Karen Brown RHIT, CCSKaren Brown RHIT, CCS

Clinical Documentation SpecialistClinical Documentation Specialist

Date: October 3, 2014Date: October 3, 2014

1. Team lead training2. Coder education3. Time study- 33 minutes per chart (average per

chart 18 mins.)4. Test claim submission- (Variance in payment)

ICD-10 Past

1. Coder retention 2. Coder engagement 3. Dual coding 4. Internal review

ICD-10Present

1. ICD-10 training 2. Physician education 3. Query revision 4. Surgery review

Clinical DocumentationPast/Present

Clinical Documentation

Respiratory Failure

Acuity Associated symptom/s(hypoxia, hypercapnia)

Acute respiratory failure with hypoxia – J9601 Acute respiratory failure with hypercapnia –

J9602

Clinical DocumentationDiseases of the Respiratory Systems

Asthma

Severity (mild, mild intermittent, moderate, severe)

Relationship to other diseases (copd)

Diseases of the Respiratory System

Congestive heart failure

Type Acuity Cause

Clinical DocumentationDiseases of the Circulatory System

Myocardial Infarction

Type (nstemi, stemi, transmural) Site Encounter (initial, subsequent)

Diseases of the Circulatory System

Fractures

Type (comminuted, transverse) Cause (traumatic, non traumatic) Laterality Alignment (displaced, non displaced) Encounter( initial, subsequent, sequela)

Injury and Poisoning

Wounds

Type (postoperative, ulcer, laceration) Cause (diabetes, venous stasis ulcer)

Injury and Poisoning

Questions

Official Coding Guidelines for ICD-10 Journal of Ahima, July 2014 Justcoding.com

References