1. HEMATOLOGY / ONCOLOGY and Other Common Documentation Tips ICD 10 Documentation Specificity Needed based on Conifer ICD 10 CDI Queries

2. 2 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD 10 Documentation Specialty Introduction ICD 10 is being mandated by CMS. Compliance date is set at October 2015.  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. 3 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. Table of Contents  Anemia5  Aplastic Anemia6  BMI – high7  BMI –low8  Cardiac Arrest9  Cellulitis10  Cerebral Edema11  Chest pain12  Coma13  Debridement14  Dementia15  Diabetes16  Dysphasia17  Encephalopathy18  Esophagitis19  Functional Quadriplegia20  Gastroparesis21  Gastrointestinal Ulcer- Upper 22  GERD23  Heart failure- acute24  Heart failure-chronic25  HIV-AIDS26  Hypertension27  Hyponatremia28  Leukemia29  Level of consciousness30  Lung Cancer31  Lymphoma32  Mental Status- Altered33  Metabolic—acidosis/ alkalosis34  Mood Disorder35  Neoplasm36  Neutropenia37  Non pressure ulcer38  Malnutrition39  Ovarian Cancer40  Pain41  Pancreatitis42  Pleurodesis43  Pneumonia- Aspiration44  Pneumonia- Hypostatic/ passive/ stasis45  Pneumonia-Specificity46  Pressure Ulcer47

4. 4 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. Table of Contents  Pulmonary embolism48  Purpera49  Renal failure- acute50  Renal failure-chronic51  Respiratory- COPD52  Respiratory- Emphysema53  Respiratory failure54  Respiratory failure post op55  Sepsis56  Shock57  Sickle Cell Disease58  Substance abuse59  Tumor Lysis Syndrome60  Urosepsis61  UTI62  Weakness63  Hospital specific  Documentation Specialists contact info64-71

5. 5 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity 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: ICD10 Documentation Needed Same as in ICD 9

6. 6 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Aplastic Anemia ICD10 Documentation Needed 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

7. 7 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation BMI > 40 with associated diagnosis of: [ ] Morbid (Severe) Obesity [ ] Overweight [ ] Obesity (unspecified) ICD10 Documentation Needed Morbidly Obese [ ] Morbid (Severe) Obesity [ ] Due to excess calories [ ] Familial [ ] Endocrine [ ] with Alveolar Hypoventilation (Pickwickian syndrome) [ ] Drug-induced (Name of drug: _____)

8. 8 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation BMI < 19 with associated diagnosis of: (check one) [ ] Underweight [ ] Protein Calorie Malnutrition: [ ] Mild [ ] Moderate [ ] Severe [ ] Unspecified [ ] Cachexia [ ] Emaciation due to malnutrition ICD10 Documentation Needed Same as ICD 9

9. 9 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Cardiac Arrest ICD10 Documentation Needed 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________

10. 10 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Cellulitis ICD10 Documentation Needed 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

11. 11 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Cerebral edema [ ] Cerebral edema / Vasogenic edema [ ] Compression of brain [ ] Findings not significant [ ] Radiologic finding only [ ] Does not apply to this patient ICD10 Documentation Needed Same as ICD 9

12. 12 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation 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 ICD10 Documentation Needed Same as ICD 9

13. 13 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Coma ICD10 Documentation Needed 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_________

14. 14 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation 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 ICD10 Documentation Needed Same as ICD 9

15. 15 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Dementia ICD10 Documentation Needed 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: ___________________

16. 16 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Diabetes ICD10 Documentation Needed 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

17. 17 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Dysphagia ICD10 Documentation Needed 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

18. 18 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Encephalopathy ICD10 Documentation Needed 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

19. 19 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Esophagitis ICD10 Documentation Needed IDENTIFY SPECIFICITY [ ] Eosinophilic Esophagitis [ ] Esophagitis with GERD / Reflux [ ] Candida Esophagitis [ ] Ulcerative Esophagitis [ ] Esophagitis Unspecified [ ] Other Esophagitis

20. 20 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Functional Quadriplegia [ ] Functional quadriplegia (complete immobility) [ ] Immobilization syndrome (impaired mobility) ICD10 Documentation Needed Same as ICD 9

21. 21 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Gastroparesis ICD10 Documentation Needed Identify if related to diabetes and if underlying disease [ ] Gastroparesis related to Diabetes [ ] Gastroparesis in underlying disease/process (please state: ______________)

22. 22 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Upper Gastrointestinal Ulcer ICD10 Documentation Needed 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: _________________

23. 23 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation GERD ICD10 Documentation Needed IDENTIFY GERD WITH OR WITHOUT ESOPHAGITIS Gastro esophageal reflux disease (GERD) with Esophagitis Gastro esophageal reflux disease (GERD) without Esophagitis

24. 24 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation 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 ICD10 Documentation Needed 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

25. 25 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation CHRONIC HEART FAILURE [ ] Chronic Systolic Heart Failure [ ] Chronic Diastolic Heart Failure [ ] Chronic Systolic and Diastolic Heart Failure ICD10 Documentation Needed SAME as ICD 9 with the addition of etiology Etiologies: [ ] Hypertension [ ] Valvular disease [ ] Rheumatic heart disease

26. 26 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation HIV-AIDS [ ] HIV infection/disease symptomatic related condition [ ] AIDS [ ] Non-HIV related condition [ ] Asymptomatic HIV infection status [ ] Non-specific serologic evidence of HIV ICD10 Documentation Needed Similar to ICD 9

27. 27 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Hypertension [ ] Malignant Hypertension [ ] Accelerated Hypertension [ ] Benign Hypertension [ ] Unspecified Hypertension ICD10 Documentation Needed Same as ICD 9

28. 28 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Hyponatremia ICD10 Documentation Needed Identify specificity [ ] Hyponatremia, unknown cause [ ] Hyponatremia due to Sodium Deficiency [ ] Hyponatremia due to SIADH (Syndrome of Inappropriate Secretion of Antidiuretic Hormone) [ ] Insignificant lab value

29. 29 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Leukemia ICD10 Documentation Needed 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

30. 30 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Level of Consciousness [ ] Coma / Comatose [ ] Encephalopathy, type: ____________________________ [ ] Persistent vegetative state [ ] Stupor ICD10 Documentation Needed Same as ICD 9

31. 31 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Lung CA ICD10 Documentation Needed 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

32. 32 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Lymphoma ICD10 Documentation Needed 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

33. 33 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Altered Mental Status ICD10 Documentation Needed 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

34. 34 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Acidosis/Alkalosis ICD10 Documentation Needed Identify Type of Acidosis or Alkalosis [ ] Acidosis: [ ] Metabolic[ ] Respiratory [ ] Lactic [ ] Renal [ ] Alkalosis: [ ] Metabolic [ ] Respiratory

35. 35 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Mood Disorder ICD10 Documentation Needed 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 [ ] With Psychosis [ ] Without Psychosis Severity: [ ] Mild [ ] Moderate [ ] Severe [ ] Unspecified

36. 36 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Neoplasm ICD10 Documentation Needed 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 ____________________________________

37. 37 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Neutropenia ICD10 Documentation Needed 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

38. 38 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Non Pressure Ulcer ICD10 Documentation Needed 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

39. 39 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Malnutrition [ ] Under-nutrition / Malnutrition: [ ] Mild [ ] Moderate [ ] Severe [ ] Unspecified [ ] Protein Calorie Malnutrition: [ ] Mild [ ] Moderate [ ] Severe [ ] Unspecified [ ] Marasmus [ ] Nutritional Edema [ ] Other Malnutrition (please specify) _______________________________ ICD10 Documentation Needed Same as ICD 9

40. 40 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Ovarian Cancer ICD10 Documentation Needed Identify laterality [ ] Ovarian Cancer [ ] Right [ ] Left[ ] Bilateral

41. 41 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Pain ICD10 Documentation Needed Identify acuity and cause [ ] Acute Pain [ ] Trauma [ ] Post- Thoracotomy [ ] Post- operative / post-procedural [ ] Other __________________ [ ] Chronic pain [ ] Trauma [ ] Post-Thoracotomy [ ] Post-operative / post-procedural [ ] Other __________________ [ ] Neoplasm pain

42. 42 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Pancreatitis ICD10 Documentation Needed Identify acuity, cause, gangrenous and alcohol induced [ ] Acute: [ ] Gallstone [ ] Biliary [ ] Idiopathic [ ] Other [ ] Chronic: [ ] Cystic [ ] Infectious [ ] Interstitial [ ] Recurrent [ ] Gangrenous [ ] Alcohol-induced:[ ] Abuse[ ] Dependence

43. 43 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Pleurodesis [ ] Talc Pleurodesis and scarification of the pleura [ ] Talc Pleurodesis only [ ] Scarification of pleura (mechanical without talc) ICD10 Documentation Needed Same as ICD 9

44. 44 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Aspiration Pneumonia ICD10 Documentation Needed 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

45. 45 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation 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)________________ ICD10 Documentation Needed Same as ICD 9

46. 46 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation 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 ICD10 Documentation Needed Similar to ICD 9

47. 47 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Pressure Ulcer ICD10 Documentation Needed 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)

48. 48 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Pulmonary Embolism ICD10 Documentation Needed Identify acuity, type and if associated acute cor pulmonale Acuity: [ ] Acute [ ] Chronic Type: [ ] Saddle [ ] Septic [ ] Other___ [ ] Pulmonary Embolism with associated Acute Cor Pulmonale

49. 49 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Purpura ICD10 Documentation Needed [ ] Allergic Purpura: [ ] Hemorrhagic [ ] Idiopathic [ ] Type (specify)__________________ [ ] Site__________________ [ ] Related process_________________ [ ] Causal organism__________________ [ ] Immune thrombocytopenic purpura [ ] Post-transfusion purpura [ ] Secondary thrombocytopenia [ ] Hereditary

50. 50 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation 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 ________ ICD10 Documentation Needed Same as ICD 9

51. 51 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation 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 IIKidney damage with mildly decreased GFRGFR 60-89 Stage III Kidney damage with moderately decreased GFR GFR 30-59 Stage IVKidney damage with severely decreased GFR GFR 16-29 Stage VKidney failureGFR<15 ESRDEnd Stage Renal DiseaseOn dialysis ICD10 Documentation Needed Same as ICD 9

52. 52 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation COPD ICD10 Documentation Needed Identify Acuity [ ] Acute exacerbation of COPD [ ] Acute exacerbation of Asthma [ ] COPD – Chronic and stable

53. 53 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Emphysema ICD10 Documentation Needed 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

54. 54 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Respiratory Failure ICD10 Documentation Needed 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

55. 55 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Post op Respiratory Issues ICD10 Documentation Needed 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

56. 56 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Sepsis ICD10 Documentation Needed 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.) _______________________

57. 57 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation SHOCK [ ] Hypovolemic shock [ ] Hemorrhagic shock [ ] Cardiogenic shock [ ] Septic shock (Circulatory failure associated with severe sepsis, represents organ failure) ICD10 Documentation Needed Same as ICD 9

58. 58 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Sickle Cell Disease ICD10 Documentation Needed 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

59. 59 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Substance Abuse ICD10 Documentation Needed 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

60. 60 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Tumor Lysis Syndrome [ ] Tumor Lysis Syndrome following anti-neoplastic drug chemotherapy [ ] Spontaneous Tumor Lysis Syndrome ICD10 Documentation Needed Same as ICD 9

61. 61 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation 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) ICD10 Documentation Needed Same as ICD 9

62. 62 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation UTI ICD10 Documentation Needed 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

63. 63 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Weakness ICD10 Documentation Needed 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

64. 64 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. Questions—contact your Clinical Documentation Specialists at your hospital  Jewish Hospital---502-587-2833 CDI office for all specialists  Jewish Shelbyville -- 502-587-2833 CDI office  Clinical Documentation Specialists --  Candy Rickard  Peggy Barlar  Charlotte Hopewell  Susan Hinkle  Dale Crosby  Becki Fudge  Sara Goff  Manager- Sandy Hodge- Bowman 502-409-2673  Supervisor- Kristen Boles 859-421-1542

65. 65 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.  Sts. Mary and Elizabeth  Clinical Documentation Specialists  Mickey Decker– 502-361-6125  Cheryl Brooks-502-361-6549  Annette Majors- 502-361-6495  Manager- Sandy Hodge- Bowman 502-409-2673  Supervisor- Kristen Boles 859-421-1542 Questions—contact your Clinical Documentation Specialists at your hospital

66. 66 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.  University of Louisville  Clinical Documentation Specialists  Katie Hernandez– 502-562-2895  Hilda Meehan—502-562-3801  Olga Soukhanova—502-562-3152  Cheryl Ward—502-562-3539  Peggy Fields—502-562-3730  Manager- Sandy Hodge- Bowman 502-409-2673  Supervisor- Kristen Boles 859-421-1542 Questions—contact your Clinical Documentation Specialists at your hospital

67. 67 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.  St Joe Main  Clinical Documentation Specialists  Michelle Ahady—859-313-2178  Tina Baker—859-313-2254  Lynnette Tuttle—859-313-1925  Ann Spero—859-313-2254  Teressa Cozine—859-313-2178  Trudy Paynter—859-313-1927  Karen Browning—859-313-1925  Manager- Sandy Hodge- Bowman 502-409-2673  Supervisor- Kristen Boles 859-421-1542 Questions—contact your Clinical Documentation Specialists at your hospital

68. 68 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.  St. Joe East  Clinical Documentation Specialists  Kimberly Gilbert-Morrison—502-316-5220  Kelly Geers—502-750-2329  Manager- Sandy Hodge- Bowman 502-409-2673  Supervisor- Kristen Boles 859-421-1542 Questions—contact your Clinical Documentation Specialists at your hospital

69. 69 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.  Flaget  Clinical Documentation Specialist  Cheryl Mitchell--502-350-5247  Manager- Sandy Hodge- Bowman 502-409-2673  Supervisor- Kristen Boles 859-421-1542 Questions—contact your Clinical Documentation Specialists at your hospital

70. 70 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.  St Joe London  Clinical Documentation Specialists  Katrina Henson—606-330-6759  Sherry Mills—606-330-6000  Manager- Sandy Hodge- Bowman 502-409-2673  Supervisor- Kristen Boles 859-421-1542 Questions—contact your Clinical Documentation Specialists at your hospital

71. 71 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.  St. Joe Mt. Sterling  Clinical Documentation Specialists  Lori Barry—859-497-5458  Manager- Sandy Hodge- Bowman 502-409-2673  Supervisor- Kristen Boles 859-421-1542 Questions—contact your Clinical Documentation Specialists at your hospital