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General Surgery Documentation Tips THE ROAD TO ICD-10 The following are important documentation tips and strategies as required by the specificity needed in ICD-10: General: a. Document diagnosis that were “present on admission” as POA. b. Include diagnoses monitored, treated, evaluated on discharge summary. c. Laterality should be specified for all body parts and sites. Diagnosis Lysis of Adhesions Concept Release site Debridement Angioplasty Site Diverticulitis Complications Gallstone/Cholecystits Acuity Obstruction Acute/Postop Resp Failure Type Sepsis Etiology Organism Specificity • Bowel(Duodenum, Jejunum, Ileum) • Colon (Ascending, Tranverse, Descending,Sigmoid) • Peritoneum • Organs Body part Type of wound (decubitus, operative wound, burn, etc.) Margin Size Depth State Excisional debridement of devitalized/necrotic tissue (if a cutting instrument was used) State Nonexcisional debridement (if no tissue was excised) All vessels that were treated Document with perforation/abscess Inflammation site (large/small bowel) Acute/Chronic With/without obstruction • Hypoxic • Hypercapnic • Hypoxic/Hypercapnic • Unknown Link to source of infection : • Vascular grafts • Devices • Implants • Infection (Pneumonia, UTI, Peritonitis, etc.) Organism if known Shock Type Ileus Anemia Type Diabetes Type Manifestations Insulin Usage Ulcers Type Location Stage POA Obesity with BMI BMI under 19 Malnutrition Type Neoplasms Type Location Pathology Morphology Tobacco Usage Frequency • Hemorrhagic • Septic • Cardiogenic • Liver, • Hypovolemic • Other Document if expected or integral to procedure Acute blood loss anemia, chronic blood loss anemia, other type of anemia • Type I DM • Type II DM • DM due to drugs/chemicals • DM due to underlying condition Document all DM manifestations such as: • DM nephropathy • DM Skin Ulcer • DM retinopathy • DM PVD Decubitus, Ishemic, DM, Stasis Upper back, ankle, sacral, buttock, etc. Decubitus only: (stage 1-4 or unstageable) Obesity is always clinically significant Morbid obesity defined as BMI 40 or > Associated diagnoses such as Underweight, Cachexia or Malnutrition • Protein Calorie Malnutrition • Mild, Moderate, Severe • Malignant, • Benign • CA in situ • Uncertain or Unspecified Behavior Primary site Secondary sites You may addend the DC summary as needed if Pathology Report finalized after patient discharge. • Use • Abuse • Dependence • Exposure Clinical Documentation Improvement Linda Rhodes, RN, CCDS Manager 815-5544 Mary Fortunato, RN, CCDS 667-7160 Surgery Sandra Steed, RN, CCDS Educator 815-5414 Peggy McKenna, RN 667-7272 Surgery
