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OB/GYN and Other Common Documentation Tips ICD 10 Documentation Specificity Needed based on Conifer ICD 10 CDI Queries.

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Presentation on theme: "OB/GYN and Other Common Documentation Tips ICD 10 Documentation Specificity Needed based on Conifer ICD 10 CDI Queries."— Presentation transcript:

1 OB/GYN and Other Common Documentation Tips ICD 10 Documentation Specificity Needed based on Conifer ICD 10 CDI Queries

2 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 Table of contents Anemia 4 Pancreatitis 18 BMI – high 5
BMI –low 6 Diabetes 7 Endometriosis 8 Headache/ Migraine 9 Hypertension 10 Hyponatremia 11 Metabolic—acidosis/ alkalosis 12 Mood Disorder 13 Neoplasm 14 Malnutrition 15 Pregnancy 16 Ovarian Cancer 17 Pancreatitis 18 Pneumonia-Specificity 19 Premature infant 20 Pressure Ulcer 21 Renal Failure—acute 22 Renal failure-chronic 23 Sepsis 24 Shock 25 Substance abuse 26 Testicular Torsion 27 Urosepsis 28 UTI 29 Hospital specific Documentation Specialists contact info

4 ICD10 documentation specificity needed
ICD10 Documentation 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: Same as in ICD 9

5 ICD10 documentation specificity needed
ICD10 Documentation Needed BMI > 40 with associated diagnosis of: [ ] Morbid (Severe) Obesity [ ] Overweight [ ] Obesity (unspecified) Morbidly Obese [ ] Morbid (Severe) Obesity [ ] Due to excess calories [ ] Familial [ ] Endocrine [ ] with Alveolar Hypoventilation (Pickwickian syndrome) [ ] Drug-induced (Name of drug: _____)

6 ICD10 documentation specificity needed
ICD10 Documentation Needed BMI < 19 with associated diagnosis of: (check one) [ ] Underweight [ ] Protein Calorie Malnutrition: [ ] Mild [ ] Moderate [ ] Severe [ ] Unspecified [ ] Cachexia [ ] Emaciation due to malnutrition Same as ICD 9

7 ICD10 documentation specificity needed
ICD10 Documentation Needed Diabetes 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

8 ICD10 documentation specificity needed
ICD10 Documentation Needed Endometriosis IDENTIFY Implant Site [ ] Uterus [ ] Fallopian tube: [ ] Right [ ] Left [ ] Ovary: [ ] Right [ ] Left [ ] Other site: ____________________ (e.g. intestine, parametrium, peritoneal, rectrovaginal septum, vaginal, vulva)

9 ICD10 documentation specificity needed
ICD10 Documentation Needed Migraine IDENTIFY SPECIFICITY [ ] With Aura [ ] With Refractory Migraine [ ] Intractable [ ] Persistent [ ] Other __________________ [ ] With CVA [ ] Hemiplegic [ ] With Status Migrainosus [ ] Menstrual [ ] Cyclical vomiting [ ] Periodic Headache Syndrome [ ] Ophthalmologic Headache IDENTIFY SPECIFICITY [ ] Tension [ ] Primary thunderclap [ ] Associated with sex, cough, exertion [ ] Cluster [ ] Post-traumatic [ ] New daily persistent [ ] Vascular [ ] Drug- induced [ ] Other_________________________

10 ICD10 documentation specificity needed
ICD10 Documentation Needed Hypertension [ ] Malignant Hypertension [ ] Accelerated Hypertension [ ] Benign Hypertension [ ] Unspecified Hypertension Same as ICD 9

11 ICD10 documentation specificity needed
ICD10 Documentation Needed Hyponatremia Identify specificity [ ] Hyponatremia, unknown cause [ ] Hyponatremia due to Sodium Deficiency [ ] Hyponatremia due to SIADH (Syndrome of Inappropriate Secretion of Antidiuretic Hormone) [ ] Insignificant lab value

12 ICD10 documentation specificity needed
ICD10 Documentation Needed Acidosis/Alkalosis Identify Type of Acidosis or Alkalosis [ ] Acidosis: [ ] Metabolic [ ] Respiratory [ ] Lactic [ ] Renal [ ] Alkalosis: [ ] Metabolic [ ] Respiratory

13 ICD10 documentation specificity needed
ICD10 Documentation Needed Mood Disorder IDENTIFY Type, Status and Severity Type (check appropriate): [ ] Manic [ ] Bipolar [ ] Manic [ ] Depressive [ ] Mixed [ ] Major Depressive Disorder [ ] With Psychosis [ ] Persistent Mood Disorder [ ] Without Psychosis Status: [ ] Single past episode [ ] Current episode [ ] In remission [ ] Partial [ ] Full Severity: [ ] Mild [ ] Moderate [ ] Severe [ ] Unspecified

14 ICD10 documentation specificity needed
ICD10 Documentation Needed Neoplasm 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 ____________________________________

15 ICD10 documentation specificity needed
ICD10 Documentation Needed Malnutrition [ ] Under-nutrition / Malnutrition: [ ] Mild [ ] Moderate [ ] Severe [ ] Unspecified [ ] Protein Calorie Malnutrition: [ ] Mild [ ] Moderate [ ] Severe [ ] Unspecified [ ] Marasmus [ ] Nutritional Edema [ ] Other Malnutrition (please specify) _______________________________ Same as ICD 9

16 ICD10 documentation specificity needed
ICD10 Documentation Needed Pregnancy Identify trimester, if preterm, gestational diabetes and any other associated diagnosis/conditions Specify trimester [ ] First (less than 14 weeks, 0 days) [ ] Second (14 weeks, 0 days to less than 28 weeks, 0 days) [ ] Third (28 weeks until delivery) [ ] Preterm labor/Preterm Delivery [ ] Gestational Diabetes [ ] Diet controlled [ ] Insulin controlled [ ] Associated diagnosis/conditions (please specify): ________

17 ICD10 documentation specificity needed
ICD10 Documentation Needed Ovarian Cancer Identify laterality [ ] Ovarian Cancer [ ] Right [ ] Left [ ] Bilateral

18 ICD10 documentation specificity needed
ICD10 Documentation Needed Pancreatitis Identify acuity, cause, gangrenous and alcohol induced [ ] Acute: [ ] Gallstone [ ] Biliary [ ] Idiopathic [ ] Other [ ] Chronic: [ ] Cystic [ ] Infectious [ ] Interstitial [ ] Recurrent [ ] Gangrenous [ ] Alcohol-induced: [ ] Abuse [ ] Dependence

19 ICD10 documentation specificity needed
ICD10 Documentation Needed 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 Similar to ICD 9

20 ICD10 documentation specificity needed
ICD10 Documentation Needed Premature Infant Prematurity [ ] Prematurity (birth weight of 1,000 – 2,499 grams) [ ] Extreme Immaturity (birth weight < 1,000 grams) [ ] Slow fetal growth [ ] Malnutrition [ ] Unable to determine [ ] Other __________________________________ Weeks of Gestation: [ ] Unspecified weeks of gestation [ ] Less than 24 completed weeks of gestation [ ] 24 completed weeks of gestation [ ] 25 to 26 completed weeks of gestation [ ] 27 to 28 completed weeks of gestation [ ] 29 to 30 completed weeks of gestation [ ] 31 to 32 completed weeks of gestation [ ] 33 to 34 completed weeks of gestation [ ] 35 to 36 completed weeks of gestation [ ] 37 or more completed weeks of gestation

21 ICD10 documentation specificity needed
ICD10 Documentation Needed Pressure Ulcer 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)

22 ICD10 documentation specificity needed
ICD10 Documentation Needed 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 ________ Same as ICD 9

23 ICD10 documentation specificity needed
ICD10 Documentation Needed 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 II Kidney damage with mildly decreased GFR GFR Stage III Kidney damage with moderately decreased GFR GFR 30-59 Stage IV Kidney damage with severely decreased GFR GFR 16-29 Stage V Kidney failure GFR<15 ESRD End Stage Renal Disease On dialysis Same as ICD 9

24 ICD10 documentation specificity needed
ICD10 Documentation Needed Sepsis  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.) _______________________

25 ICD10 documentation specificity needed
ICD10 Documentation Needed SHOCK [ ] Hypovolemic shock [ ] Hemorrhagic shock [ ] Cardiogenic shock [ ] Septic shock (Circulatory failure associated with severe sepsis, represents organ failure) Same as ICD 9

26 ICD10 documentation specificity needed
ICD10 Documentation Needed Substance Abuse 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

27 ICD10 documentation specificity needed
ICD10 Documentation Needed Testicular Torsion Identify Extra or Intra vaginal and site [ ] Extravaginal: [ ] Epididymis [ ] Spermatic Cord [ ] Testicle/Testis [ ] Intravaginal:

28 ICD10 documentation specificity needed
ICD10 Documentation Needed 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) Same as ICD 9

29 ICD10 documentation specificity needed
ICD10 Documentation Needed UTI 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

30 Questions—contact your Clinical Documentation Specialists at your hospital
Jewish Hospital CDI office Jewish Shelbyville -- Clinical Documentation Specialists Candy Rickard Peggy Barlar Charlotte Hopewell Susan Hinkle Dale Crosby Becki Fudge Sara Goff Manager- Sandy Hodge- Bowman Supervisor- Kristen Boles

31 Questions—contact your Clinical Documentation Specialists at your hospital
Sts. Mary and Elizabeth Clinical Documentation Specialists Mickey Decker Cheryl Brooks Annette Majors Manager- Sandy Hodge- Bowman Supervisor- Kristen Boles

32 Questions—contact your Clinical Documentation Specialists at your hospital
University of Louisville Clinical Documentation Specialists Katie Hernandez Hilda Meehan Olga Soukhanova Cheryl Ward Peggy Fields Manager- Sandy Hodge- Bowman Supervisor- Kristen Boles

33 Questions—contact your Clinical Documentation Specialists at your hospital
St Joe Main Clinical Documentation Specialists Michelle Ahady Tina Baker Lynnette Tuttle Ann Spero Teressa Cozine Trudy Paynter Karen Mitchell Manager- Sandy Hodge- Bowman Supervisor- Kristen Boles

34 Questions—contact your Clinical Documentation Specialists at your hospital
St. Joe East Clinical Documentation Specialists Kimberly Gilbert-Morrison Kelly Geers Manager- Sandy Hodge- Bowman Supervisor- Kristen Boles

35 Questions—contact your Clinical Documentation Specialists at your hospital
Flaget Clinical Documentation Specialist Cheryl Mitchell— Manager- Sandy Hodge- Bowman Supervisor- Kristen Boles

36 Questions—contact your Clinical Documentation Specialists at your hospital
St Joe London Clinical Documentation Specialists Katrina Henson— Sherry Mills— Manager- Sandy Hodge- Bowman Supervisor- Kristen Boles

37 Questions—contact your Clinical Documentation Specialists at your hospital
St. Joe Mt. Sterling Clinical Documentation Specialists Lori Barry Manager- Sandy Hodge- Bowman Supervisor- Kristen Boles


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