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OB/GYN 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 Anemia 4 BMI – high 5 Pancreatitis 18 BMI –low 6 Pneumonia-Specificity 19 Diabetes 7 Premature infant 20 Endometriosis 8 Pressure Ulcer 21 Headache/ Migraine 9 Renal Failure—acute 22 Hypertension 10 Renal failure-chronic 23 Hyponatremia 11 Sepsis 24 Metabolic—acidosis/ alkalosis 12 Shock 25 Mood Disorder 13 Substance abuse 26 Neoplasm 14 Testicular Torsion 27 Malnutrition 15 Urosepsis 28 Pregnancy 16 UTI 29 Ovarian Cancer 17 Hospital specific Documentation Specialists contact info 30-37 ©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: 4 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. Same as in ICD 9 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: _____) 5 ©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 6 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 Documentation Needed Same as ICD 9 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 7 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Endometriosis ICD10 Documentation Needed IDENTIFY Implant Site [ ] Uterus [ ] Fallopian tube: [ ] Right [ ] Left [ ] Ovary: [ ] Left [ ] Right [ ] Other site: ____________________ (e.g. intestine, parametrium, peritoneal, rectrovaginal septum, vaginal, vulva) 8 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. 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 [ [ [ [ [ [ [ [ [ 9 ©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 Hypertension [ ] Malignant Hypertension [ ] Accelerated Hypertension [ ] Benign Hypertension [ ] Unspecified Hypertension 10 ©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 11 ©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 12 ©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 13 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. [ ] Mixed 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 ____________________________________ 14 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. 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) _______________________________ 15 ICD10 Documentation Needed ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Pregnancy ICD10 Documentation Needed Identify trimester, if preterm, gestational diabetes and any other associated diagnosis/conditions Specify trimester [ ] First (less than 14 weeks, 0 days) [ ] Second (14 weeks, 0 days to less than 28 weeks, 0 days) [ ] Third (28 weeks until delivery) [ ] Preterm labor/Preterm Delivery [ ] Gestational Diabetes [ ] Diet controlled [ ] Insulin controlled [ ] Associated diagnosis/conditions (please specify): ________ 16 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Ovarian Cancer ICD10 Documentation Needed Identify laterality [ ] Ovarian Cancer [ ] Right 17 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. [ ] Left [ ] Bilateral 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 18 ©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 19 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 Documentation Needed Similar to ICD 9 ICD10 documentation specificity needed ICD9 Documentation ICD10 Documentation Needed Premature Infant Prematurity [ ] Prematurity (birth weight of 1,000 – 2,499 grams) [ ] Extreme Immaturity (birth weight < 1,000 grams) [ ] Slow fetal growth [ ] Malnutrition [ ] Unable to determine [ ] Other __________________________________ Weeks of Gestation: [ ] Unspecified weeks of gestation gestation [ ] Less than 24 completed weeks of [ ] 24 completed weeks of gestation [ ] 25 to 26 completed weeks of gestation [ ] 27 to 28 completed weeks of gestation [ ] 29 to 30 completed weeks of gestation [ ] 31 to 32 completed weeks of gestation [ ] 33 to 34 completed weeks of gestation [ ] 35 to 36 completed weeks of gestation [ ] 37 or more completed weeks of gestation 20 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. 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) 21 ©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 ________ 22 ©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 23 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 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.) _______________________ 24 ©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) 25 ©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 26 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. [ ] Hallucinations [ ] ICD10 documentation specificity needed ICD9 Documentation ICD10 Documentation Needed Testicular Torsion Identify Extra or Intra vaginal and site [ ] Extravaginal: [ ] Epididymis [ ] Spermatic Cord [ ] Testicle/Testis [ ] Intravaginal: [ ] Epididymis [ ] Spermatic Cord [ ] Testicle/Testis 27 ©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) 28 ©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 29 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. [ Questions—contact your Clinical Documentation Specialists at your hospital Jewish Hospital---502-587-2833 CDI office Jewish Shelbyville - 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 30 ©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 Cheryl Brooks Annette Majors Manager- Sandy Hodge- Bowman 502-409-2673 Supervisor- Kristen Boles 859-421-1542 31 ©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 Hilda Meehan Olga Soukhanova Cheryl Ward Peggy Fields Manager- Sandy Hodge- Bowman 502-409-2673 Supervisor- Kristen Boles 859-421-1542 32 ©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 Tina Baker Lynnette Tuttle Ann Spero Teressa Cozine Trudy Paynter Karen Mitchell Manager- Sandy Hodge- Bowman 502-409-2673 Supervisor- Kristen Boles 859-421-1542 Manager- Sandy Hodge- Bowman 502-409-2673 Supervisor- Kristen Boles 859-421-1542 33 ©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 Kelly Geers Manager- Sandy Hodge- Bowman 502-409-2673 Supervisor- Kristen Boles 859-421-1542 34 ©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 35 ©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 36 ©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 Manager- Sandy Hodge- Bowman 502-409-2673 Supervisor- Kristen Boles 859-421-1542 37 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
