Introduction: Overview & Goals
� Documentation is the cornerstone to disease and treatment information
� As with ICD-9, ICD-10 code assignment relies solely upon physician documentation of diagnoses and procedures
� “Documentation” is mentioned over 70 times in the ICD-10-CM guidelines document.
� “Querying” is referred to over 20 times in the guidelines document
� ICD-10 is a clinical classification system that is sophisticated enough, and specific enough, to keep up with the changes in medicine and with regulations
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Value of Clinical Documentation Audit
Each assigned code should be compared, contrasted, and analyzed to:� Confirm presence of clinical documentation as expected
�Assess quality and content of clinical documentation to support assigned codes
�Evaluate assigned codes vs. the application of final ICD-10 codes based on a coding professional’s manual review of the clinical documentation
Value of Clinical Documentation Audit- continued
Clinical documentation review allows your organization to understand the possibilities related to:
� Current coding and documentation practices
� Strengths and opportunities to ensure that the impact of the transition to ICD-10 is positive in terms of accuracy and appropriate reimbursement.
CDI Audit Worksheet Sample
ORIGINAL (ICD-9) HRS (ICD-9) HRS (ICD-10)
Reviewer Scenario Number Admit Date: Disch Date: FinClass MS-DRG DRG Description MS-DRG DRG Description MS-DRG DRG Description Service
HRS HRS024 6/24/13 6/26/13 HMO 470
MAJOR JOINT REPLACEMENT OR
REATTACHMENT OF LOWER EXTREMITY
W/O MCC
470
MAJOR JOINT REPLACEMENT OR
REATTACHMENT OF LOWER EXTREMITY W/O
MCC
470
MAJOR JOINT REPLACEMENT OR
REATTACHMENT OF LOWER EXTREMITY
W/O MCC
DIAGNOSES
Code Type SEQ# CLIENT ICD-9 CODE CLIENT ICD-9 DESCRIPTION HRS ICD-9 CODE HRS ICD-9 DESCRIPTION HRS ICD-9 COMMENTS HRS ICD-10 CODE HRS ICD-10 CODE DESCRIPTIONDocumentation Impact
CodeDocumentation Impact Description Reviewer Comments
DxAdmitting / First-
Listed Dx71536
Osteoarthrosis, localized, not specified
whether primary or secondary, lower leg71536
Osteoarthrosis, localized, not
specified whether primary or
secondary, lower leg
M179 Osteoarthritis of knee, unspecified 000No Impact; Documentation Supports
Code
Dx Principal Dx 71536Osteoarthrosis, localized, not specified
whether primary or secondary, lower leg71536
Osteoarthrosis, localized, not
specified whether primary or
secondary, lower leg
M179 Osteoarthritis of knee, unspecified 002Insufficient Documentation (Disease:
Type)
To support a more specific ICD-10 codeassignment, the type of
OA should be documented. i.e. Primary, post traumatic,
secondary
Dx 2 2449 Unspecified acquired hypothyroidism 2449 Unspecified acquired hypothyroidism E039 Hypothyroidism, unspecified 002Insufficient Documentation (Disease:
Type)
To support a more specific ICD-10 codeassignment, the type of
hypothyroidism should be documented. i.e., postinfectious,
due to iodine deficiency
Dx 3 4019 Unspecified essential hypertension 4019 Unspecified essential hypertension I10 Essential (primary) hypertension 000No Impact; Documentation Supports
Code
Dx 4 53081 Esophageal reflux 53081 Esophageal reflux K219Gastro-esophageal reflux disease without
esophagitis000
No Impact; Documentation Supports
Code
Dx 5 2724 Other and unspecified hyperlipidemia 2724 Other and unspecified hyperlipidemia E785 Hyperlipidemia, unspecified 002Insufficient Documentation (Disease:
Type)
To support a more specific ICD-10 code assignment, the type
of hyperlipidemia should be documented. i.e., Mixed, Type A-
D
Dx 6 V1582 Personal history of tobacco use V1582 Personal history of tobacco use Z87891 Personal history of nicotine dependence 000No Impact; Documentation Supports
Code
Dx 7 #N/A #N/A #N/A #N/A
Dx 8 #N/A #N/A #N/A #N/A
Dx 9 #N/A #N/A #N/A #N/A
Dx 10 #N/A #N/A #N/A #N/A
Dx 11 #N/A #N/A #N/A #N/A
Dx 12 #N/A #N/A #N/A #N/A
Dx 13 #N/A #N/A #N/A #N/A
Dx 14 #N/A #N/A #N/A #N/A
Dx 15 #N/A #N/A #N/A #N/A
Dx 16 #N/A #N/A #N/A #N/A
Dx 17 #N/A #N/A #N/A #N/A
Dx 18 #N/A #N/A #N/A #N/A
Dx 19 #N/A #N/A #N/A #N/A
Dx 20 #N/A #N/A #N/A #N/A
PROCEDURES
Code Type SEQ# CLIENT ICD-9 CLIENT ICD-9 DESCRIPTION HRS ICD-9 HRS ICD-9 DESCRIPTION HRS ICD-9 COMMENTS HRS ICD-10 CODE HRS ICD-10 CODE DESCRIPTIONDocumentation Impact
CodeDocumentation Impact Description Reviewer Comments
PxPrincipal / First-
Listed Px8154 Total knee replacement 8154 Total knee replacement 0SRT0J9
Replace R Knee Jt, Femoral w Synth Sub,
Cement, Open000
No Impact; Documentation Supports
Code
Px 2 #N/A #N/A #N/A #N/A
Px 3 #N/A #N/A #N/A #N/A
Px 4 #N/A #N/A #N/A #N/A
Px 5 #N/A #N/A #N/A #N/A
Px 6 #N/A #N/A #N/A #N/A
Px 7 #N/A #N/A #N/A #N/A
Px 8 #N/A #N/A #N/A #N/A
Px 9 #N/A #N/A #N/A #N/A
Px 10 #N/A #N/A #N/A #N/A
Px 11 #N/A #N/A #N/A #N/A
Px 12 #N/A #N/A #N/A #N/A
Clinical Documentation Audit
Key Findings Legend (Snapshot)
Impact
Code
ICD-10
Documentation
Objectives
Explanation Example
001 Insufficient
Documentation
(Disease: Acuity)
ICD-10-CM code that will replace the ICD-9-CM code used for the
same reimbursement will need more specific disease identification
The acuity of respiratory failure should be documented. i.e., acute, chronic or acute on chronic. The acuity of bronchitis should be documented. i.e., acute or chronic
002 Insufficient
Documentation
(Disease: Type)
ICD-10-CM has more than one disease category under a broad
disease category. (i.e.. Diabetes-Type 1, Type 2, secondary, drug or
chemical induced).
The type of iron deficiency anemia should be documented. i.e., due to chronic blood loss, due to inadequate iron intake. The type of hypothyroidism should be documented. i.e., due to medication, due to infectious process, post-surgical.
003 Insufficient
Documentation
(Disease: Stage)
ICD-10-CM has stages or levels of disease, such as mild intermittent,
late onset early onset, intractable or not intractable, stages of disease
kidney or pressure ulcer, post and pre.
Chronic kidney disease should be documented. i.e., Stage I-V, end stage. The phase of the dysphagia should be documented. i.e., oral, oropharyngeal, pharyngeal, pharyngoesophageal, cervical.
004 Insufficient
Documentation
(Laterality)
Codes that are assigned in ICD-10 based on laterality The laterality of the acute osteomyelitis of the hand should be documented. i.e. right, left, bilateral.
005 Insufficient
Documentation (Site
Specificity)
Codes that are assigned in ICD-10-CM based on documented site The site of the furuncle should be documented. i.e., abdominal wall, back, chest wall, groin. The site of Crohn's disease should be documented. i.e., colon, duodenum, ileum, jejunum. The site of the abdominal pain. i.e., LLQ, pelvic or perineal, periumbilical, RLQ, epigastric, LUQ, RUQ.
006 Insufficient
Documentation
(Combination codes)
Combination codes are single codes in ICD-10-CM that are used to
classify: two diagnoses, a diagnosis with an associated secondary
process (manifestation), a diagnoses with an associated
complication
The documentation should include any manifestations of the acute respiratory failure. i.e., with hypercapnia or with hypoxemia. The documentation should include any manifestations of Crohn's disease. i.e., abscess, fistula, intestinal obstruction, rectal bleeding.
How Can You Prepare?
Begin physician education and add the following to queries:
� Asthma
� Severity/Acuity
� Myocardial Infarction
� Specific site
� Major Depression
� Severity/Acuity
How Can You Prepare? continued
..add the following to queries:�Differentiation between general and focal seizures� General seizures require type specificity
� Identify intractable (treatment-resistant) seizures
� Trimester of pregnancy�Default to the trimester when the complication occurred, not the discharge trimester when an admission crosses trimesters
� Identification of the substance related to adverse effect, poisoning, or toxic effect
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How Can You Prepare? continued
…add the following to queries:
� Glasgow (Coma Scale) � Need a score from each of the three assessment areas, NOT a total score
� Eye opening
� Verbal response
� Motor response
� Gustilo Open Fracture Classification � I, II, III, IIIA, IIIB, or IIIC
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How Can You Prepare?-continued
…add the following to queries:
�Approach
�Laterality
�Root operation
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How Can You Prepare?-continued
What policies and procedures need revision?� ICD-10-CM/PCS have new Coding Clinic advice
What documentation templates need revision?� Operative reports
� History and physicals
� Query forms
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Conclusion /Next Steps
There is much still to do…
� Start Small
� Pick your Battles
� Encourage Teamwork
� Inventory your Query Library
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Kim Carr
RHIT, CCS, CDIP, CCDS,
AHIMA-Approved ICD-10-CM/PCS Trainer
Director, Clinical Documentation
1777 Reisterstown Road, Suite #330
Baltimore, Maryland 21208
Phone (410) 653-0194