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FAMILY PRACTICE and Other Common Documentation Tips ICD 10 Documentation Specificity Needed based on Conifer ICD 10 CDI Queries 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. 2 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. Table of contents 3 Alzheimer's 5 Esophagitis 27 Anemia 6 Functional Quadriplegia 28 Aplastic Anemia 7 Gastroparesis 29 Atrial Fib 8 Gastrointestinal Ulcer- Upper 30 BMI – high 9 GERD 31 BMI –low 10 Gout 32 Cardiac Arrest 11 Headache/ Migraine 33 Cellulitis 12 Heart failure- acute 34 Cerebral Edema 13 Heart failure-chronic 35 Chest pain 14 Hepatitis 36 Cirrhosis of Liver 15 HIV-AIDS 37 Colitis 16 Hypertension 38 Coma 17 Hyponatremia 39 Crohn’s Disease / Regional Enteritis 18 Influenza 40 CVA 19 Level of consciousness 41 Debridement 20 Lymphoma 42 Degenerative Disc Disease 21 Meningitis 43 Dementia 22 Mental Status- Altered 44 Diabetes 23 Metabolic—acidosis/ alkalosis 45 Diverticulitis 24 Mood Disorder 46 Dysphasia 25 Myocardial Infarction 47 Encephalopathy 26 Neoplasm 48 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. Table of Contents cont 4 Neutropenia 49 Non pressure ulcer 50 Malnutrition 51 Osteomyelitis 52 Pain 53 Pancreatitis 54 Personal Injury 55 Pneumonia- Aspiration Respiratory- Emphysema 67 Respiratory failure 68 Respiratory failure post op 69 Sepsis 70 Shock 71 Sickle Cell Disease 72 56 Substance abuse 73 Pneumonia- Hypostatic /passive/ stasis 57 TIA 74 Pneumonia-Specificity 58 Urosepsis 75 Pressure Ulcer 59 UTI 76 Prostatitis 60 Weakness 77 Pulmonary embolism 61 Hospital specific Renal Failure—acute 62 Documentation Specialists contact info 78-85 Renal failure-chronic 63 Respiratory-asthma 64 Respiratory- Bronchitis 65 Respiratory- COPD 66 ©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 ICD10 Documentation Needed 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: 6 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. Same as in ICD 9 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 ICD10 Documentation Needed BMI > 40 with associated diagnosis Morbidly Obese of: [ ] Morbid (Severe) Obesity [ ] Morbid (Severe) Obesity [ ] Due to excess calories [ ] Overweight [ ] Obesity (unspecified) [ ] 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 10 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 Documentation Needed Same as ICD 9 ICD10 documentation specificity needed ICD9 Documentation ICD10 Documentation Needed Cardiac Arrest 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 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 ©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 13 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 Documentation Needed Same as ICD 9 ICD10 documentation specificity needed ICD9 Documentation Chest Pain Same as ICD 9 [ ] 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 14 ICD10 Documentation Needed ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Cirrhosis of Liver ICD10 Documentation Needed Identify if alcoholic or non-alcoholic, if congenital, biliary obstructive, laennec’s and if portal [ ] Alcoholic [ ] Non-alcoholic [ ] Congenital ____ (underlying disease) [ ] Biliary / Obstructive: [ ] Primary [ ] Secondary [ ] Laennec’s: [ ] Alcoholic with: [ ] dependence [ ] non-dependence [ ] Non-alcoholic [ ] Portal: [ ] Alcoholic [ ] Non-alcoholic 15 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Colitis ICD10 Documentation Needed Identify Site, Type and Complications Site (if applicable): [ ] Small Intestine [ ] Large Intestine [ ] Other site __ Type: [ ] Colitis due to radiation [ ] Ulcerative Colitis [ ] Infectious Colitis [ ] Toxic Colitis [ ] Ischemic Colitis [ ] Colitis due to ___________________ [ ] Chronic Colitis Complications: [ ] Rectal Bleeding [ ] Intestinal Obstruction [ ] Fistula [ ] Abscess [ ] Other complication _________________ [ ] Unspecified complication 16 ©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_________ 17 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Crohn’s Disease / Regional Enteritis ICD10 Documentation Needed Identify specificity, site and associated diagnosis [ ] Abscess [ ] Fistula [ ] Intestinal obstruction [ ] Rectal bleeding [ ] Other (specify) _______________ Site: [ ] Small Intestine [ ] Large Intestine [ ] both small and large intestines Associated diagnoses / conditions (specify)________ 18 ©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 [ ] Dysphagia 19 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. [ ] Left [ ] Unspecified 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 20 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 Documentation Needed Same as ICD 9 ICD10 documentation specificity needed ICD9 Documentation Degenerative Disc Disease ICD10 Documentation Needed Identify Location and if with Myelopathy/Neuritis/Radiculopathy/Radiulitis [ ] Degenerative Cervical Disc Disease Specify level of spine: ___________ [ ] With Myelopathy [ ] With Neuritis, Radiculopathy, Radiculitis [ ] Other/Unspecified [ ] Degenerative Sacrococcygeal Disc Disease [ ] Degenerative Lumbar Disc Disease [ ] With Myelopathy [ ] With Neuritis, Radiculopathy, Radiculitis [ ] Other/Unspecified [ ] Degenerative Thoracic Disc Disease [ ] With Myelopathy [ ] With Neuritis, Radiculopathy, Radiculitis [ ] Other/Unspecified [ ] Degenerative Thoraco-Lumbar Disc Disease [ ] With Myelopathy [ ] With Neuritis, Radiculopathy, Radiculitis [ ] Other/Unspecified [ ] Degenerative Lumbosacral Disc Disease [ ] With Myelopathy [ ] Other/Unspecified 21 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. [ ] With Neuritis, Radiculopathy, Radiculitis 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: ___________________ 22 ©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 23 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation ICD10 Documentation Needed Diverticulitis IDENTIFY Acuity, Severity, Site and Type Acuity: [ ] Acute [ ] Chronic [ ] Acute on Chronic Severity: [ ] Bleeding [ ] No bleeding [ ] Abscess [ ] No abscess [ ] Perforation [ ] No perforation Site: [ ] Ileum [ ] Small Intestine [ ] Large Intestine [ ] Unspecified Intestine Type: [ ] Meckel’s diverticulum with diverticulitis [ ] Meckel’s diverticulum without diverticulitis 24 ©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 25 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation ICD10 Documentation Needed Encephalopathy 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 26 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation ICD10 Documentation Needed Esophagitis IDENTIFY SPECIFICITY [ [ [ [ [ [ 27 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ] Eosinophilic Esophagitis ] Esophagitis with GERD / Reflux ] Candida Esophagitis ] Ulcerative Esophagitis ] Esophagitis Unspecified ] Other Esophagitis ICD10 documentation specificity needed ICD9 Documentation ICD10 Documentation Needed Functional Quadriplegia Same as ICD 9 [ ] Functional quadriplegia (complete immobility) [ ] Immobilization syndrome (impaired mobility) 28 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation ICD10 Documentation Needed Gastroparesis Identify if related to diabetes and if underlying disease [ ] Gastroparesis related to Diabetes [ ] Gastroparesis in underlying disease/process (please state: ______________) 29 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation ICD10 Documentation Needed Upper Gastrointestinal Ulcer 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: _________________ 30 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation ICD10 Documentation Needed GERD IDENTIFY GERD WITH OR WITHOUT ESOPHAGITIS Gastro esophageal reflux disease (GERD) with Esophagitis Gastro esophageal reflux disease (GERD) without Esophagitis 31 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation ICD10 Documentation Needed Gout IDENTIFY Type, joint involved and acuity Specify the type/cause of gout: [ ] Drug-induced [ ] Secondary [ ] Idiopathic [ ] Syphilitic [ ] Lead-induced [ ] Primary [ ] With renal impairment (specify the specific renal disease/disorder, including acuity and/or state)____ Specify the specific joint involved _ [ ] Right [ ] Left Specificity acuity of gout: 32 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. [ ] Acute [ ] Chronic – with or without tophus [ ] Gout attack [ ] Gout flare ICD10 documentation specificity needed ICD9 Documentation ICD10 Documentation Needed Migraine IDENTIFY SPECIFICITY Headache [ [ [ [ ] With Aura [ ] With Refractory Migraine ] Intractable ] Persistent ] Other __________________ [ [ [ [ [ [ [ ] With CVA [ ] Hemiplegic ] Intractable ] With Status Migrainosus ] Menstrual ] Cyclical vomiting ] Periodic Headache Syndrome ] Ophthalmologic IDENTIFY SPECIFICITY [ [ [ [ [ [ [ [ [ 33 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ] Tension ] Primary thunderclap ] Associated with sex, cough, exertion ] Cluster ] Post-traumatic ] New daily persistent ] Vascular ] Drug- induced ] Other_________________________ ICD10 documentation specificity needed ICD9 Documentation ACUTE HEART FAILURE [ ] Acute Systolic Heart Failure [ ] Acute Diastolic Heart Failure ICD10 Documentation Needed SAME as ICD 9 with the addition OTHER ETIOLOGIES OF HEART FAILURE [ ] Heart Failure Due To Valvular Disease [ ] Acute Systolic and Diastolic Heart Failure [ ] Right Heart Failure / Acute Cor Pulmonale [ ] Right Heart Failure / Chronic Cor Pulmonale [ ] Rheumatic Heart Disease ACUTE ON CHRONIC HEART FAILURE [ ] Endocarditis (valvular) [ ] Acute On Chronic Systolic Heart Failure [ ] Myocarditis [ ] Pericarditis [ ] Acute On Chronic Diastolic Heart Failure [ ] Acute On Chronic Systolic and Diastolic Heart Failure 34 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation ICD10 Documentation Needed CHRONIC HEART FAILURE SAME as ICD 9 with the addition of etiology [ ] Chronic Systolic Heart Failure [ ] Chronic Diastolic Heart Failure [ ] Chronic Systolic and Diastolic Heart Failure 35 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. Etiologies: [ ] Hypertension [ ] Valvular disease [ ] Rheumatic heart disease ICD10 documentation specificity needed ICD9 Documentation Hepatitis ICD10 Documentation Needed IDENTIFY Acuity, Etiology and associated diagnosis Acuity: [ ] Acute [ ] Chronic Etiology: [ ] Alcoholic [ ] Drug induced (specify)____ [ ] Viral (type A,B,C,E)_______ Associated Diagnosis: [ ] with hepatic coma [ ] without hepatic coma [ ] with delta agent [ ] without delta agent 36 ©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 37 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 Documentation Needed Similar to ICD 9 ICD10 documentation specificity needed ICD9 Documentation Hypertension [ ] Malignant Hypertension [ ] Accelerated Hypertension [ ] Benign Hypertension [ ] Unspecified Hypertension 38 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 Documentation Needed Same as ICD 9 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 39 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Influenza ICD10 Documentation Needed IDENTIFY Organism and associated factors [ ] Influenza caused by ______ (specify organism) [ ] Influenza-associated Encephalopathy [ ] Influenza-associated Pneumonia 40 ©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 41 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 Documentation Needed Same as ICD 9 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 42 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Meningitis ICD10 Documentation Needed Identify Type, Organism and Present on Admission [ ] Viral Meningitis [ ] Specify organism (i.e. adenovirus, enterovirus, measles, etc.) ___________ [ ] Bacterial Meningitis - Acute [ ] Specify organism (i.e. gram negative, staph, strep, e coli, etc.)___________ [ ] Due to (please specify cause) _________ [ ] Aseptic - Acute [ ] Late effect [ ] Septic [ ] Present on Admission [ ] Yes [ ] Unable to determine 43 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. [ ] No ICD10 documentation specificity needed ICD9 Documentation ICD10 Documentation Needed Altered Mental Status 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 44 ©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 45 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. [ ] Respiratory ICD10 documentation specificity needed ICD9 Documentation Mood Disorder ICD10 Documentation Needed IDENTIFY Type, Status and Severity Type (check appropriate): [ ] Manic [ ] Bipolar [ ] Manic [ ] Depressive [ ] 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 46 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. [ ] Mixed 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 [ ] Posterior [ ] Inferior [ ] Q Wave [ ] Unspecified [ ] Septal [ ] Other _____________________ SPECIFIC ARTERY (Based on site) 47 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. [ ] Left Main Coronary [ ] Diagonal [ ] Left Anterior Descending [ ] Oblique Marginal [ ] Right Coronary Artery [ ] Other ___________________ [ ] Left Circumflex [ ] Unspecified ICD10 documentation specificity needed ICD9 Documentation Neoplasm ICD10 Documentation Needed Identify Site, Laterality, Type, Malignancy and associated conditions Site: Identify:_______________ Laterality: [ ] Right [ ] Left Type: [ ] Primary [ ] Secondary [ ] Bilateral [ ] 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 ____________________________________ 48 ©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 49 ©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 50 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. [ ] No ICD10 documentation specificity needed ICD9 Documentation Malnutrition Same as ICD 9 [ ] Under-nutrition / Malnutrition: [ ] Mild [ ] Moderate [ ] Severe [ ] Unspecified [ ] Protein Calorie Malnutrition: [ ] Mild [ ] Moderate [ ] Severe [ ] Unspecified [ ] Marasmus [ ] Nutritional Edema [ ] Other Malnutrition (please specify) _______________________________ 51 ICD10 Documentation Needed ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Osteomyelitis ICD10 Documentation Needed Identify site, acuity and if related to diabetes Osteomyelitis site: ____________ [ ] Acute osteomyelitis directly related to diabetes mellitus [ ] Acute osteomyelitis unrelated to diabetes mellitus [ ] Chronic osteomyelitis directly related to diabetes mellitus [ ] Chronic osteomyelitis unrelated to diabetes mellitus 52 ©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 53 ©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 54 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation ICD10 Documentation Needed Injury For this injury _________, please document the following information: How the injury occurred (i.e. fall, MVA, etc.) ___________________ Location where the injury occurred (i.e. home, work, school, etc.) ____________________________ Activity at time of injury (i.e. running, gardening, skating, etc.) ______________________________ Status at time of injury (i.e. civilian, military, volunteer, etc.) ______________________________ 55 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation ICD10 Documentation Needed Aspiration Pneumonia 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 56 ©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)________________ 57 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 Documentation Needed Same as ICD 9 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 58 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 Documentation Needed Similar to ICD 9 ICD10 documentation specificity needed ICD9 Documentation ICD10 Documentation Needed Pressure Ulcer 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) 59 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation ICD10 Documentation Needed Prostatitis Identify acuity, bacterial vs viral and organism if know [ ] Acute Prostatitis: [ ] Bacterial (organism __________ if known) [ ] Viral (organism ______________if known) [ ] Chronic Prostatitis: [ ] Bacterial (organism ________ if known) [ ] Viral (organism ____________if known) 60 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation ICD10 Documentation Needed Pulmonary Embolism Identify acuity, type and if associated acute cor pulmonale Acuity: [ ] Acute [ ] Chronic Type: [ ] Saddle [ ] Septic [ ] Other___ [ ] Pulmonary Embolism with associated Acute Cor Pulmonale 61 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation ICD10 Documentation Needed 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 ________ 62 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. Same as ICD 9 ICD10 documentation specificity needed ICD9 Documentation ICD10 Documentation Needed 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 II 60-89 Kidney damage with mildly decreased GFR GFR Stage III Kidney damage with moderately decreased GFR GFR 30-59 Stage IV Kidney damage with severely decreased GFR GFR 16-29 63 Stage V Kidney failure GFR<15 ESRD End Stage Renal Disease On dialysis ©2015 Conifer Health Solutions, LLC. All Rights Reserved. Same as ICD 9 ICD10 documentation specificity needed ICD9 Documentation ICD10 Documentation Needed Asthma Identify acuity and type [ ] Acute exacerbation of Asthma [ ] Status Asthmaticus [ ] Acute exacerbation of Allergic Bronchitis [ ] Asthma: [ ] Mild intermittent [ ] Mild persistent [ ] Moderate persistent [ ] Severe Persistent Type: [ ] Childhood [ ] Exercise induced [ ] Late onset [ ] Mixed [ ] Other (specify)________________ [ ] COPD [ ] Chronic obstructive bronchitis [ ] Acute lower respiratory infection 64 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation ICD10 Documentation Needed Bronchitis Identify acuity and due to [ ] Acute exacerbation of Bronchitis [ ] Acute on Chronic Bronchitis [ ] Chronic Bronchitis obstructive [ ] Bronchitis due to: [ ] Fumes [ ] Radiation [ ] Viral or Bacterial Organism____________ 65 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation ICD10 Documentation Needed COPD Identify Acuity [ ] Acute exacerbation of COPD [ ] Acute exacerbation of Asthma [ ] COPD – Chronic and stable 66 ©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 67 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation ICD10 Documentation Needed Respiratory Failure 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 68 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation ICD10 Documentation Needed Post op Respiratory Issues 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 69 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. [ ] Chronic [ ] Acute on Chronic ICD10 documentation specificity needed ICD9 Documentation ICD10 Documentation Needed Sepsis 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 dysfunction [ ] without organ [ ] 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 dysfunction [ ] without organ [ ] Septic shock [ ] Sepsis related to a device (i.e. port, IV line, pacer / ICD leads, Foley, etc.) _______________________ 70 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation ICD10 Documentation Needed SHOCK Same as ICD 9 [ ] Hypovolemic shock [ ] Hemorrhagic shock [ ] Cardiogenic shock [ ] Septic shock (Circulatory failure associated with severe sepsis, represents organ failure) 71 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation ICD10 Documentation Needed Sickle Cell Disease 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 72 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation ICD10 Documentation Needed Substance Abuse 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 [ ] Withdrawal [ ] In remission [ ] Uncomplicated Complications: [ ] Intoxication [ ] Other complication: ____________ [ ] Unspecified complication Substance-Induced Disorders: [ ] Psychosis:[ ] Delirium [ ] Delusions [ ] Perceptual Disturbances: Sexual Dysfunction [ ] Anxiety Disorder [ ] Sleep Disorder [ ] Unspecified substance-induced disorder [ ] Other substance-induced disorder: ________________________________ [ ] No substance-induced disorder 73 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. [ ] Hallucinations [ ] ICD10 documentation specificity needed ICD9 Documentation ICD10 Documentation Needed TIA 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) 74 ©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) 75 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 Documentation Needed Same as ICD 9 ICD10 documentation specificity needed ICD9 Documentation ICD10 Documentation Needed UTI 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 76 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. [ ICD10 documentation specificity needed ICD9 Documentation ICD10 Documentation Needed Weakness 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 77 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. [ ] Non-dominant side 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 78 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. Questions—contact your Clinical Documentation Specialists at your hospital 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 79 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. Questions—contact your Clinical Documentation Specialists at your hospital 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 80 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. Questions—contact your Clinical Documentation Specialists at your hospital 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 81 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. Questions—contact your Clinical Documentation Specialists at your hospital 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 82 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. Questions—contact your Clinical Documentation Specialists at your hospital Flaget Clinical Documentation Specialist Cheryl Mitchell—502-350-5247 Manager- Sandy Hodge- Bowman 502-409-2673 Supervisor- Kristen Boles 859-421-1542 83 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. Questions—contact your Clinical Documentation Specialists at your hospital 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 84 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. Questions—contact your Clinical Documentation Specialists at your hospital 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 85 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
