EMERGENCY MEDICINE and Other Common Documentation Tips ICD 10 Documentation Specificity Needed based on Conifer ICD 10 CDI Queries

EMERGENCY MEDICINE and Other Common Documentation TipsICD 10 Documentation Specificity Needed based on Conifer ICD 10 CDI Queries

2 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.

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.


Table of contents Anemia 5

Aplastic Anemia 6

Atrial Fib 7

Cardiac Arrest 8

Cellulitis 9

Cerebral Edema 10

Chest pain 11

Cirrhosis of Liver 12

Coma 13

Cor Pulmonale 14

Crohn’s Disease / Regional Enteritis 15

CVA 16

Debridement 17

Diabetes 18

Diverticulitis 19

Encephalopathy 20

Fracture-Bone 21

Gastrointestinal Ulcer- Upper 22

Headache/ Migraine 23

Heart failure- acute 23

Heart failure-chronic 24

Hepatitis 25

HIV-AIDS 26

Hypertension 27

Hyponatremia 28

Level of consciousness 29

Meningitis 30

Mental Status- Altered 31

Metabolic—acidosis/ alkalosis 32

Myocardial Infarction 33

Non pressure ulcer 34

Malnutrition 35

Open Fracture 36

Pancreatitis 37

Personal Injury 38

Pneumonia- Aspiration 39

Pneumonia-Specificity 40


Table of Contents

Pressure Ulcer 41

Pulmonary embolism 42

Renal Failure—acute 43

Respiratory-asthma 44

Respiratory- Bronchitis 45

Respiratory- COPD 46

Respiratory- Emphysema 47

Respiratory failure 48

Sepsis 49

Shock 50

Sickle Cell Disease 51

Substance abuse 52

Testicular Torsion 53

TIA 54

Urosepsis 55

UTI 56

Hospital specific

Documentation Specialists contact info 57-64


ICD10 documentation specificity needed

ICD9 Documentation

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:

ICD10 Documentation Needed

Same as in ICD 9



ICD9 Documentation

Aplastic Anemia


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



ICD9 Documentation

A fib


IDENTIFY TYPE

[ ] Paroxysmal Atrial Fibrillation

[ ] Persistent Atrial Fibrillation

[ ] Chronic Atrial Fibrillation (includes permanent Atrial Fibrillation)

[ ] Unspecified Atrial Fibrillation



ICD9 Documentation

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________



ICD9 Documentation

Cellulitis


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



ICD9 Documentation

Cerebral edema

[ ] Cerebral edema / Vasogenic edema

[ ] Compression of brain

[ ] Findings not significant

[ ] Radiologic finding only

[ ] Does not apply to this patient


Same as ICD 9



ICD9 Documentation

Chest Pain[ ] Costochronditis

[ ] Pleurisy

[ ] Pleuritic pain

[ ] Angina with known coronary artery disease

[ ] Angina: [ ] Stable [ ] Unstable

[ ] Psychogenic cardiovascular disorder

[ ] Chest wall pain

[ ] Cholelithiasis / Cholecystitis

[ ] GERD

[ ] Esophagitis



Same as ICD 9



ICD9 Documentation

Cirrhosis of Liver


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



ICD9 Documentation

Coma


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_________



ICD9 Documentation

Cor Pulmonale

[ ] Acute Cor Pulmonale

[ ] Chronic Cor Pulmonale

[ ] Pulmonary Hypertension



Same as ICD 9



ICD9 Documentation

Crohn’s Disease / Regional Enteritis


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)________



ICD9 Documentation

CVA


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 [ ] Left [ ] Unspecified[ ] Dysphagia



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


Same as ICD 9



ICD9 Documentation

Diabetes


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



ICD9 Documentation

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



ICD9 Documentation

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



ICD9 Documentation

Bone fracture


IDENTIFY Site, Laterality, Type, Cause and EncounterSite: ________ Laterality: [ ] Right [ ] Left

Type of fracture: Check all that apply

[ ] Traumatic fracture [ ] Pathologic fracture

[ ] Osteoporosis fracture---

[ ] Disuse [ ] Drug- induced

[ ] Postmenopausal

[ ] Idiopathic [ ] Post-surgical

malabsorption [ ] Other (specify)___________

[ ] Stress or fatigue fracture

[ ] Neoplastic fracture

Other type of fracture: Check all that apply

[ ] Non-displaced [ ] Displaced

[ ] Open (Gustilo) [ ] Closed (greenstick, spiral)

[ ]Salter-Harris—specify type_________

External cause of fracture (fall, skiing) _________________________

Encounter type:

[ ] Initial encounter

[ ] Subsequent encounter---

[ ] Routine healing [ ] Delayed healing [ ] Nonunion

[ ] Malunion [ ] Sequela



ICD9 Documentation

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: _________________



ICD9 Documentation

Migraine


IDENTIFY SPECIFICITY

[ ] With Aura [ ] With Refractory Migraine[ ] Intractable[ ] Persistent[ ] Other __________________

[ ] With CVA [ ] Hemiplegic [ ] Intractable[ ] With Status Migrainosus[ ] Menstrual[ ] Cyclical vomiting[ ] Periodic Headache Syndrome[ ] Ophthalmologic

Headache IDENTIFY SPECIFICITY

[ ] Tension[ ] Primary thunderclap[ ] Associated with sex, cough, exertion[ ] Cluster[ ] Post-traumatic[ ] New daily persistent[ ] Vascular[ ] Drug- induced[ ] Other_________________________



ICD9 Documentation

ACUTE HEART FAILURE

[ ] Acute Systolic Heart Failure

[ ] Acute Diastolic Heart Failure

[ ] Acute Systolic and Diastolic Heart Failure

ACUTE ON CHRONIC HEART FAILURE

[ ] Acute On Chronic Systolic Heart Failure

[ ] Acute On Chronic Diastolic Heart Failure

[ ] Acute On Chronic Systolic and Diastolic Heart Failure


SAME as ICD 9 with the addition

OTHER ETIOLOGIES OF HEART FAILURE

[ ] Heart Failure Due To Valvular Disease

[ ] Right Heart Failure / Acute Cor Pulmonale

[ ] Right Heart Failure / Chronic Cor Pulmonale

[ ] Rheumatic Heart Disease

[ ] Endocarditis (valvular)

[ ] Myocarditis

[ ] Pericarditis



ICD9 Documentation

Hepatitis


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



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


Similar to ICD 9



ICD9 Documentation

Hypertension

[ ] Malignant Hypertension

[ ] Accelerated Hypertension

[ ] Benign Hypertension

[ ] Unspecified Hypertension


Same as ICD 9



ICD9 Documentation

Hyponatremia


Identify specificity

[ ] Hyponatremia, unknown cause

[ ] Hyponatremia due to Sodium Deficiency

[ ] Hyponatremia due to SIADH (Syndrome of Inappropriate Secretion of Antidiuretic Hormone)

[ ] Insignificant lab value



ICD9 Documentation

Level of Consciousness[ ] Coma / Comatose

[ ] Encephalopathy, type: ____________________________

[ ] Persistent vegetative state

[ ] Stupor


Same as ICD 9



ICD9 Documentation

Meningitis


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 [ ] No

[ ] Unable to determine



ICD9 Documentation

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



ICD9 Documentation

Acidosis/Alkalosis


Identify Type of Acidosis or Alkalosis

[ ] Acidosis:

[ ] Metabolic [ ] Respiratory

[ ] Lactic [ ] Renal

[ ] Alkalosis:

[ ] Metabolic [ ] Respiratory



ICD9 Documentation

Myocardial Infarction

ICD10 Documentation NeededIdentify Type, Age of Infarction, Encounter,

Site and ArteryMI 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


ENCOUNTER:

[ ] Initial [ ] Subsequent

If STEMI, SITE:

[ ] Anterior [ ] Apical

[ ] Lateral [ ] Inferior

[ ] Posterior [ ] Q Wave [ ] Septal

[ ] Unspecified [ ] Other _____________________

SPECIFIC ARTERY (Based on site)

[ ] Left Main Coronary [ ] Diagonal

[ ] Left Anterior Descending [ ] Oblique Marginal

[ ] Right Coronary Artery [ ] Other ___________________

[ ] Left Circumflex [ ] Unspecified



ICD9 Documentation

Non Pressure Ulcer


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 [ ] No



ICD9 Documentation

Malnutrition

[ ] Under-nutrition / Malnutrition:

[ ] Mild [ ] Moderate

[ ] Severe [ ] Unspecified

[ ] Protein Calorie Malnutrition:

[ ] Mild [ ] Moderate [ ] Severe

[ ] Unspecified

[ ] Marasmus

[ ] Nutritional Edema

[ ] Other Malnutrition (please specify) _______________________________


Same as ICD 9



ICD9 Documentation

Open Fraction


Specificity for open fractures of the forearm, femur, and lower leg require documentation to Specify Gustilo Type I through Type IIIC.

OPEN Fracture(s): ___________________________

Site: __Laterality: [ ] Right [ ] Left Gustilo type:___

GUSTILO CLASSIFICATION

Type I: Wound < 1cm, clean, generally caused by a fracture fragment that pierces the skin

Type II: Wound > 1cm, not contaminated, without mod soft tissue injury or defect.

Type III: Wound > 1 cm. with significant soft tissue disruption, severely unstable fracture with varying degrees of fragmentation

Type IIIA: Wound < 10 cm, crush injury and contamination, sufficient soft tissue to cover the bone without the need for local or distant flap coverage

Type IIIB: Disruption of the soft tissue is extensive, such that local or distant flap coverage is necessary to cover the bone. The wound maybe contaminated and serial irrigation and debridement procedures are necessary to ensure a clean surgical wound >10 cm, crushed tissue

Type IIIC: Any open Fracture associated with an arterial injury that requires repair.



ICD9 Documentation

Pancreatitis


Identify acuity, cause, gangrenous and alcohol induced

[ ] Acute:

[ ] Gallstone [ ] Biliary [ ] Idiopathic

[ ] Other

[ ] Chronic:

[ ] Cystic [ ] Infectious [ ] Interstitial

[ ] Recurrent

[ ] Gangrenous

[ ] Alcohol-induced: [ ] Abuse [ ] Dependence



ICD9 Documentation

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.) ______________________________



ICD9 Documentation

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



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


Similar to ICD 9



ICD9 Documentation

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)



ICD9 Documentation

Pulmonary Embolism


Identify acuity, type and if associated acute cor pulmonale

Acuity:


Type:

[ ] Saddle [ ] Septic [ ] Other___

[ ] Pulmonary Embolism with associated Acute Cor Pulmonale



ICD9 Documentation

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 ________


Same as ICD 9



ICD9 Documentation

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



ICD9 Documentation

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____________



ICD9 Documentation

COPD


Identify Acuity

[ ] Acute exacerbation of COPD

[ ] Acute exacerbation of Asthma

[ ] COPD – Chronic and stable



ICD9 Documentation

Emphysema


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



ICD9 Documentation

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



ICD9 Documentation

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 [ ] without organ dysfunction

[ ] 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 [ ] without organ dysfunction

[ ] Septic shock

[ ] Sepsis related to a device (i.e. port, IV line, pacer / ICD leads, Foley, etc.) _______________________



ICD9 Documentation

SHOCK

[ ] Hypovolemic shock

[ ] Hemorrhagic shock

[ ] Cardiogenic shock

[ ] Septic shock (Circulatory failure associated with severe sepsis, represents organ failure)


Same as ICD 9



ICD9 Documentation

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



ICD9 Documentation

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

Complications:

[ ] Intoxication [ ] Withdrawal [ ] In remission [ ] Uncomplicated

[ ] Other complication: ____________ [ ] Unspecified complication

Substance-Induced Disorders:

[ ] Psychosis: [ ] Delirium [ ] Delusions [ ] Hallucinations

[ ] Perceptual Disturbances: [ ] Anxiety Disorder [ ] Sexual Dysfunction

[ ] Sleep Disorder

[ ] Unspecified substance-induced disorder

[ ] Other substance-induced disorder: ________________________________

[ ] No substance-induced disorder



ICD9 Documentation

Testicular Torsion


Identify Extra or Intra vaginal and site

[ ] Extravaginal:

[ ] Epididymis

[ ] Spermatic Cord

[ ] Testicle/Testis

[ ] Intravaginal:

[ ] Epididymis

[ ] Spermatic Cord

[ ] Testicle/Testis



ICD9 Documentation

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)



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)


Same as ICD 9



ICD9 Documentation

UTI


Identify acuity, site and due to

Acuity:


[ ] Acute on Chronic

Site: [ ] Kidney [ ] Ureter

[ ] Bladder [ ] Urethra [ ] Other site __________


[ ] UTI due to or related to:

[ ] Indwelling catheter

[ ] Self-catheterization

[ ] Neurogenic bladder

[ ] Suprapubic catheter


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


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


Questions—contact your Clinical Documentation Specialists at your hospital


University of Louisville


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





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





St. Joe East

Clinical Documentation Specialists Kimberly Gilbert-Morrison—502-316-5220

Kelly Geers—502-750-2329





Flaget

Clinical Documentation Specialist Cheryl Mitchell—502-350-5247





St Joe London


Katrina Henson—606-330-6759

Sherry Mills—606-330-6000





St. Joe Mt. Sterling


Lori Barry—859-497-5458




Documents

EMERGENCY MEDICINE and Other Common Documentation Tips ICD 10 Documentation Specificity Needed based on Conifer ICD 10 CDI Queries