1. CARDIOTHORACIC SURGERY and 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  Atrial Fib7  BMI – high8  BMI –low9  Cardiac Arrest10  Cellulitis11  Cerebral Edema12  Chest pain13  Factor VII14  Coma15  Cor Pulmonale16  CVA17  Debridement18  Dementia19  Diabetes20  Encephalopathy21  Heart failure- acute22  Heart failure-chronic23  Hypertension24  Hyponatremia25  Level of consciousness26  Lung Cancer27  Lymphoma28  Mental Status- Altered29  Metabolic—acidosis/ alkalosis30  Myocardial Infarction31  Neoplasm32  Non pressure ulcer33  Malnutrition34  Pain35  Pancreatitis36  Pleurodesis37  Pneumonia- Aspiration38  Pneumonia- Hypostatic /passive/ stasis39  Pneumonia-Specificity 40  Pressure Ulcer41  Pulmonary embolism42  Renal Failure—acute43  Renal failure-chronic44  Respiratory- COPD45

4. 4 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. Table of Contents  Respiratory failure46  Respiratory failure post op47  Sepsis48  Shock49  Substance abuse50  TIA51  Urosepsis52  UTI53  Weakness54  Hospital specific  Documentation Specialists contact info 55-62

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 A fib ICD10 Documentation Needed IDENTIFY TYPE [ ] Paroxysmal Atrial Fibrillation [ ] Persistent Atrial Fibrillation [ ] Chronic Atrial Fibrillation (includes permanent Atrial Fibrillation) [ ] Unspecified Atrial Fibrillation

8. 8 ©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: _____)

9. 9 ©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

10. 10 ©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________

11. 11 ©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

12. 12 ©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

13. 13 ©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

14. 14 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Factor VII ICD10 Documentation Needed 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

15. 15 ©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_________

16. 16 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Cor Pulmonale [ ] Acute Cor Pulmonale [ ] Chronic Cor Pulmonale [ ] Pulmonary Hypertension [ ] Does not apply to this patient ICD10 Documentation Needed Same as ICD 9

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

18. 18 ©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

19. 19 ©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: ___________________

20. 20 ©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

21. 21 ©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

22. 22 ©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

23. 23 ©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

24. 24 ©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

25. 25 ©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

26. 26 ©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

27. 27 ©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

28. 28 ©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

29. 29 ©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

30. 30 ©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

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

32. 32 ©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 ____________________________________

33. 33 ©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

34. 34 ©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

35. 35 ©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

36. 36 ©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

37. 37 ©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

38. 38 ©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

39. 39 ©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

40. 40 ©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

41. 41 ©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)

42. 42 ©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

43. 43 ©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

44. 44 ©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

45. 45 ©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

46. 46 ©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

47. 47 ©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

48. 48 ©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.) _______________________

49. 49 ©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

50. 50 ©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

51. 51 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation TIA ICD10 Documentation Needed 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)

52. 52 ©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

53. 53 ©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

54. 54 ©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

55. 55 ©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

56. 56 ©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

57. 57 ©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

58. 58 ©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

59. 59 ©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

60. 60 ©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

61. 61 ©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

62. 62 ©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