the transition to what you need to know for general surgery/trauma date | presenter information
TRANSCRIPT
The Transition toWhat you need to know for General Surgery/Trauma
Date | Presenter Information
Tools Available
Twitter @AdvocateICD10
Flat Screens in lounges
AMGDoctors.com
How can we reach our
physicians?
Intranet
Email BlastsPhysician Relations
Team
Website
APP Newsletter
Pocket Cards
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Ongoing Support for ICD-10Physician Advisors
Clinical Informatics
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-Public Reporting-Reimbursement-Physician Scorecards-Quality Improvement
What’s in it for me?• Better reflection of the quality of the care you
provided to your patient• A more accurate assessment of the Severity of Illness
(SOI) i.e. how sick your patient was during the hospitalization
• Improves your publicly reported quality measure scores
• Supports the improvement of your patient’s clinical outcomes and safety
• Enables a better capture of SOI (severity of illness) and ROM (risk of mortality)
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What should be documented?
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ReimbursementAdmit
• HPI: tell “the story”
• PMH: all chronic conditions in as much detail as available (e.g., Chronic Systolic CHF)
• PSH: all surgeries (e.g., left hip arthroplasty)
• Assessment and Plan:• Differential diagnosis• Working diagnoses• Other conditions being
treated
Daily
• Rule out or confirm differential diagnosis based on test results, imaging results and response to empiric treatment.
Discharge
• All treated/resolved diagnoses should be documented.
• For diagnoses that are documented as suspected, possible, probable at the time of discharge should be listed in the discharge summary.
No Matter How Obvious it is to the Clinician• It is not appropriate for the coder to report a diagnosis based on abnormal findings:
– Laboratory
– Pathology
– Imaging
• A query must be sent to document a definitive diagnosis
• Only a physician can establish a cause and effect relationship between a diagnosis such as gastroparesis and diabetes
• Possible, probable and suspected conditions can be reported, but ONLY if documented at the time of discharge (for inpatient records)
• Outpatient Surgical and Observation Records: Enter as much information as known at the time.
Patient with shortness of breath and lung nodule. Coded to shortness of breath and lung nodule.
Patient with shortness of breath and lung nodule, suspected lung cancer with pathology pending. Coded to shortness of breath and lung nodule.
We would not code a possible condition as an established diagnosis on outpatient records.
What Coders are Unable to Assume
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Key Changes Needed to Support ICD-10 Coding
Anemia, Blood Loss
• Document, when appropriate:– Anemia due to acute
blood loss– Anemia due to chronic
blood loss – Postoperative anemia
due to acute blood loss
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Appendicitis • Document severity:
– Acute– Chronic– Recurrent– Relapsing– Subacute
• Document if with:– Peritoneal
abscess– Peritonitis– Gangrene– Perforation
Complication of Surgery• Physicians documentation must include the
cause and effect relationship between the care provided and the condition that may be considered a complication.
• Physician documentation must indicate that condition is a complication.
• The physician may be asked for clarification if the complication is not clearly documented as either a complication or as an expected outcome
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Neoplasms• Document if neoplasm is benign or malignant• Document site and laterality such as:
– Lung– Prostate– Kidney– Breast– Colon– Other anatomic sites
• Differentiate between primary and secondary (metastatic) site– Document primary site and if it is still present
• For secondary sites:– Document suspected and final pathology results– EVEN IF RECEIVED AFTER THE PATIENT IS DISCHARGED
WITH A LATE ENTRY DATED AS NEEDED
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Obesity• Document etiology:
– Due to excess calories or nutritional
– Due to drugs– Other, for example, due
to thyroid or pituitary disorder
• Specify if morbidly obese• Document BMI• Document if:
– With alveolar hypoventilation/ hypoventilation syndrome
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Ascites• Document if ascites is
malignant• Document neoplasm
linked to malignant ascites
Crohn’s Disease• Document anatomical site:
– Large intestine– Small intestine– Small and large intestine
• Document any associated complications, such as: – Bleeding – Intestinal obstructions– Fistula– Abscess– Perforation
• Don’t use the term “inflammatory bowel disease.” Use of this term when your intended diagnosis is Crohn’s disease may understate severity of illness and risk of mortality
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Encephalopathy• Document acute/chronic• Document type:
– Metabolic– Toxic– Alcoholic– Septic– Hepatic– Anoxic
• Document cause:– Infection– Electrolyte imbalance– Substance abuse and
resulting disease – Viral hepatitis
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Hernia• Document site and
laterality:– Bilateral inguinal
hernia– Femoral hernia– Umbilical hernia– Ventral hernia– Diaphragmatic/hiatal
hernia• Document if with:
– Gangrene– Obstruction– Gangrene and
obstruction
Gastritis• Document severity:
– Acute– Chronic
• Document underlying cause:– Alcohol induced – Diet deficiency– Viral– Allergic
• Document associated complications– bleeding
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Pancreatitis• Document severity:
– Acute– Chronic
• Document etiology and show cause and effect:– Idiopathic cute
pancreatitis– Acute pancreatitis due
to alcohol abuse– Gallstones or biliary– Drug induced
Hepatic Failure
• Document type:– Acute– Subacute– Chronic
• Document if with hepatic coma
• Document etiology, for example:– Due to alcohol or
drugs
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Irritable Bowel Syndrome
• Document if with diarrhea
• Document if psychogenic
Peptic Ulcer Disease
• Document severity:– Acute – Chronic
• Document site:– Duodenal– Esophagus– Gastric– Other
• Document underlying cause:– Alcohol– Drug or chemical
• Document if associated with:– Perforation– Hemorrhage– Perforation and hemorrhage
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Gastrointestinal Bleed
• Document etiology and show cause and effect, for example:– Acute GI bleed due to
bleeding esophageal varices– Acute GI bleed due to
hemorrhoids– Acute GI bleed due to
gastritis• Document where blood was
observed:– Rectal– Hematochezia– Hematemesis
Ulcerative Colitis• Use the following terms to further define the anatomical site:
– Pancolitis– Proctitis– Rectosigmoiditis
• Document any associated complications:– Bleeding– Intestinal obstruction– Fistula– Abscess– Perforation
• Don’t use the term “inflammatory bowel disease.” Use of this term when your intended diagnosis is Ulcerative Colitis may understate severity of illness and risk of mortality
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