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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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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.
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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
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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
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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: _____)
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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
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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
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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)
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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_________________________
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ICD10 documentation specificity needed
ICD10 Documentation Needed Hypertension [ ] Malignant Hypertension [ ] Accelerated Hypertension [ ] Benign Hypertension [ ] Unspecified Hypertension Same as ICD 9
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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
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ICD10 documentation specificity needed
ICD10 Documentation Needed Acidosis/Alkalosis Identify Type of Acidosis or Alkalosis [ ] Acidosis: [ ] Metabolic [ ] Respiratory [ ] Lactic [ ] Renal [ ] Alkalosis: [ ] Metabolic [ ] Respiratory
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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
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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 ____________________________________
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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
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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): ________
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ICD10 documentation specificity needed
ICD10 Documentation Needed Ovarian Cancer Identify laterality [ ] Ovarian Cancer [ ] Right [ ] Left [ ] Bilateral
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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
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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
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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
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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)
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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
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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
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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.) _______________________
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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
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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
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ICD10 documentation specificity needed
ICD10 Documentation Needed Testicular Torsion Identify Extra or Intra vaginal and site [ ] Extravaginal: [ ] Epididymis [ ] Spermatic Cord [ ] Testicle/Testis [ ] Intravaginal:
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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
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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
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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
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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
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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
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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
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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
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Questions—contact your Clinical Documentation Specialists at your hospital
Flaget Clinical Documentation Specialist Cheryl Mitchell— Manager- Sandy Hodge- Bowman Supervisor- Kristen Boles
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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
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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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