DRGs 689/690 RW = Altered Mental Status MS-DRGs 947/948 RW = Alzheimer’s Disease Parkinson’s Disease MS-DRGs 056/557 RW = Dementia and Vascular Dementia MS-DRG 884 RW = Toxic and Anoxic Encephalopathy MS-DRGs 091/092/093 RW = 29

Cerebral Infarction Specify etiology or cause of the infarct:
Thrombosis Embolism Occlusion or stenosis Document specific artery involved and laterality: Precerebral arteries which include: Carotid artery Basilar artery Vertebral artery Cerebral arteries which include: Anterior cerebral artery Cerebellar artery Middle cerebral artery Posterior cerebral artery

Cerebral Infarction Following Surgery
Document etiology of cerebral infarction: Embolism Thrombosis Occlusion Stenosis Specify artery involved: Anterior cerebral artery Basilar artery Carotid artery Cerebellar artery Middle cerebral artery Posterior cerebral artery Vertebral artery Document the link between the occluded vessel and the CVA, if appropriate Requires laterality distinction (left vs. right) Intraoperative or postprocedural cerebral infarction occurring during cardiac or other type of surgery The etiology of a cerebral infarction, or stroke, is classified primarily by whether it is due to thrombosis or embolism. ICD-10 has lots of new codes for cerebral infarction which identify the specific artery involved, and when applicable, whether right or left. For example, the codes for cerebral infarction due to thrombosis of the anterior cerebral artery. Keep in mind, coders can’t get the details of the etiology, site, or laterality from ancillary services reports, such as radiology, since coding must be based on what you document….so be sure to include these details your notes. ICD-10 also provide codes for cerebral infarction that occur intraoperatively or postoperatively during cardiac surgery or another type of surgery.

Documentation Requirements for Injuries
Documentation of Encounter Specificity Initial – patient is receiving active treatment for the condition such as: Surgical treatment Emergency department encounter, and Evaluation and treatment by a new physician Subsequent – patient has received active treatment of the condition and is currently receiving routine care for the condition during the healing or recovery phase. Cast change or removal Removal of external or internal fixation device Adjustment of medication Other aftercare and follow-up visits following treatment of the injury or condition Sequela – used for complications or conditions – late effects that arise as a direct result of a condition.

Injury of Spleen Specify type of injury Contusion Laceration
Minor – contusion of spleen less than 2 cm Major – contusion of spleen greater than 2 cm Laceration Superficial/minor – laceration of spleen less than 1 cm Moderate – laceration of spleen 1 to 3 cm Major/massive – laceration of spleen greater than 3 cm; multiple lacerations of spleen 33

Injury of Liver Specify type of injury Contusion Laceration
Minor – laceration involving capsule only, or, without significant involvement of hepatic parenchyma (i.e., less than 1 cm deep) Moderate – laceration involving parenchyma but without major disruption of parenchyma (i.e., less than 10 cm long and less than 3 cm deep) Major – laceration with significant disruption of hepatic parenchyma (i.e., greater than 10 cm long and 3 cm deep); multiple moderate lacerations, with or without hematoma 34

Pneumothorax ICD-10 documentation for pneumothorax will need to include: Spontaneous – primary, secondary or tension Also note underlying cause such as due to underlying lung disease or connective tissue disorder Postprocedural Traumatic Chronic If postoperative pneumothorax, please specify the significance or that it is an insignificant finding not impacting the patient. 35

Injury of Heart Specify type of injury
Contusion (EKG changes, elevated troponin) Laceration Mild – laceration of heart without penetration of heart chamber Moderate – laceration of heart with penetration of heart chamber Major – laceration of heart with penetration of multiple heart chambers Document presence of hemopericardium 36

Cardiac Arrest Document the underlying cause or etiology if known or suspected Indicate a linkage to the known or suspected etiology by selecting words such as “due to” or “secondary to”

Head Injury Many of the following terms may be considered nonspecific:
Closed head injury (CHI) Traumatic brain injury (TBI) - diffuse or focal Intracranial injury Please document the specific type of injury: Cerebral edema Compression of brain/brain herniation – diffuse or focal injury Concussion Contusion of brain Hemorrhage of brain Laceration of brain Also specify if any loss of consciousness and the time duration

Traumatic Brain Hemorrhage
Specify site Left or right cerebrum Cerebellum Brainstem Epidural Subdural Subarachnoid Specify if with LOC and for how long in order to accurately report time. Unique ICD-10 codes are reported for traumatic brain hemorrhage of left cerebrum withloss of con < 30 Minutes of the sites you see here when you include this information in your notes. Additionally, you have the capability to report any associated loss of consciousness and how long it lasted. For example, 1 code is reported for loss of consciousness up to 30 minutes; a different code is reported for up to 59 minutes, etc…so include this information in the patient record.

Spinal Cord Injury Document by specific type of injury:
Anterior cord syndrome Brown-Séquard syndrome Central cord syndrome Complete lesion Spinal concussion Spinal edema Specific level for each vertebral segment (C1), rather than a range (C1-C4) Encounter: initial, subsequent or sequela Example: “C4 and C5 spinal cord injury with closed nondisplaced fracture of C4 & C5 vertebrae, initial encounter"

Coma Glasgow Coma Scale (GCS)
Based on 3 categories of responsiveness: eye opening, best motor response, and best verbal response. Lower the GCS, the deeper the level of unconsciousness. 90% with a score < or equal to 8 are in a coma 50% with score < than or equal to 8 at six hours die Head injury classification: Severe – GCS 8 or less Moderate – GCS 9 to 12 Mild – GCS 13 to 15

Documentation Requirements for Fractures
Gustilo Open Fracture Classification The following is required for open fractures of the forearm, femur, lower leg or ankle: Type I: clean wound less than 1 cm with minimal soft tissue injury. Bone fracture is simple with minimal comminution. Type II: moderately contaminated wound greater than 1 cm with moderate soft tissue injury. Fracture contains moderate comminution. Type III: extensive skin damage involving muscle or nerves. Type III is further subdivided as follows: Type III A: extensive laceration of soft tissues with bone fragments from severe comminution or segmental fractures Type III B: extensive lesion of soft tissues with periosteal stripping and contamination which usually requires a flap to cover the exposed bone Type III C: exposed fracture with major vascular injury requiring repair for limb salvage

Documentation Requirements for Fractures
Salter-Harris Classification The following is required on growth plate fractures Type I – transverse fracture through the hypertrophic zone of the physis Type II – fracture through the physis and metaphysis, but does not involve the epiphysis. This is the most common type and may cause minimal shortening, but rarely results in functional limitations Type III – fracture though the hypertrophic layer of the physis extending to split the epiphysis thereby damaging the reproductive layer of the physis Type IV – fracture through epiphysis, physis and metaphysis Type V – fracture involving only the physis which results in a compressive deformity of the growth plate

Documentation Examples for Fractures
Examples of specificity: Nondisplaced intertrochanteric fracture of right femur, initial encounter for open fracture type II (S72.144B) Torus fracture of lower end of left humerus, subsequent encounter for fracture with delayed healing (S42.482G) Displaced oblique fracture of shaft of right tibia, initial encounter for closed fracture (S82.231A)

Traumatic Vertebral Fractures
Document: Level of vertebral column For example, L1 Part of vertebra fractured For example, posterior arch Displaced versus nondisplaced Specify: Type of fracture For example: Type II dens fracture of the 2nd cervical vertebra Type III spondylolisthesis of the 2nd cervical vertebra Stable or unstable burst fracture of L1 Traumatic wedge compression fracture Zone I-III or Type 1-4 sacral fracture Traumatic vertebral fractures can be reported with a high degree of specificity in ICD-10. The level of the vertebra should be documented, such as L1. The fracture should be described as displaced or nondisplaced. The part of the vertebra fractured should be included in your notes, such as “displaced posterior arch fracture of the first cervical vertebra.” Additional clinical terms used to describe a specific type of fracture should also be documented, such as Type II dens fracture of the 2nd cervical vertebra, stable versus unstable burst fracture of L1, wedge compression fracture of L3, and Zone I-III or Type 1-4 sacral fractures.

Documentation Requirements for Pathological Fractures
Specify: Exact location of fracture Site Laterality Etiology of fracture Bone disease/lesion Neoplastic disease Osteoporosis (age related or disuse) Encounter type Initial encounter for fracture Subsequent encounter for fracture Sequela Cause of fracture A fracture will default to traumatic unless otherwise documented The coding of pathological fractures, especially vertebral and hip fractures, is particularly problematic for coders due to lack of documentation regarding the cause, except in the case of obvious traumatic fractures, such as a car accident. Coders understand that some fractures, can occur in the elderly due to a minor fall or other relatively minor circumstance that would not have caused a fracture in a normal, healthy bone; consequently, when your documentation indicates a minor fall in an elderly patient who also has osteoporosis or other disease affecting the bone, the question arises as to whether this should be coded and reported as a pathologic or traumatic fracture. You should document your clinical opinion as to whether a fracture is traumatic or pathologic, when the history of the patient does not indicate an obvious traumatic cause, and if pathologic, the type of disease causing the fracture. Additionally, a diagnosis of compression fracture can be considered either traumatic or pathologic. Your final diagnosis should state “pathologic” or “fracture due to xyz” if in your opinion, osteoporosis or some other disease is the cause of the fracture.

Blood Loss Anemia Blood loss anemia may be due to trauma, gastrointestinal conditions, obstetrical delivery or surgery or other causes Document: Anemia due to acute blood loss Anemia due to chronic blood loss Postoperative anemia due to blood loss Link anemia to the blood loss, when appropriate Anemia following surgery with an expected amount of blood loss may be documented as acute blood loss anemia. It is imperative that you document the acuity of the blood loss anemia (acute, chronic, postoperative). When acute blood loss anemia is due to blood loss resulting from surgery, a diagnosis of “postoperative anemia” is not enough. Document instead “postoperative anemia due to acute blood loss,” if appropriate.

Adult Malnutrition Classification of adult malnutrition is based on the documented known or suspected etiology: Starvation-related Chronic disease-related Acute disease or injury-related Two or more of the following six characteristics required:* Insufficient energy intake Weight loss Loss of muscle mass Loss of subcutaneous fat Localized or generalized fluid accumulation that may mask weight loss Diminished functional status as measured by hand grip strength *May 2012, the Academy of Nutrition and Dietetics (Academy) and the American Society for Parenteral and Enteral Nutrition (ASPEN)

Neoplasms Document specific site and laterality:
Example: Malignant neoplasm of right upper lobe of the lung Example: Benign neoplasm of splenic flexure Document primary and all secondary sites In the case of admission for treatment of secondary malignancy, specify if the primary site is still present It’s perfectly acceptable to state a diagnosis or anatomical site as probable or suspected Example: Probable osteosarcoma of left femur 49

Sepsis Urosepsis imprecise No IDD-10 a code for urosepsis
Sepsis is classified by the bacteria causing the infection Streptococcal sepsis (group A, group B, Streptococcus pneumoniae, other streptococcal) or Other sepsis (e.g., MRSA, pseudomonas) Severe sepsis is associated with organ dysfunction/failure Document the specific associated organ dysfunction (not MOD) and Document presence of septic shock Sepsis is classified to one of two categories in ICD-10; either Streptococcal Sepsis or Other Sepsis. Streptococcal sepsis is further specified as being due to group A or group B streptococcus, Streptococcus pneumoniae, or other streptococcal infection. As mentioned earlier, the professional coding staff cannot simply read the laboratory results such as a blood culture to code an organism responsible for an infectious proces and it is therfore necessary for you to indicate a cause and effect relationship between the organism and the sepsis, if known, or suspected, in your notes. There are now combination codes for severe sepsis or SIRS due to an infectious process with acute/multi-organ dysfunction with or without septic shock. It is important to document shock as well as any associated organ dysfunction such as acute respiratory failure, acute renal failure, acute hepatic failure, disseminated intravascular coagulopathy, and so forth as they support the appropriate use of resources to provide good patient care and they are important indicators of severity of illness and risk of mortality in the critically ill patient. Sometimes we use the terms ‘sepsis’, ‘ bacteremia’, ‘septicemia’ and ‘severe sepsis’ interchangeably or indiscriminately in records. Make certain to clearly document the term that accurately describes your patient’s condition and update it should the patient progress along the sepsis continuum as the condition is treated or resolved. On another note, should you have a patient with SIRS due to a non-infectious process such as trauma, ICD-10 requires you to document if there is associated acute organ dysfunction.

“Postoperative” Diagnosis: Two Definitions
Clinical Definition “A condition occurring in the postoperative period”. Coder Definition “A diagnosis related to the surgical procedure” Complication-900 code “Coder cannot make the determination if it is a complication or an expected outcome” (Coding Clinic 4/27/2011) .

Examples Complication Non-Complication Postop ileus (997.4 + 560.1)
Ileus secondary to surgery ( ) Post op atelectasis ( ) Post op anemia ( ) Non-Complication Ileus Prolonged ileus Expected ileus Incidental atelectasis Atelectasis Acute blood loss anemia 5252

ICD-10 Documentation Requirements for Procedures
Laterality of site Left Right Bilateral Specificity of approach Open Percutaneous Percutaneous endoscopic Via natural or artificial opening Via natural or artificial opening- endoscopic Open with percutaneous endoscopic assistance External

Documentation of a procedure: Example stent ICD-10-PCS
Section Body System Root Operation Body Part Approach Device Qualifier 0 2 7 B 3 4 Z Med/Surg Dilatation Percutaneous None We have med/surg which is the majority of the PCS procedure codes …………by far the majority are med/surg…….. Then an example body system would be respiratory system, excision would be the operation, body part would be the upper lung lobe, and so forth. ….. So each one has a meaning……….. “Z” just in general for your information ………means that there is nothing or doesn’t apply. So “Z”, in this case, is showing you that there was no device…… Heart & Great Vessels Coronary Artery Transluminal Device, Drug Eluting

Fracture Treatment Reduction: open vs. closed
Fixation: internal vs. external vs. no fixation device Reduction = “reposition” in ICD-10-PCS Example “Closed reduction with percutaneous internal fixation of right femoral neck fracture” ICD-10 coding of fracture treatment doesn’t necessarily require additional documentation from you since you would typically document all elements needed to determine the ICD-10 code, These elements are: bone involved, laterality, approach, and type of fixation device, if any. If an external fixation device is applied, additional elements of documentation would be monoplanar, ring, or hybrid. Here is the table the coder will use to construct a code for fracture reduction of some of the lower bones. Note that ICD-10 uses the terminology of “reposition” instead of “reduction” to describe the procedure You won’t have to change your vocabulary; the coder will know that ICD-10 reposition operations include fracture reduction. For example, the code for closed reduction with percutaneous internal fixation of a right femoral neck fracture is 0-Q-S Z.

Amputation Status ICD-9-CM ICD-10-CM
Just like for joint replacement status, as in ICD-9, ICD-10 provides codes to identify patients who are status post amputation. As you can see on screen, again the only difference is that ICD-10 codes provide additional specificity for laterality. Additional codes not seen here are provided for status post amputation of other body parts, such as toe, foot, and upper limb.

Joint Replacement Status
ICD-9-CM ICD-10-CM As in ICD-9, ICD-10 provides codes to identify patients with one or more joint prostheses. As you can see on screen, the only difference is that ICD-10 codes provide additional specificity for laterality. Not seen here are the codes for presence of artificial joints of the shoulder, elbow, wrist, and ankle.

Coronary Artery Bypass Graft (CABG)
Specific location of both bypass attachments Coronary to coronary Coronary to thoracic artery or abdominal artery Coronary to aorta Internal mammary, right or left Specific graft used Autologous venous tissue/Autologous arterial tissue Synthetic substitute Nonautologous tissue substitute Number of bypass grafts Approach Open Percutaneous endoscopic Specific vein harvested for graft (greater/lesser saphenous vein: left/right) April 5, 2006 58

Coronary Angioplasty Specify the number of sites
If stent inserted, drug-eluting versus non-drug eluting Coronary Angioplasty Documentation of coronary artery angioplasty requires (1st bullet on screen) YOU TO SPECIFY the number of sites within the coronary arteries that HAVE BEEN dilated… and not JUST the number of coronary arteries THAT WERE dilated. (2nd bullet on screen) Stents should be described as drug-eluting or non drug eluting (or bare metal). (Table should come on screen as the following is said) Here you see the table the coder will use to construct a code. For example, PTCA with drug-eluting stent insertion X 3 into the left circumflex, obtuse marginal, and posterior descending is classified IN ICD-10 as (red box on left should come on screen)“Coronary Artery, Three Sites” and (red box on right should come on screen) “Intraluminal Device, Drug-eluting.”

Coronary Angioplasty Objective of the procedure Root operation “dilation” is defined as “expanding an orifice or the lumen of a tubular body part” Coronary artery and the number of sites receiving treatment (e.g., one, two, three or four more sites) Approach is open, percutaneous, or percutaneous endoscopic Drug-eluting or non-drug-eluting device

Heart Biopsy Specific site of heart from which tissue is taken
1st bullet on screen. The specific site of the heart from which tissue is taken should be documented for a heart biopsy. Again, here you see the table the coder will use to construct the code. Of particular interest is the column on the left labeled Body Part which lists EACH ANATOMIC SITE of the heart from which the coder must THEN choose. For example, DOCUMENTATION WAS FOR a heart biopsy of the right atrium PERFORMED BY WAY OF A percutaneous approach is coded as (red boxes highlighting each code number on screen as the code is read) 0-2-B-6-3-Z-X.

Mechanical Ventilation
Root operation: Performance (Completely taking over a physiological function by extracorporeal means) Body system: Respiratory Duration: Less than 24 consecutive hours 24-96 consecutive hours Greater than 96 consecutive hours Document duration Mechanical Ventilation 36 Hours 5A1945Z

Document the type of debridement:
Wound Debridement Document the type of debridement: Excisional debridement or “cutting away or excision of tissue” Non-excisional debridement or “minor removal of loose fragments” Specify the depth of debridement: Skin Subcutaneous tissue Fascia Muscle Bone Document instruments used during procedure

Suture of Laceration Example: Suture of 6x2 cm, left supraorbital deep facial laceration. Closure was performed of subcutaneous tissue with #5-0 Vicryl followed by skin closure with #5-0 nylon. Here you see the table the coder will use to construct the code for this procedure. The first 3 digits of the code come from here indicating a repair procedure involving Subcutaneous Tissue and Fascia. It is important for you to note when laceration repairs involve closure of subcutaneous tissue and fascia. Repairs involving skin only are coded using a different table. The next digit of the code captures the specific body part, in this case the subcutaneous tissue and fascia of the face. The approach was stated is open. “No Device” indicates a device was not left in the body; devices do not include items such as sutures and drains. Finally, the coder will select Z, No qualifier, because the others of diagnostic does not pertain to suturing procedures which are obviously therapeutic in nature.

Spinal Stabilization Device
Use of flexible material that stabilizes the vertebrae Device is used in conjunction with surgery or separately Surgical approach Open Percutaneous Percutaneous endoscopic Specific device used to accomplish the stabilization Interspinous process Pedicle-based Facet Replacement

Excision of Intervertebral Disc
Example: “removal of some adjacent disc material” Since only a portion of the disc was removed, a code for excision will be assigned Coding Example: Excision of Intervertebral Disc Take for example open removal of “some adjacent disc material.” Since only a portion of the disc was removed, a code for “excision” will be assigned. Here you see the table the coder will use to construct the code for this procedure. The first 3 digits of the code come from here indicating an excision procedure involving the lower joints. (red box on left on screen) The next digit of the code captures the specific body part, in this case the lumbar vertebral disc. The approach was stated as open. “No Device” indicates a device was not left in the body. Finally, without a statement by you of biopsy or indication the procedure was performed for diagnostic purposes, the coder will select Z, No Qualifier. The resulting code generated by the coder based on the documentation is 0-S-B-2-0-Z-Z.

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© 3M M Confidential - For Customer's Internal Review Only

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Presentation on theme: "© 3M M Confidential - For Customer's Internal Review Only"— Presentation transcript:

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About project

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