General Surgery - tfhd.com

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General Surgery

INSTEAD OF PLEASE CONSIDER

Low or No Severity Diagnosis—NO

High Severity Diagnosis---YES

ICD 10 Themes: e.g. Acute on Chronic Systolic Heart Failure

Acuity/Severity/Type/Staging

Acute/Chronic/Acute on Chronic

Mild, Moderate, Severe

Systolic, Diastolic, Combined

Stage I, II, III, IV

e.g. Malignant neoplasm of lower lobe right bronchus

Anatomy/Site Specificity

Location of tumor

Bone/Joint/Muscle involved

e.g. Decubitus Ulcer, Stage 3, Right Buttocks, Present on Admission

Laterality

Right/Left/Bilateral/Overlapping (see Neoplasm re overlaps two or more contiguous (next to each other) sites)

e.g. Hypertensive heart disease with chronic systolic heart failure

Manifestations – LINK IT!

Associated or Related Conditions

‘With’/‘Secondary’ to/’Due to’

‘Evidence of’ and causative organism

Use ‘no organism isolated’, instead of ‘negative culture’

e.g. Likely Sepsis secondary to UTI; Evidence of Bacterial Pneumonia (‘Evidence of’ in outpt setting can be captured as a diagnosis)

Etiology – ‘DUE TO’ WhAt?

‘LIKELY’ suspects….Who dun it?

Possible, Probable, Suspected (Inpt Only)

Evidence of, As Evidenced by (Outpt Setting and Inpt Setting)

e.g. Drug Poisoning/Adverse Effect Episode of Care/Incidence of Encounter (Trauma/Fractures/Medication.Chemical Event(Drug Poisoning))

Initial/Subsequent/Sequela

Intestinal or Peritoneal Adhesions With Obstruction/Without Obstruction

Intestinal Obstruction Type/Etiology: Paralytic ileus, Intussusceptions, Volvulus, Gallstone ileus impaction, Adhesions (other).

Cholecystitis with or without Cholelithiasis Acuity: Acute/Chronic/Acute on Chronic

Anatomical Site: Gallbladder/Bile Duct/Gallbladder & Bile Duct

With Obstruction/Without Obstruction

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Diverticulitis Anatomical Site: Small, Large or Both Intestines, e.g. sigmoid colon

With or Without Bleeding

With or Without Hemorrhage

With or Without Perforation/Abscess

Appendicitis Acuity: Acute/Chronic/Acute on Chronic/Recurrent

With or Without Rupture

If rupture: With Localized or Generalized Peritonitis

With or Without Perforation

With or Without (Peritoneal) Abscess

Traumatic Pneumothorax/Hemothorax Type: Traumatic, Traumatic Hemothorax, Traumatic Hemopneumothorax, Other (Specify)

With or Without Open wound into Thorax; Open; Closed

Encounter: Initial/Subsequent/Sequela

Neoplasm of Breast Type: Malignant (Primary; Secondary/Metastatic); Benign; In-Situ; Uncertain Behavior (include cell type)

(Uncertain behavior is a specific pathologic diagnosis indicating behavior that cannot be predicted, as opposed to a diagnosis of unknown pathology)

Morphology: Adenocarcinoma; Sarcoma; Lymphoma etc

Note: A primary malignant neoplasm that overlaps two or more contiguous (next to each other) sites should be classified 'overlapping lesion', unless the combination is specifically indexed elsewhere. For multiple neoplasms of the same site that are not contiguous, such as tumors in different quadrants of the same breast, codes for each site should be assigned.

Behavior: Primary or Secondary Site; Designate if Overlapping

For Secondary Site…document if primary site still exists

Gender: Male or Female

Laterality: Right; Left; Bilateral

Anatomical Site: Breast: Upper-Outer; Upper-Inner; Lower Outer; Lower-Inner; Midline; Central; Nipple; Areola; Axillary tail etc

Neoplasm of Colon Type: Malignant; Benign; In-Situ; Metastatic; Distant Metastatic Staging; With invasion or adherence to (other organs/submucosa/muscularis propria/muscularis propria into pericolorectal tissues); Uncertain Behavior (include cell type)

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(Uncertain behavior is a specific pathologic diagnosis indicating behavior that cannot be predicted, as opposed to a diagnosis of unknown pathology)

Morphology: Adenocarcinoma; Sarcoma; Lymphoma; With or Without BRCA Gene Mutation, etc

Note: A primary malignant neoplasm that overlaps two or more contiguous (next to each other) sites should be classified 'overlapping lesion', unless the combination is specifically indexed elsewhere. For multiple neoplasms of the same site that are not contiguous, such as tumors in different quadrants of the same breast, codes for each site should be assigned.

Behavior: Primary or Secondary Site; Designate if Overlapping For Secondary Site…document if primary site still exists

Laterality: Right; Left; Bilateral

Anatomical Site: Ascending; Descending; Sigmoid, Transverse; Cecum; Hepatic Flexure; Splenic Flexure; With Rectum; Regional Lymph Node involvement; etc

Spleen Laceration Anatomical Site: Extending into Parenchyma Cavity

With or Without Open Wound into Cavity

Severity: Major (greater than 3 cm); Moderate (1 to 3 cm); Superficial (less than 1 cm)


Hemorrhage/Infection Complicating Procedure Anatomical Site: i.e. seroma


Volvulus Anatomical Site: Intestinal; Ileal; Jejunal; Ascending Colon; Descending Colon etc

With or Without Perforation

Abscess Anatomical Site: Abdominal/Lung/Wound/Teeth/Extremity, etc

Laterality: Right/Left/Bilateral

Manifestations: i.e. Febrile Neutrophilic Dermatosis/Lymphangitis

Causative Agent: Viral or Bacterial

Causative Organism (if known)

Episode of Care: Initial/Subsequent/Sequela (if ‘Wound’ related)

Ileus Type: Paralytic; Gallstone; Mechanical; Spastic; Obstructive; Post-operative

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Traumatic Fractures (Fracture Clavicle; Tib/Fib, Femur, Hip)

Location: Specific Part of Body - Name of specific bone and specific site on bone

Laterality

LEO C. FAUR

(acronym to remember elements of fracture documentation)

Zupko and Associates

Episode of Care/Encounter:

Initial (receiving active treatment);

Subsequent (encounters AFTER the patient has

received active treatment of the condition and is

receiving routine care):

o Routine Healing or Delayed Healing

o Non-Union or Mal-union:

If non union: State if delayed Tx,

(it’s Initial Encounter, otherwise

it’s ‘Subsequent’)

Sequela (Use for complications or conditions

that arise as a direct result of a condition…no

time limit….i.e. Neuropathy of lower leg, ankle

and foot due to previous crush injury)

Open or Closed

Classifications: Open use Gustilo Classification: Type I, II, IIIA, IIIB, or IIIC (used for soft tissue classification); Salter; Physeal etc

Fracture Pattern/Type/Orientation, i.e.:

Greenstick Comminuted Torus

Spiral Segmental

Transverse Avulsed

Oblique Torus

Alignment: Displaced or Nondisplaced

Underlying Bone Diseases: i.e. Fragility (Pathologic), Stress, Traumatic in healthy etc

Results: Routine or Delayed Healing; Non union or Malunion

Complications of Surgery Affected Body System

Specific Condition

Timeframe: Intra operatively or Post operatively

(Punctures or lacerations that are unavoidable or inherent to the procedure are not complications. When NOT a complication…include the medical decision making and characterize the event as ‘intentional’, ‘unavoidable’, or ‘inherent’ to the

Link Complication to Diagnosis: ‘due to’/’secondary to’ etc… There is no timeframe/deadline for a Postoperative Complication (current condition due to previous

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procedure) surgery or procedure)

NOT Complications Document: Inherent, Expected, Intended

Avoid ‘Accidental/Complication/Unavoidable/Slip/ Iatrogenic/Unintended’ etc when it is not a complication. Avoid using ‘Post operative’ when not a complication; if used, include that it was ‘intended, expected, inherent’ etc.

Additional Terms that suggest non-accidental: to facilitate; necessary; required; intentional; integral; routinely expected

Procedure Coding System (PCS) – New with ICD 10

Pre-operative/Post Operative Diagnosis State difference b/w pre and post dx, as applicable

Link ‘findings’ with post operative diagnosis

Procedure Performed Be Explicit, including unplanned

Post op drains/tubes – Specify type of drain/tube

Be specific re ‘intent’ of surgery i.e. Excision/Biopsy etc

Types of Anesthesia/Estimated Blood Loss (EBL)/Transfusions

-Site infused (Central/Peripheral) - Type & Volume of Fluid (Fresh/Frozen/Autologous)

Procedure – Coder needs ALL elements addressed in order to be able to assign a code…..physician can use their own language for coder to translate, yet all information needs to be available. Coders must have a clear understanding of the ‘intent’ of the procedure..it will help the coder properly assign the appropriate code.

-Intent of the Procedure - Excision (partial removal i.e. biopsy)/Resection (total removal)/Drain fluid/Inspect i.e. endoscopy etc. -Approach—Specify technique used to reach the site i.e. open, percutaneous, use of scopes etc -Prose for steps and technique, not the name of procedure -Laterality of incision/Relative Location -Anatomical site – Be specific re site/Body Cavity (instead of quadrants)/How much of body part removed (all, partial, or measurements) - Devices Used Intraoperatively – material or appliance that remains in the body after the procedure is completed. i.e. Biological or synthetic material (i.e. joint prosthesis, intrauterine device; Therapeutic material (i.e. radioactive implant); Mechanical or electronic appliances ( i.e. orthopedic pin, pacemaker) etc. -Intraoperative Grafting – source and destination site -Modality of Guidance

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-Specimens – specify if sent to pathology are intended to diagnose and help treatment decisions following the procedure.

-Medications applied at Surgical Site

-Closure – type/area -Complications

Procedure Documentation:

Lymph Node Removal Differentiate between removal of: -One or more (portion) lymph nodes Versus -Removal of an entire chain of lymph nodes

Anatomical Site: Head; Right/Left Neck; Right/Left Axillary; Mesenteric; Right/Left inguinal etc

Lysis of Adhesions (The body part value coded, is the body part being freed, not the tissue being manipulated or cut to free the body part.)

Anatomical Site of each organ or body part RELEASED/FREED, i.e. -Greater Omentum -Lesser Omentum -Mesentery

Etiology: i.e. previous surgery; chronic infection/inflammation; preventing access to surgical site

(Adhesions that exist without being organized or without causing any symptoms or without increasing the difficulty of performing the operative procedure will not be coded separately.)

Amount: Extensive; Numerous etc

Timeframe: i.e. Extensive lysis; Tedious lysis; long time to lyse

Excisional Debridement

‘Non-excisional’ Debridement - Minor removal of loose fragments with scissors or using a sharp instrument to scrape away tissue (typically involves mechanical removal of tissue with brushing, scrubbing, washing etc). Debridement is usually only to level of subcutaneous tissue.

Excisional Debridement - Involves cutting outside or beyond the wound margin. A scalpel is used to remove devitalized tissue.

I & D, Debridement, Sharp Debridement If it is actually an ‘excisional debridement’ designate the procedure as such, instead of stating I & D.

‘EXCISIONAL’ Debridement – Documentation to include:

‘Technique’ used (e.g., excisional, excised,

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cutting etc)

‘Instrument’ used (e.g. scalpel, curette)

Nature of ‘tissue’ removed (e.g. necrotic, devitalized tissue, nonviable tissue)

The ‘appearance’ and ‘size’ of the wound (e.g. down to flesh, bleeding tissue, 7cm x 10 cm etc)

‘Depth’ of debridement (e.g. skin, subcutaneous, fascia, muscle, bone, etc.)

Secondary Conditions:

Incidental to Pregnant State vs. Impacting Pregnancy

State “Does not affect or complicate the pregnancy” if incidental, otherwise will code as ‘impacting the pregnancy’

e.g. Pregnant patient with burn of hand, “Burn of hand does not affect or complicate the pregnancy”

Anemia Acuity: Acute/Chronic

(Acute Blood Loss Anemia does not reflect a complication of surgery, unless surgeon states it’s a complication and there is a cause and effect relationship; May state ‘expected’/’inherent’; Documentation of ‘Post-op Anemia’ is not enough, instead ‘Post Operative Anemia due to Acute Blood Loss’)

Etiology: Blood Loss; Iron Deficiency; Chemotherapy; Neoplastic; Aplastic, etc

Nutritional Anemia Type: i.e. if nutritional due to iron deficiency: Sideropenic iron deficiency anemia; Iron deficiency due to inadequate dietary iron intake

Vitamin B12 type i.e. Due to intrinsic factor deficiency; Vitamin B12 malabsorption

Folate Deficiency type: i.e. Due to diet; Drug induced

Other Nutritional Types: i.e. Protein deficiency

Anemia in Chronic Disease Link to Chronic Disease i.e. -Anemia due to chronic kidney disease -Anemia due to colon cancer

Neutropenia Type: Agranulocytosis/Other Drug Induced/Congenital/Cyclic

Etiology: Cancer Chemotherapy/Infection etc.

If Drug-induced: - Specify Drug

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- Purpose of drug’s use (e.g. chemotherapy) - Specify the malignancy (e.g. Cytoxan for primary

malignancy upper-inner quadrant of left breast

Associated Conditions (e.g. infection)

Adverse Effect (e.g. fever or mucositis)

Thrombocytopenia Classification: -Idiopathic -Primary -Secondary -Congenital or Hereditary -Heparin Induced

Secondary Thrombocytopenia: - Underlying Condition (e.g. alcohol induced)

Specify Hemorrhagic Conditions (e.g. qualitative platelet defects)

Pancytopenia Definition - Anemia (e.g. Hct < 32%); and, - Thrombocytopenia (e.g. PPC < 150K); and, - Neutropenia (e.g. ANC < 1,500)

–

Physician must describe underlying cause and what individual component has been treated

- e.g. Platelets for thrombocytopenia - PRBC transfusion for acute blood loss anemia

Etiology - Malignancy (Specify Malignancy) - Drug induced (Specify specific drug) - ‘Pancytopenia due to antineoplastic

chemotherapy’ or - ‘Pancytopenia secondary to Cisplatin and

disease’ , Or - ‘Pancytopenia due to HIV disease.’

Urinary Tract Infection Acuity: Acute or Chronic

e.g. ‘Chronic Cystitis with hematuria’; ‘Acute Urethritis due to E.Coli’; ‘Acute on Chronic Pyelonephritis due to foley catheter with Candida’

Specific Site: Bladder (Cystitis)/Urethra (Urethritis)/Kidney (Pyelonephritis)

Manifestations: Hematuria etc.

Causative Organism i.e. E Coli or Candida

IF related to a device i.e. foley catheter, state ‘due to’ or ‘secondary to’

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Sepsis Type: Sepsis/Severe Sepsis/Septic Shock

(fyi: negative or inconclusive blood cultures do not preclude a diagnosis of sepsis in patients with clinical evidence of the condition)


(fyi: Bacteremia is a non specific diagnosis and indicates the presence of bacteria in the blood, but does not indicate the bacteria are pathological or has any resulting systemic illness needing treatment.)

Underlying Systemic Infection (the source of infection) i.e. Sepsis due to UTI

(fyi: Urosepsis is non descriptive term and is NOT synonymous with sepsis and there is no default for coders…please .use ‘Sepsis due to UTI’ instead) (fyi: Sepsis Syndrome is a non specific term..avoid using it)

Any Associated Organ Dysfunction i.e. Acute Renal Failure; Acute Respiratory Failure; Encephalopathy

SIRS Infectious or Non-infectious (If ‘non-infectious’ specify what ‘due to’, i.e. ‘SIRS due to Burn’)

Always document the Etiology!! With severe Sepsis or Without Sepsis

With or Without Organ Dysfunction

(Does NOT code to Sepsis, unless stated ‘with sepsis’)

Defaults to the underlying infectious process i.e. Pneumonia

Dehydration Manifestations: With Hyponatremia or Hypernatremia

Etiology: Decreased Intake i.e. stomatitis; Increased output i.e. diarrhea; Increased Insensible losses i.e. fever

Atrial Fibrillation Type: Paroxysmal/Persistent/Chronic

Pneumonia Type: Healthcare Associated/Aspiration/Ventilator Associated/Radiation Induced

CAUTION: CAP-Community Acquired PNA- defaults to a ‘simple pna’ with low severity; if documented, please also include if it is Viral or Bacterial (and other items listed from list on right, as applicable) to capture the true severity.



Associated Illnesses: influenza/ lung abscess/Sepsis

Common Secondary Conditions: Acute Respiratory Failure; Exacerbation of COPD, etc.

Clinically significant diagnostic results from Lab and Radiology in the medical record. i.e. if elevated white count; infiltrate on CXR

History of Tobacco Use, Present or Past

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COPD Acute Exacerbation or Decompensated

(Chronic RF is very common in pt with severe COPD) CAUTION: ‘Respiratory Distress’ and ‘Respiratory Insufficiency’ are vague and symptomatic of underlying condition – is the intended diagnosis Respiratory Failure OR what is other underlying condition?

If with acute lower respiratory infection, as applicable (also include causative organism, if known)

IF Oxygen Dependent

Common Secondary Conditions: Acute, Chronic, Acute on Chronic Respiratory Failure; Pneumonia, etc.

History of Tobacco Use, Present or Past

Respiratory Failure Acuity: Acute/Chronic/Acute on Chronic

(Chronic RF is very common in pt with severe COPD) CAUTION: ‘Respiratory Distress’ and ‘Respiratory Insufficiency’ are vague and symptomatic of underlying condition – is the intended diagnosis Respiratory Failure OR what is other underlying condition?

Manifestation: With Hypoxia or With Hypercapnia, or both

Etiology: if known (i.e. due to COPD Exacerbation; Pneumonia; Surgery, Trauma, etc)

Asthma Severity: Mild/Moderate/ Severe

Type: Intermittent or Persistent

With or Without Exacerbation

With or Without Status Asthmaticus

Pulmonary Embolism Severity: Acute/Chronic (still present) vs. Healed (Old)

Type: Saddle/Septic

Manifestations: With or Without Acute Cor Pulmonale

Pleural Effusion Type: Malignant (Specify site and morphology of tumor if possible); Influenzal; Tuberculosis; In heart failure

Diabetes Type: Type 1 or Type 2 ; Drug or Chemical Induced; or Gestational

Terms i.e. ‘uncontrolled’ or ‘inadequately controlled’ code to ‘hyperglycemia’…even if recent ‘hypoglycemia’…..specifically use Hypoglycemia or Hyperglycemia instead. Or if used, stipulate if not hyperglycemic.

Control Status (Insulin):

With: Hypoglycemia/Hyperglycemia

Insulin Use

Associated Diagnosis/Conditions: i.e. ulcers

Manifestations or Secondary related problems

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(document LINK to Diabetes): i.e. neuropathy; nephropathy; retinopathy; ketoacidosis

Heart Failure Severity: Acute/Chronic/Acute on Chronic

Type: Systolic/Diastolic/Combined Systolic and Diastolic/Congestive

Etiology, if known, i.e. due to ischemic or primary cardiomyopathy

Associated Conditions: i.e. Hypertension/Pericarditis

Alcohol Dependence with or without Alcohol Withdrawal

Frequency of Usage: Use/Abuse/Dependence/In Remission

Type of Dependence: Uncomplicated; In Remission, Current Intoxication

Manifestations: Delirium, Delusions, Hallucinations, Anxiety, etc;

Specify intoxication/withdrawal as: Uncomplicated or With Delirium

Atrial Flutter Type: Typical (Type 1) or Atypical (Type 2)

Obesity BMI 19 or less = Indicates Malnutrition

BMI 25 – 29.9 = Overweight

(BMI can be taken from Nursing Documentation; MD needs to document the diagnosis and etiology/manifestation correlating to BMI)

BMI 30.0 – 39.9 = Obesity

BMI ≥ 40 = Morbid Obesity (state Etiology: Excess Calories ; Other and Manifestation: Alveolar Hypoventilation, as applicable)

Etiology: Excess Calories (for Morbid Obesity); Drug Induced; Endocrine; Familial; Constitutional; etc

Manifestation: Alveolar Hypoventilation (for Morbid Obesity)

Malnutrition BMI 19 or less = Indicates Malnutrition

Acuity: Acute (< 3 mo); Chronic (>3 mo)

Severity: Mild/Moderate/Severe

(BMI can be taken from Nursing Documentation; MD needs to document the diagnosis and etiology/manifestation correlating to BMI)

Type: Protein Calorie; Protein Energy

Etiology: Renal Disease; Pregnancy Related; Diabetes; Following Gastrointestinal Surgery, etc

Utilize Dietician’s Assessment to assist you with diagnosis. To review MNT Nutrition Evaluation in CPSI, Go to <chartlink> <C/H Section tab> <MNT

Manifestations: Insufficient Energy Intake; Unintentional Weight Loss; Significant Edema or Ascites; Diminished Functional Capacity; Cachexia; Dehydration;

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Nutrition Evaluation, page 1 and 2.

Kidney Failure Note: Re Chronic: ‘insufficiency’ and no ‘stage’ codes to ‘unspecified’ code and does not reflect the severity of the patient

Acuity: Acute/Chronic/Acute on Chronic If Chronic:

Stage 1 (GFR ≥ 90) – Kidney Damage with normal or ↑ GFR

Stage 2 (mild) (GFR 60 – 90) + Kidney Damage

Stage 3 (moderate) (GFR 30-59)

Stage 4 (severe) (GFR 15-29)

Stage 5 (GFR ‹ 15)

End Stage Renal Disease Above per KDIGO 2012 Clinical Practice Guidelines

Re Acute: ‘insufficiency’ and ‘kidney disease’ do not report ‘failure, acute renal’

If Acute: due to traumatic injury or non trauma event

Manifestations: With-Acute Tubular Necrosis (ATN)/Acute Cortical Necrosis/Medullary Necrosis

Etiology: Pre-renal AKI/ ATN/Post-Renal Obstructive AKI/Diabetic/Hypertensive

Hypotension Etiology: Postural; Orthostatic (chronic); Neurogenic (Orthostatic); Postoperative; Drug-induced; Cardiogenic; Idiopathic; etc

Atelectasis Etiology: i.e. Morbid Obesity/Pleural Effusion/Malignancy etc

Associated Conditions: i.e. Apnea

Present on Admission, if applicable

Gastrointestinal Bleed Acuity: Acute or Chronic

Manifestations: Hemorrhage; Perforation; Obstruction

Etiology: ETOH; Ulcer, Drug i.e. NSAIDS, Esophageal Varices, etc

Anatomical Site: Esophagus; Intestinal; Gastric, etc

Non Pressure Ulcer Wound Acuity: Chronic

Laterality

Severity/Depth of Tissue Involved: Skin Breakdown; Fat Layer Exposed; Muscle Necrosis; Bone Necrosis; Unspecified Severity

Etiology: Diabetes; Infection (specify); Other (specify)


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Pressure Ulcer Anatomical Site

Laterality

Stage: 1, 2, 3, 4 (Staging can be taken from wound care RN )

Associated Illnesses: i.e. Diabetes

Gangrene, if applicable


Osteomyelitis Acuity: Acute/Subacute/Chronic

Anatomic Site: Body part (i.e. thigh); Specific bone (i.e. femur); Joint (i.e. shoulder)

Laterality: Right/Left/Bilateral



Etiology/’Due to’: i.e. Acute osteomyelitis, left humerus, ‘due to’ infect hip

Complications: Abscess/Amputation/Avascular necrosis/Gangrene/Meningitis etc.

Depression Acuity: Acute/Chronic/Recurrent/Single Episode

Severity: Mild/Moderate/Severe

Type: Anxious/Bipolar/Atypical/Post-Partum

CAUTION: ‘Unspecified Depression’ codes to MAJOR Depressive Disorder….is it actually a LESS severe disorder i.e. Adjustment Disorder; Anxiety Depression..please be specific

Etiology: Dementia; Head Injury; Multiple Sclerosis; Stroke; Pregnancy;

Manifestations: Anxiety/Suicidal Ideation/Somatization

Remission Status: Partial/Complete

Underdosing Intentional vs. Unintentional

Reason for Underdosing i.e. financial hardship or Age related dementia

Episode of Care: Initial/Subsequent/Sequela

Tobacco Use Use/Dependence/Contact with Second Hand Exposure (Acute or Chronic)

Current/No longer Use Tobacco/Never

Type of Tobacco Product: Cigarette/Chewing Tobacco/Nicotine

If Dependence: Uncomplicated/In remission/With withdrawal/With other Nicotine induced disorder

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ADDITIONAL DOCUMENTATION TIPS

Radiology Tests Ordered

‘Better info given →Better outcome on Report’

Reason for Exam –Be Specific as to what looking for - Anatomical Site Specificity/Where specifically the

problem is…i.e. ‘tender over T9’ instead of ‘back pain’

- Indication for Xray, i.e. Lt Pleuritic Chest Pain; Orthopnea; SOB at rest

- Why doing exam/What are you looking for? i.e. re Cancer…’Looking for Metastasis

- AVOID: R/O, Pre –Op, Vague terms i.e. cough, dizzy. Instead state, fever, shakes, chills so Radiologist can help you capture Pneumonia if present.

- Example of Reason for Exam: ‘Pt fell of ladder, pain medial aspect Lt ankle x 3 days’ instead of ‘ankle pain’; OR, ‘Pt with fever, chills, productive cough green sputum x 2 days’ instead of, ‘cough’.

Chronic Conditions/Secondary Diagnosis Capture the Severity!!!

Avoid stating ‘History of’ ……Instead document what you are doing for Chronic Conditions now! Examples of documentation showing link between the additional disease and this admission’s evaluation, treatment, or monitoring:

Hypertensive Heart Disease and Chronic Kidney Disease (CKD), stage 3 (Strict I & O, Monitor BP)

Chronic Systolic Heart Failure (Echo, Lasix 40 mg)

Hypokalemia (K+ repleted)

Acute Blood Loss Anemia (2 U PRBC’s)

Indicate “Present on Admission” (POA) status, as applicable

A diagnosis without documentation of being present on admission could be inadvertently considered a hospital-acquired condition (HAC). Example: Pneumonia not definitively diagnosed until hospital day two but suspected, probable, or likely on admission should be noted as such. This allows coders to most accurately report the condition as being POA as opposed to hospital-acquired.

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AVOID Signs and Symptoms as Diagnosis Definitive diagnoses are preferred in the inpatient setting and support a higher evaluation and management (E/M) fee. In the inpatient setting, coders can capture ‘probable’, ‘likely’, ‘suspected’, or presumed diagnoses when patients present with the signs and symptoms of the diagnoses being ruled out…. as long as those diagnoses are restated in the discharge summary and have not been ruled out during the stay.

Discharge Summary Wrap it all up!!

For all ‘Rule Out’ situations: Rule it in!/ Rule it Out!/or state ‘Resolved’

Avoid Conflicting with previous documentation substantiated in the record……Caution: If primary physician subsequent dictation conflicts with previous ‘consult’ note, the primary physician’s diagnosis is taken.

INCLUDE: Reason for hospitalization: Chief Complaint; including description of the initial diagnostic evaluation Significant Findings: -Admitting Diagnosis - reason for hospitalization -Discharge Diagnosis - significant findings/diagnoses -As well as those conditions resolved during hospitalization -List all possible and probable diagnoses as well -Hospital Course (procedures performed and findings/surgical findings/test results/treatment rendered/consults) -Discharge Disposition – pt condition at discharge -Education -Follow up needed -Diet -Medications – discharge meds; changes; discontinued meds -Discharge Instructions (instructions to patient and family, including follow up)

References: 3M physician video; CMS Road to 10; Coding Guidelines; 3M Doc tips; AHIMA ACDIS ICD 10 Webinar 12.2014; ACDIS ICD 10 CDI Bootcamp 2014; ACDIS Annual Conference 2015; TFHS P & P.

Check out www.tfhd.com/icd10

http://www.tfhd.com/icd10

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General Surgery - tfhd.com