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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 Alzheimer's 6 Dementia 26 Anemia 7 Diabetes 27
Aplastic Anemia 8 Atrial Fib 9 BMI – high 10 BMI –low 11 Cardiac Arrest 12 Cellulitis 13 Cerebral Edema 14 Chest pain 15 Cirrhosis of Liver 16 Cleft Palate 17 Factor VII 18 Colitis 19 Coma 20 Cor Pulmonale 21 Crohn’s Disease / Regional Enteritis 22 CVA 23 Debridement 24 Degenerative Disc Disease 25 Dementia 26 Diabetes 27 Diverticulitis 28 Dysphasia 29 Encephalopathy 30 Endometriosis 31 Epidymitis 32 Esophagitis 33 Foot deformity 34 Fracture- Bone 35 Functional Quadriplegia 36 Gastroparesis 37 Gastrointestinal Ulcer- Upper 38 GERD 39 Gout 40 Headache/ Migraine 41 Heart failure- acute 42 Heart failure-chronic 43 Hepatitis 44 HIV-AIDS 45 Hypertension 46
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Table of Contents Hyponatremia 47 Pain 67 Influenza 48 Pancreatitis 68
Joint complication 49 Leukemia 50 Level of consciousness 51 Lung Cancer 52 Lymphoma 53 Meningitis 54 Mental Status- Altered 55 Metabolic—acidosis/ alkalosis 56 Mood Disorder 57 Myocardial Infarction 58 Neoplasm 59 Neutropenia 60 Non pressure ulcer 61 Malnutrition 62 Pregnancy 63 Open Fracture 64 Osteomyelitis 65 Ovarian Cancer 66 Pain 67 Pancreatitis 68 Personal Injury 69 Pleurodesis 70 Pneumonia- Aspiration 71 Pneumonia- Hypostatic /passive/ stasis 72 Pneumonia-Specificity 73 Premature infant 74 Pressure Ulcer 75 Prostatitis 76 Pulmonary embolism 77 Purpera 78 Renal Failure—acute 79 Renal failure-chronic 80 Respiratory-asthma 81 Respiratory- Bronchitis 82 Respiratory- COPD 83
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Table of Contents Respiratory- Emphysema 84 Respiratory failure 85
Respiratory failure post op 86 Schatzki Ring 87 Scoliosis 88 Sepsis 89 Shock 90 Sickle Cell Disease 91 Substance abuse 92 Testicular Torsion 93 TIA 94 Tumor Lysis Syndrome 95 Urosepsis 96 UTI 97 Weakness 98 Hospital specific Documentation Specialists contact info
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ICD10 documentation specificity needed
ICD10 Documentation Needed ICD9 Documentation Alzheimer’s Identify onset, behavior disturbances and with dementia or associated delirium [ ] Alzheimer’s disease [ ] Early onset [ ] Late onset [ ] Unspecified [ ] Other [ ] Alzheimer’s disease with behavioral disturbances [ ] Aggressive [ ] Combative [ ] Violent [ ] Unspecified [ ] Other_______ [ ] Alzheimer’s disease with dementia [ ] Acute [ ] Sub acute [ ] With wandering [ ] Alzheimer’s disease with associated delirium
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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 ICD9 Documentation Aplastic Anemia Identify Specificity [ ] Acquired pure red cell aplasia: [ ] Chronic [ ] on Treatment [ ] Transient [ ] Other [ ] Constitutional: [ ] Congenital [ ] Idiopathic [ ] Acquired [ ] Drug Induced (please specify drug): ________ [ ] Due to other external causes (please specify cause, i.e. radiation, etc): _______________________ [ ] Idiopathic [ ] Unspecified [ ] Sideroblastic Anemia: [ ] Hereditary [ ] Due to disease [ ] Due to drugs/toxins [ ] Congenital [ ] Anemia in Neoplastic Disease
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ICD10 documentation specificity needed
ICD10 Documentation Needed A fib IDENTIFY TYPE [ ] Paroxysmal Atrial Fibrillation [ ] Persistent Atrial Fibrillation [ ] Chronic Atrial Fibrillation (includes permanent Atrial Fibrillation) [ ] Unspecified Atrial Fibrillation
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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 Cardiac Arrest Identify underlying cause, post procedure or intra-op arrest [ ] Underlying cardiac condition (specify)___________ [ ] Underlying other condition (specify)______ [ ] Cause unspecified [ ] Post procedural cardiac arrest following cardiac surgery [ ] Post procedural cardiac arrest following other surgery [ ] Intra-operative cardiac arrest during cardiac surgery [ ] Intra-operative cardiac arrest during other surgery [ ] Any associated diagnoses / conditions________
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ICD10 documentation specificity needed
ICD10 Documentation Needed Cellulitis Identify location, laterality and if related to Location: _________________ Laterality: [ ] Left [ ] Right [ ] Bilateral [ ] Upper [ ] Lower [ ] Cheek-internal [ ] Cheek-external [ ] N/A_____ [ ] Bacterial - Causative Agent (if known): ____ [ ] Viral [ ] R/T Lymphangitis (chronic / subacute) [ ] R/T Venous Stasis ulcer with PVD [ ] Manifestation of Diabetes [ ] Does not apply to this patient – no cellulitis
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ICD10 documentation specificity needed
ICD10 Documentation Needed Cerebral edema [ ] Cerebral edema / Vasogenic edema [ ] Compression of brain [ ] Findings not significant [ ] Radiologic finding only [ ] Does not apply to this patient Same as ICD 9
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ICD10 documentation specificity needed
ICD10 Documentation Needed Chest Pain [ ] Costochronditis [ ] Pleurisy [ ] Pleuritic pain [ ] Angina with known coronary artery disease [ ] Angina: [ ] Stable [ ] Unstable [ ] Psychogenic cardiovascular disorder [ ] Chest wall pain [ ] Cholelithiasis / Cholecystitis [ ] GERD [ ] Esophagitis [ ] Does not apply to this patient Same as ICD 9
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ICD10 documentation specificity needed
ICD10 Documentation Needed Cirrhosis of Liver Identify if alcoholic or non-alcoholic, if congenital, biliary obstructive, laennec’s and if portal [ ] Alcoholic [ ] Non-alcoholic [ ] Congenital ____ (underlying disease) [ ] Biliary / Obstructive: [ ] Primary [ ] Secondary [ ] Laennec’s: [ ] Alcoholic with: [ ] dependence [ ] non-dependence [ ] Non-alcoholic [ ] Portal: [ ] Alcoholic [ ] Non-alcoholic
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ICD10 documentation specificity needed
ICD10 Documentation Needed Cleft Palate Identify Type, Laterality and any associated diagnosis [ ] Hard [ ] Medial [ ] Soft [ ] Uvula [ ] Hard with Soft [ ] Cleft Lip Involvement [ ] Unilateral Cleft Lip [ ] Bilateral Cleft Lip [ ] Median Cleft Lip [ ] Associated diagnosis/conditions (please specify): ___________________
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ICD10 documentation specificity needed
ICD10 Documentation Needed Factor VII Identify for Reason for Factor VII administration [ ] Idiopathic acquired coagulation defect [ ] Surgical acquired coagulation defect (Bleeding related to a coagulopathy after surgery, not correctable by surgery) [ ] Unspecified coagulation defect [ ] Congenital coagulation defect [ ] Acquired coagulation defect secondary to: _______ [ ] Disseminated intravascular coagulation [ ] Hereditary Factor VIII deficiency [ ] VII [ ] IX [ ] XI [ ] Primary Thrombophilia: [ ] Von Willebrand’s disease [ ] Lupus anticoagulant [ ] Hemorrhagic Disorder: [ ] circulating anticoagulants [ ] Intrinsic [ ] Extrinsic
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ICD10 documentation specificity needed
ICD10 Documentation Needed Colitis Identify Site, Type and Complications Site (if applicable): [ ] Small Intestine [ ] Large Intestine [ ] Other site __ Type: [ ] Colitis due to radiation [ ] Ulcerative Colitis [ ] Infectious Colitis [ ] Toxic Colitis [ ] Ischemic Colitis [ ] Colitis due to ___________________ [ ] Chronic Colitis Complications: [ ] Rectal Bleeding [ ] Intestinal Obstruction [ ] Fistula [ ] Abscess [ ] Other complication _________________ [ ] Unspecified complication
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ICD10 documentation specificity needed
ICD10 Documentation Needed Coma Identify specificity [ ] Coma / Comatose [ ] Persistent vegetative state [ ] Stupor [ ] Drowsiness [ ] Somnolence [ ] Catatonic stupor [ ] Semicoma [ ] Associated injury (skull fracture, intracranial injury) _________________________________ [ ] Glasgow coma score_____________ Eye opening describe ________ Verbal response describe _________ Motor functioning describe_________
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ICD10 documentation specificity needed
ICD10 Documentation Needed Cor Pulmonale [ ] Acute Cor Pulmonale [ ] Chronic Cor Pulmonale [ ] Pulmonary Hypertension [ ] Does not apply to this patient Same as ICD 9
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ICD10 documentation specificity needed
ICD10 Documentation Needed Crohn’s Disease / Regional Enteritis Identify specificity, site and associated diagnosis [ ] Abscess [ ] Fistula [ ] Intestinal obstruction [ ] Rectal bleeding [ ] Other (specify) _______________ Site: [ ] Small Intestine [ ] Large Intestine [ ] both small and large intestines Associated diagnoses / conditions (specify)________
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ICD10 documentation specificity needed
ICD10 Documentation Needed ICD9 Documentation CVA Identify Laterality, type, location and manifestations [ ] CVA -- Laterality: [ ] Right [ ] Left [ ] Bilateral [ ] Unspecified [ ] Hemorrhage (non-traumatic): Please specify Artery: _____________________ [ ] Subarachnoid [ ] Intracerebral [ ] Extradural [ ] Subdural: [ ] Acute [ ] Subacute [ ] Chronic [ ] Cerebral Infarction [ ] Cerebral [ ] Pre-Cerebral Please specify Artery: ___________ [ ] Thrombosis [ ] Embolism [ ] Unspecified occlusion or stenosis [ ] Venous Thrombosis [ ] Other Cerebral Infarction [ ] Cerebral Infarction Unspecified (Stroke NOS) [ ] Occlusion / Stenosis without Cerebral Infarction [ ] Pre-Cerebral Artery: [ ] Vertebral [ ] Carotid [ ] Other Pre-Cerebral Artery [ ] Cerebral Artery: [ ] Middle [ ] Anterior [ ] Posterior [ ] Cerebellar [ ] Other Cerebral Artery [ ] Unspecified Cerebral Artery [ ] Manifestations / Residual Effects [ ] Hemiplegia [ ] Right [ ] Left [ ] Unspecified [ ] Dysphagia
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ICD10 documentation specificity needed
ICD10 Documentation Needed Debridement [ ] Excisional Debridement: [ ] Excised [ ] Removed [ ] Cut away [ ] Other: ________ Depth / layer: (deepest layer of debridement): [ ] Skin/SubQ [ ] Fascia [ ] Muscle [ ] Bone Margins: (please specify): ___ / __ x __ x ___ Instruments used: [ ] Scissors [ ] Scalpel [ ] Curette [ ] Tweezers/forceps [ ] Soft tissue clipper [ ] Other: _____ [ ] Non-excisional Debridement - Removal by flushing, brushing, or washing [ ] Incision and Drainage only (No Debridement): Depth: [ ] Skin & Sub Q only [ ] Into soft tissue [ ] Escharectomy Same as ICD 9
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ICD10 documentation specificity needed
ICD10 Documentation Needed Degenerative Disc Disease Identify Location and if with Myelopathy/Neuritis/Radiculopathy/Radiulitis [ ] Degenerative Cervical Disc Disease Specify level of spine: ___________ [ ] With Myelopathy [ ] With Neuritis, Radiculopathy, Radiculitis [ ] Other/Unspecified [ ] Degenerative Sacrococcygeal Disc Disease [ ] Degenerative Lumbar Disc Disease [ ] With Myelopathy [ ] With Neuritis, Radiculopathy, Radiculitis [ ] Degenerative Thoracic Disc Disease [ ] With Myelopathy [ ] With Neuritis, Radiculopathy, Radiculitis [ ] Degenerative Thoraco-Lumbar Disc Disease [ ] Degenerative Lumbosacral Disc Disease [ ] With Myelopathy [ ] With Neuritis, Radiculopathy, Radiculitis
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ICD10 documentation specificity needed
ICD10 Documentation Needed Dementia Identify type and accompanying behaviors Type of Dementia (check all appropriate): [ ] Vascular (due to cerebrovascular infarct or HTN) [ ] Frontotemporal [ ] Pick’s Disease [ ] In Substance Use/Abuse/Dependence Specify substance: ____________________ [ ] With Lewy Bodies (in Parkinson’s Disease) [ ] In other specified diseases (such as Alzheimer’s,, Parkinson’s, or other degenerative nervous system disease) [ ] Unspecified (such as Senile or Pre-senile) [ ] Unable to determine type of Dementia Accompanying Behaviors (check all appropriate): [ ] Behavioral disturbances (aggressive, combative, violent) [ ] Psychosis [ ] Delirium [ ] Delusions [ ] Hallucinations [ ] Depression [ ] Wandering [ ] Other behaviors: ___________________
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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 Diverticulitis IDENTIFY Acuity, Severity, Site and Type Acuity: [ ] Acute [ ] Chronic [ ] Acute on Chronic Severity: [ ] Bleeding [ ] No bleeding [ ] Abscess [ ] No abscess [ ] Perforation [ ] No perforation Site: [ ] Ileum [ ] Small Intestine [ ] Large Intestine [ ] Unspecified Intestine Type: [ ] Meckel’s diverticulum with diverticulitis [ ] Meckel’s diverticulum without diverticulitis
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ICD10 documentation specificity needed
ICD10 Documentation Needed Dysphagia IDENTIFY PHASE, TYPE and ACUITY Phase: [ ] Oral [ ] Oropharyngeal [ ] Pharyngeal [ ] Pharyngoesophageal Type: [ ] Cervical [ ] Functional [ ] Hysterical [ ] Nervous [ ] Neurogenic [ ] Siderpenic [ ] Spastica Following Non-Traumatic: [ ] SAH [ ] Intracerebral Hemorrhage [ ] Intracranial Hemorrhage [ ] CVA Acuity: [ ] Acute [ ] Chronic [ ] Acute on Chronic [ ] Other specified Dysphagia:___________ [ ] Unspecified Dysphagia
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ICD10 documentation specificity needed
ICD10 Documentation Needed Encephalopathy IDENTIFY Acuity, Etiology and Severity Acuity: [ ] Acute [ ] Subacute [ ] Chronic Etiology: [ ] Hypertensive [ ] Metabolic [ ] Toxic [ ] Toxic Metabolic [ ] Hepatic [ ] Hypoxic [ ] Septic [ ] Alcohol [ ] Drugs (specify)_______________ [ ] Post procedural (specify)______________ Severity: [ ] with coma [ ] without coma
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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 Epididymitis IDENTIFY Organism and With/Without Abscess [ ] Bacterial (specify organism if known: ____________) [ ] Viral (specify organism if known: _______________) [ ] With abscess [ ] Without abscess
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ICD10 documentation specificity needed
ICD10 Documentation Needed Esophagitis IDENTIFY SPECIFICITY [ ] Eosinophilic Esophagitis [ ] Esophagitis with GERD / Reflux [ ] Candida Esophagitis [ ] Ulcerative Esophagitis [ ] Esophagitis Unspecified [ ] Other Esophagitis
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ICD10 documentation specificity needed
ICD10 Documentation Needed Foot Deformity IDENTIFY SPECIFICITY (for any deformity marked below specify): [ ] Congenital [ ] Acquired [ ] Talipes equinovarus [ ] left [ ] right [ ] bilateral [ ] Talipes calcaneovarus [ ] left [ ] right [ ] bilateral [ ] Metatarsus varus [ ] left [ ] right [ ] bilateral [ ] Talipes calcaneovalgus [ ] left [ ] right [ ] bilateral [ ] Pes planus [ ] left [ ] right [ ] bilateral [ ] Pes cavus [ ] left [ ] right [ ] bilateral [ ] Vertical talus deformity [ ] left [ ] right [ ] bilateral [ ] Other foot deformity (please specify): _________ [ ] Associated diagnosis/conditions (please specify): __
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ICD10 documentation specificity needed
ICD10 Documentation Needed Bone fracture IDENTIFY Site, Laterality, Type, Cause and Encounter Site: ________ Laterality: [ ] Right [ ] Left Type of fracture: Check all that apply [ ] Traumatic fracture [ ] Pathologic fracture [ ] Osteoporosis fracture--- [ ] Disuse [ ] Drug- induced [ ] Postmenopausal [ ] Idiopathic [ ] Post-surgical malabsorption [ ] Other (specify)___________ [ ] Stress or fatigue fracture [ ] Neoplastic fracture Other type of fracture: Check all that apply [ ] Non-displaced [ ] Displaced [ ] Open (Gustilo) [ ] Closed (greenstick, spiral) [ ]Salter-Harris—specify type_________ External cause of fracture (fall, skiing) _________________________ Encounter type: [ ] Initial encounter [ ] Subsequent encounter--- [ ] Routine healing [ ] Delayed healing [ ] Nonunion [ ] Malunion [ ] Sequela
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ICD10 documentation specificity needed
ICD10 Documentation Needed Functional Quadriplegia [ ] Functional quadriplegia (complete immobility) [ ] Immobilization syndrome (impaired mobility) Same as ICD 9
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ICD10 documentation specificity needed
ICD10 Documentation Needed Gastroparesis Identify if related to diabetes and if underlying disease [ ] Gastroparesis related to Diabetes [ ] Gastroparesis in underlying disease/process (please state: ______________)
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ICD10 documentation specificity needed
ICD10 Documentation Needed Upper Gastrointestinal Ulcer Identify acuity, type and any related or contributing disease Acuity: [ ] Acute [ ] Chronic [ ] Hemorrhage -or- [ ] No Hemorrhage [ ] Perforation -or- [ ] No Perforation Type: [ ] Gastric Ulcer [ ] Esophageal Ulcer [ ] Duodenal, Duodenum [ ] Other location ________________ [ ] Any related or contributing disease(s) Alcohol or drugs: _________________
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ICD10 documentation specificity needed
ICD10 Documentation Needed GERD IDENTIFY GERD WITH OR WITHOUT ESOPHAGITIS Gastro esophageal reflux disease (GERD) with Esophagitis without Esophagitis
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ICD10 documentation specificity needed
ICD10 Documentation Needed Gout IDENTIFY Type, joint involved and acuity Specify the type/cause of gout: [ ] Drug-induced [ ] Secondary [ ] Idiopathic [ ] Syphilitic [ ] Lead-induced [ ] Primary [ ] With renal impairment (specify the specific renal disease/disorder, including acuity and/or state)____ Specify the specific joint involved _ [ ] Right [ ] Left Specificity acuity of gout: [ ] Acute [ ] Chronic – with or without tophus [ ] Gout attack [ ] Gout flare
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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 ACUTE HEART FAILURE [ ] Acute Systolic Heart Failure [ ] Acute Diastolic Heart Failure [ ] Acute Systolic and Diastolic Heart Failure ACUTE ON CHRONIC HEART FAILURE [ ] Acute On Chronic Systolic Heart Failure [ ] Acute On Chronic Diastolic Heart Failure [ ] Acute On Chronic Systolic and Diastolic Heart Failure SAME as ICD 9 with the addition OTHER ETIOLOGIES OF HEART FAILURE [ ] Heart Failure Due To Valvular Disease [ ] Right Heart Failure / Acute Cor Pulmonale [ ] Right Heart Failure / Chronic Cor Pulmonale [ ] Rheumatic Heart Disease [ ] Endocarditis (valvular) [ ] Myocarditis [ ] Pericarditis
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ICD10 documentation specificity needed
ICD10 Documentation Needed CHRONIC HEART FAILURE [ ] Chronic Systolic Heart Failure [ ] Chronic Diastolic Heart Failure [ ] Chronic Systolic and Diastolic Heart Failure SAME as ICD 9 with the addition of etiology Etiologies: [ ] Hypertension [ ] Valvular disease [ ] Rheumatic heart disease
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ICD10 documentation specificity needed
ICD10 Documentation Needed Hepatitis IDENTIFY Acuity, Etiology and associated diagnosis Acuity: [ ] Acute [ ] Chronic Etiology: [ ] Alcoholic [ ] Drug induced (specify)____ [ ] Viral (type A,B,C,E)_______ Associated Diagnosis: [ ] with hepatic coma [ ] without hepatic coma [ ] with delta agent [ ] without delta agent
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ICD10 documentation specificity needed
ICD10 Documentation Needed HIV-AIDS [ ] HIV infection/disease symptomatic related condition [ ] AIDS [ ] Non-HIV related condition [ ] Asymptomatic HIV infection status [ ] Non-specific serologic evidence of HIV Similar to ICD 9
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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 Influenza IDENTIFY Organism and associated factors [ ] Influenza caused by ______ (specify organism) [ ] Influenza-associated Encephalopathy [ ] Influenza-associated Pneumonia
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ICD10 documentation specificity needed
ICD10 Documentation Needed Complication of Joint IDENTIFY Location, Laterality and Due to Location of joint with prosthesis: ___ [ ] Right [ ] Left Complication of internal joint prosthesis due to: [ ] Infection (if known, specify organism______) [ ] Mechanical: [ ] Broken specify organism: prosthesis [ ] Dislocation [ ] Loosening [ ] Osteolysis [ ] Breakdown of prosthesis [ ] Displacement of prosthesis [ ] Wear of articular bearing [ ] Peri-prosthetic Fracture (specify site: ____ [ ] Other mechanical complication: ________ [ ] Pain [ ] Hemorrhage
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ICD10 documentation specificity needed
ICD10 Documentation Needed Leukemia IDENTIFY Acuity, Type and Status Acuity: [ ] Acute [ ] Chronic Type: [ ] Lymphoid (Cell type: _______) [ ] Myeloid (Cell type: ___________) [ ] Monocytic (Cell type: ________) [ ] Other Leukemias of specified cell type: ____________ [ ] Leukemia of unspecified cell type Status: [ ] Has not achieved remission [ ] In Remission [ ] In Relapse
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ICD10 documentation specificity needed
ICD10 Documentation Needed Level of Consciousness [ ] Coma / Comatose [ ] Encephalopathy, type: ____________________________ [ ] Persistent vegetative state [ ] Stupor Same as ICD 9
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ICD10 documentation specificity needed
ICD10 Documentation Needed Lung CA IDENTIFY Site, Laterality, Type and Malignancy Site: [ ] Carina [ ] Main bronchus [ ] Upper lobe [ ] Middle Lobe [ ] Lower Lobe [ ] Other ___________ Laterality: [ ] Right [ ] Left Type: [ ] Primary [ ] Secondary [ ] In situ [ ] Overlapping primary [ ] Malignant [ ] Benign [ ] Kaposi’s Sarcoma [ ] Other___________ Malignancy: [ ] Excised [ ] Eradicated [ ] Treatment still provided for primary and/or metastatic site [ ] Evidence of remaining malignancy at primary site
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ICD10 documentation specificity needed
ICD10 Documentation Needed Lymphoma IDENTIFY Anatomical Site, Type and Cell Type Anatomical Site: _______________________) Type: [ ] Hodgkins (Cell type: _________) [ ] Follicular (Cell type: _________) [ ] Non-Follicular (Cell type: _________) [ ] Mature T/NK Cell (Cell type: _________) [ ] Other Specified/ Unspecified Non-Hodgkin’s (Cell type: ___________________) [ ] Other Specified T/NK Cell (Cell type: _____) [ ] Unspecified
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ICD10 documentation specificity needed
ICD10 Documentation Needed Meningitis Identify Type, Organism and Present on Admission [ ] Viral Meningitis [ ] Specify organism (i.e. adenovirus, enterovirus, measles, etc.) ___________ [ ] Bacterial Meningitis - Acute [ ] Specify organism (i.e. gram negative, staph, strep, e coli, etc.)___________ [ ] Due to (please specify cause) _________ [ ] Aseptic - Acute [ ] Late effect [ ] Septic [ ] Present on Admission [ ] Yes [ ] No [ ] Unable to determine
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ICD10 documentation specificity needed
ICD10 Documentation Needed Altered Mental Status IDENTIFY SPECIFICITY Altered Mental Status: [ ] Delirium [ ] Mild Cognitive Impairment [ ] Drug-Induced Delirium [ ] Mental Disorder (Specify): __________ [ ] Other (Specify): ________ Altered Level of Consciousness: [ ] Coma [ ] Somnolence [ ] Persistent Vegetative State [ ] Stupor (Catatonic) [ ] Transient Alteration of Awareness Encephalopathy: [ ] Alcoholic [ ] Due to Drugs [ ] Hepatic [ ] Hypertensive [ ] Anoxic / hypoxic [ ] Other (Specify): ___________ [ ] Metabolic / Septic [ ] Traumatic [ ] Hypoglycemic
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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 Myocardial Infarction Identify Type, Age of Infarction, Encounter, Site and Artery MI TYPE: [ ] Acute Coronary Syndrome (ACS) without Acute MI (Per coding guidelines, ACS equates to Unstable Angina) [ ] STEMI (please also specify site and artery—see below) [ ] NSTEMI AGE OF INFARCTION: [ ] Less than 4 weeks of admission [ ] Greater than 4 weeks of admission [ ] Less than 8 weeks [ ] Greater than 8 weeks [ ] Unable to determine ENCOUNTER: [ ] Initial [ ] Subsequent If STEMI, SITE: [ ] Anterior [ ] Apical [ ] Lateral [ ] Inferior [ ] Posterior [ ] Q Wave [ ] Septal [ ] Unspecified [ ] Other _____________________ SPECIFIC ARTERY (Based on site) [ ] Left Main Coronary [ ] Diagonal [ ] Left Anterior Descending [ ] Oblique Marginal [ ] Right Coronary Artery [ ] Other ___________________ [ ] Left Circumflex [ ] 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 Neutropenia Identify Cause [ ] Congenital [ ] Secondary to chemotherapy (list chemotherapeutic drug: __________) [ ] Drug induced (list drug: ________________) [ ] Due to infection (infection site: _______ Organism: _________________________) [ ] Cyclic [ ] Does not apply to this patient [ ] Unspecified
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ICD10 documentation specificity needed
ICD10 Documentation Needed Non Pressure Ulcer Identify Location, laterality, depth, type and gangrenous Location [ ] Back [ ] Buttock [ ] Lower limb [ ] Ankle [ ] Calf [ ] Heel/ midfoot [ ] Thigh [ ] Other__________ Laterality [ ] Left [ ] Right [ ] Bilateral [ ] Upper [ ] Lower [ ] N/A Depth [ ] Skin only [ ] Fat exposed [ ] Muscle Necrosis [ ] Bone Necrosis Type [ ] Diabetic [ ] Vascular r/t PVD [ ] Varicose [ ] Atherosclerosis of lower limb [ ] Postphlebitic syndrome [ ] Postthrombotic syndrome [ ]Chronic venous hypertension [ ] Other (specify) ______ Gangrene [ ] Yes [ ] No
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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 Open Fraction Specificity for open fractures of the forearm, femur, and lower leg require documentation to Specify Gustilo Type I through Type IIIC. OPEN Fracture(s): ___________________________ Site: __Laterality: [ ] Right [ ] Left Gustilo type:___ GUSTILO CLASSIFICATION Type I: Wound < 1cm, clean, generally caused by a fracture fragment that pierces the skin Type II: Wound > 1cm, not contaminated, without mod soft tissue injury or defect. Type III: Wound > 1 cm. with significant soft tissue disruption, severely unstable fracture with varying degrees of fragmentation Type IIIA: Wound < 10 cm, crush injury and contamination, sufficient soft tissue to cover the bone without the need for local or distant flap coverage Type IIIB: Disruption of the soft tissue is extensive, such that local or distant flap coverage is necessary to cover the bone. The wound maybe contaminated and serial irrigation and debridement procedures are necessary to ensure a clean surgical wound >10 cm, crushed tissue Type IIIC: Any open Fracture associated with an arterial injury that requires repair.
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ICD10 documentation specificity needed
ICD10 Documentation Needed Osteomyelitis Identify site, acuity and if related to diabetes Osteomyelitis site: ____________ [ ] Acute osteomyelitis directly related to diabetes mellitus [ ] Acute osteomyelitis unrelated to diabetes mellitus [ ] Chronic osteomyelitis directly related to diabetes mellitus [ ] Chronic osteomyelitis unrelated to diabetes mellitus
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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 Pain Identify acuity and cause [ ] Acute Pain [ ] Trauma [ ] Post- Thoracotomy [ ] Post- operative / post-procedural [ ] Other __________________ [ ] Chronic pain [ ] Post-Thoracotomy [ ] Post-operative / post-procedural [ ] Neoplasm pain
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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
69
ICD10 documentation specificity needed
ICD10 Documentation Needed Injury For this injury _________, please document the following information: How the injury occurred (i.e. fall, MVA, etc.) ___________________ Location where the injury occurred (i.e. home, work, school, etc.) ____________________________ Activity at time of injury (i.e. running, gardening, skating, etc.) ______________________________ Status at time of injury (i.e. civilian, military, volunteer, etc.) ______________________________
70
ICD10 documentation specificity needed
ICD10 Documentation Needed Pleurodesis [ ] Talc Pleurodesis and scarification of the pleura [ ] Talc Pleurodesis only [ ] Scarification of pleura (mechanical without talc) Same as ICD 9
71
ICD10 documentation specificity needed
ICD10 Documentation Needed Aspiration Pneumonia IDENTIFY SPECIFICITY and any associated illnesses [ ] Aspiration Bronchitis [ ] Pneumonia secondary to______ (specify organism / underlying disease) [ ] Community Acquired (simple) Pneumonia [ ] Healthcare / Hospital Acquired Pneumonia (outside facility / prior hospitalization) [ ] Ventilator associated [ ] Radiation induced [ ] Associated illness: [ ] Respiratory failure [ ] Sepsis [ ] Underlying lung disease [ ] Other specify)_____ [ ] Pneumonia of unknown etiology [ ] Infiltrates without evidence of Pneumonia
72
ICD10 documentation specificity needed
ICD10 Documentation Needed Hypostatic Passive/ Stasis Pneumonia [ ] Hypostatic Passive/ Stasis Pneumonia [ ] Pneumonia due to (specify organism/ underlying disease)_____________ [ ] Ventilator-associated [ ] Radiation induced [ ] Associated illness: [ ] Respiratory Failure [ ] Underlying lung disease [ ] Other (specify)________________ Same as ICD 9
73
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
74
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
75
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)
76
ICD10 documentation specificity needed
ICD10 Documentation Needed Prostatitis Identify acuity, bacterial vs viral and organism if know [ ] Acute Prostatitis: [ ] Bacterial (organism __________ if known) [ ] Viral (organism ______________if known) [ ] Chronic Prostatitis: [ ] Bacterial (organism ________ if known) [ ] Viral (organism ____________if known)
77
ICD10 documentation specificity needed
ICD10 Documentation Needed Pulmonary Embolism Identify acuity, type and if associated acute cor pulmonale Acuity: [ ] Acute [ ] Chronic Type: [ ] Saddle [ ] Septic [ ] Other___ [ ] Pulmonary Embolism with associated Acute Cor Pulmonale
78
ICD10 documentation specificity needed
ICD10 Documentation Needed Purpura [ ] Allergic Purpura: [ ] Hemorrhagic [ ] Idiopathic [ ] Type (specify)__________________ [ ] Site__________________ [ ] Related process_________________ [ ] Causal organism__________________ [ ] Immune thrombocytopenic purpura [ ] Post-transfusion purpura [ ] Secondary thrombocytopenia [ ] Hereditary
79
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
80
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
81
ICD10 documentation specificity needed
ICD10 Documentation Needed Asthma Identify acuity and type [ ] Acute exacerbation of Asthma [ ] Status Asthmaticus [ ] Acute exacerbation of Allergic Bronchitis [ ] Asthma: [ ] Mild intermittent [ ] Mild persistent [ ] Moderate persistent [ ] Severe Persistent Type: [ ] Childhood [ ] Exercise induced [ ] Late onset [ ] Mixed [ ] Other (specify)________________ [ ] COPD [ ] Chronic obstructive bronchitis [ ] Acute lower respiratory infection
82
ICD10 documentation specificity needed
ICD10 Documentation Needed Bronchitis Identify acuity and due to [ ] Acute exacerbation of Bronchitis [ ] Acute on Chronic Bronchitis [ ] Chronic Bronchitis obstructive [ ] Bronchitis due to: [ ] Fumes [ ] Radiation [ ] Viral or Bacterial Organism____________
83
ICD10 documentation specificity needed
ICD10 Documentation Needed COPD Identify Acuity [ ] Acute exacerbation of COPD [ ] Acute exacerbation of Asthma [ ] COPD – Chronic and stable
84
ICD10 documentation specificity needed
ICD10 Documentation Needed Emphysema Identify Acuity and Type Acuity: [ ] Acute exacerbation of Emphysema [ ] Chronic and stable Emphysema Type: [ ] Unilateral: [ ] Sawyer-James Syndrome [ ] Unilateral Hyper-Lucent Lung [ ] Unilateral Pulmonary Artery Functional Hypoplasia [ ] Pan lobular [ ] Centrilobar
85
ICD10 documentation specificity needed
ICD10 Documentation Needed Respiratory Failure IDENTIFY TYPE, ACUITY and ETIOLOGY Acute Respiratory Failure: [ ] with Hypoxia [ ] with Hypercapnia Acute On Chronic Respiratory Failure: [ ] with Hypoxia [ ] with Hypercapnia Acute Respiratory Failure caused by: _____ (etiology) [ ] Acute Respiratory Insufficiency following [ ] trauma [ ] other
86
ICD10 documentation specificity needed
ICD10 Documentation Needed Post op Respiratory Issues Identify Acuity and surgery type [ ] Post-op Acute pulmonary insufficiency [ ] Thoracic surgery [ ] Non-Thoracic surgery [ ] Post-op Acute respiratory failure [ ] Thoracic surgery [ ] Non-Thoracic surgery [ ] Post-op Chronic pulmonary insufficiency [ ] Post-op Chronic respiratory failure [ ] Hypoxia [ ] Respiratory failure not related to surgical procedure [ ] Acute [ ] Chronic [ ] Acute on Chronic
87
ICD10 documentation specificity needed
ICD10 Documentation Needed Schatzki Ring [ ] Schatzki Ring - Congenital [ ] Schatzki Ring - Acquired [ ] Schatzki Ring - unable to determine / unspecified Same as ICD 9
88
ICD10 documentation specificity needed
ICD10 Documentation Needed SCOLIOSIS Identify Type, Acuity and Site Type: [ ] Infantile Idiopathic [ ] Juvenile Idiopathic [ ] Adolescent [ ] Other idiopathic [ ] Thoracogenic [ ] Neuromuscular [ ] Other secondary Acuity: [ ] PROGRESSIVE [ ] RESOLVING Site: [ ] Occipito-atlanto-axial [ ] Cervical [ ] Cervicothoracic [ ] Thoracic [ ] Thoracolumbar [ ] Lumbar [ ] Lumbosacral [ ] Sacral [ ] Sacrococcygeal
89
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.) _______________________
90
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
91
ICD10 documentation specificity needed
ICD10 Documentation Needed Sickle Cell Disease Identify Type and Acuity Type: [ ] Hb-C [ ] Hb-ss [ ] Hb-SD / Hb-SE / Specified NEC / Spherocytosis [ ] Thalassemia Acuity: [ ] With Crisis: [ ] Acute Chest Syndrome [ ] Splenic Sequestration [ ] Without Crisis
92
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
93
ICD10 documentation specificity needed
ICD10 Documentation Needed Testicular Torsion Identify Extra or Intra vaginal and site [ ] Extravaginal: [ ] Epididymis [ ] Spermatic Cord [ ] Testicle/Testis [ ] Intravaginal:
94
ICD10 documentation specificity needed
ICD10 Documentation Needed TIA Identify TIA TYPE [ ] TIA Stenosis / Syndrome related to: [ ] Vertebro-Basilar Artery [ ] Carotid Artery [ ] Multiple / Bilateral Pre-Cerebral Artery [ ] Cerebral / Pre-cerebral occlusion / stenosis [ ] Small vessel disease of the brain / cerebral vascular disease [ ] Transient Global amnesia [ ] Amaurosis Fugax [ ] Other TIA [ ] Unspecified TIA (spasm of cerebral artery, transient cerebral ischemia)
95
ICD10 documentation specificity needed
ICD10 Documentation Needed Tumor Lysis Syndrome [ ] Tumor Lysis Syndrome following anti-neoplastic drug chemotherapy [ ] Spontaneous Tumor Lysis Syndrome Same as ICD 9
96
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
97
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
98
ICD10 documentation specificity needed
ICD10 Documentation Needed Weakness Identify due to and laterality [ ] Weakness due to __________ [ ] Hemiparesis [ ] Hemiplegia Laterality (please check all that apply): [ ] Right side [ ] Left side [ ] Upper extremity [ ] Lower extremity [ ] Dominant side [ ] Non-dominant side
99
Questions—contact your Clinical Documentation Specialists at your hospital
Jewish Hospital CDI office for all specialists Jewish Shelbyville CDI office Clinical Documentation Specialists -- Candy Rickard Peggy Barlar Charlotte Hopewell Susan Hinkle Dale Crosby Becki Fudge Sara Goff Manager- Sandy Hodge- Bowman Supervisor- Kristen Boles
100
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
101
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
102
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 Browning— Manager- Sandy Hodge- Bowman Supervisor- Kristen Boles
103
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
104
Questions—contact your Clinical Documentation Specialists at your hospital
Flaget Clinical Documentation Specialist Cheryl Mitchell Manager- Sandy Hodge- Bowman Supervisor- Kristen Boles
105
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
106
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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