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CARDIOLOGY 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 4 Anemia 5 Aplastic Anemia 6 Atrial Fib 7 BMI – high 8 BMI –low 9 Cardiac Arrest 10 Chest pain 11 Coma 12 Cor Pulmonale 13 Dementia 14 Diabetes 15 Encephalopathy 16 GERD 17 Heart failure- acute 18 Heart failure-chronic 19 HIV-AIDS 20 Hypertension 21 Hyponatremia 22 Mental Status- Altered 23 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. Metabolic/ acidosis/alkalosis 24 Mood Disorder 25 Myocardial Infarction 26 Non pressure ulcer 27 Malnutrition 28 Pneumonia- Aspiration 29 Pneumonia-Specificity 30 Pressure Ulcer 31 Pulmonary embolism 32 Renal Failure—acute 33 Renal failure-chronic 34 Respiratory- COPD 35 Respiratory- Emphysema 36 Respiratory failure 37 Respiratory failure post op 38 Sepsis 39 Shock 40 Substance abuse 41 Urosepsis 42 UTI 43 Hospital specific Documentation Specialists contact info 44-51 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 4 ©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: 5 ©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 6 ©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 7 ©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: _____) 8 ©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 9 ©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________ 10 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. 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 11 ICD10 Documentation Needed ©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_________ 12 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. ICD10 documentation specificity needed ICD9 Documentation Cor Pulmonale [ ] Acute Cor Pulmonale [ ] Chronic Cor Pulmonale [ ] Pulmonary Hypertension [ ] 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 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: ___________________ 14 ©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 15 ©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 16 ©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 17 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. 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 18 ©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 19 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. Etiologies: [ ] Hypertension [ ] Valvular disease [ ] Rheumatic heart disease 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 20 ©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 21 ©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 22 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. 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 23 ©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 24 ©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 25 ©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) 26 ©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 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 27 ©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) _______________________________ 28 ICD10 Documentation Needed ©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 29 ©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 30 ©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) 31 ©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 32 ©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 ________ 33 ©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 34 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 COPD Identify Acuity [ ] Acute exacerbation of COPD [ ] Acute exacerbation of Asthma [ ] COPD – Chronic and stable 35 ©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 36 ©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 37 ©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 38 ©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.) _______________________ 39 ©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) 40 ©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 41 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. [ ] Hallucinations [ ] 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) 42 ©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 43 ©2015 Conifer Health Solutions, LLC. All Rights Reserved. [ 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 44 ©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 45 ©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 46 ©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 47 ©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 48 ©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 49 ©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 50 ©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 51 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
