cardiology and other common documentation tips icd 10 documentation specificity needed based on...
Post on 02-Jan-2016
238 Views
Preview:
TRANSCRIPT
CARDIOLOGYand Other Common Documentation TipsICD 10 Documentation Specificity Needed based on Conifer ICD 10 CDI Queries
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 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
Table of contents
Alzheimer's 4
Anemia 5
Aplastic Anemia 6
Atrial Fib 7
BMI – high 8
BMI –low 9
Cardiac Arrest 10
Chest pain 11
Coma 12
Cor Pulmonale 13
Dementia 14
Diabetes 15
Encephalopathy16
GERD 17
Heart failure- acute 18
Heart failure-chronic 19
HIV-AIDS 20
Hypertension 21
Hyponatremia 22
Mental Status- Altered 23
Metabolic/ acidosis/alkalosis 24
Mood Disorder 25
Myocardial Infarction 26
Non pressure ulcer 27
Malnutrition 28
Pneumonia- Aspiration 29
Pneumonia-Specificity 30
Pressure Ulcer 31
Pulmonary embolism 32
Renal Failure—acute 33
Renal failure-chronic 34
Respiratory- COPD 35
Respiratory- Emphysema 36
Respiratory failure 37
Respiratory failure post op 38
Sepsis 39
Shock 40
Substance abuse 41
Urosepsis 42
UTI 43
Hospital specific
Documentation Specialists contact info 44-51
4 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Alzheimer’s
ICD10 Documentation Needed
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
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 ©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 ©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 ©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 ©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 ©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 ©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
12 ©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_________
13 ©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
14 ©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: ___________________
15 ©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
16 ©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
17 ©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
18 ©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
19 ©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
20 ©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
21 ©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
22 ©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
23 ©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
24 ©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
25 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Mood Disorder
ICD10 Documentation NeededIDENTIFY Type, Status and SeverityType (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
26 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Myocardial Infarction
ICD10 Documentation NeededIdentify Type, Age of Infarction, Encounter,
Site and ArteryMI 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
27 ©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
28 ©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
29 ©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
30 ©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
31 ©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)
32 ©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
33 ©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
34 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 DocumentationChronic 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 GFRGFR > 90
Stage II Kidney damage with mildly decreased GFRGFR 60-89
Stage III Kidney damage with moderately decreased GFR GFR 30-59
Stage IV Kidney damage with severely decreased GFRGFR 16-29
Stage V Kidney failure GFR<15
ESRD End Stage Renal Disease On dialysis
ICD10 Documentation Needed
Same as ICD 9
35 ©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
36 ©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
37 ©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
38 ©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
39 ©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.) _______________________
40 ©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
41 ©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
42 ©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
43 ©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
44 ©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
45 ©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
46 ©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
47 ©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
48 ©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
49 ©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
50 ©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
51 ©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
top related