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PLASTIC SURGERY 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.
3 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
Table of contents Anemia 4
BMI – high 5
BMI –low 6
Cellulitis 7
Cleft Palate 8
Debridement 9
Dementia 10
Diabetes 11
Foot deformity 12
Fracture-bone 13
Neoplasm 14
Non pressure ulcer 15
Malnutrition 16
Open Fracture 17
Osteomyelitis 18
Pain 19
Personal Injury 20
Pneumonia-Specificity 21
Pressure Ulcer 22
Respiratory failure post op 23
• Sepsis 24
Shock 25
Urosepsis 26
UTI 27
Hospital specific
Documentation Specialists contact info 28-35
4 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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
5 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
BMI > 40 with associated diagnosis of:
[ ] Morbid (Severe) Obesity
[ ] Overweight
[ ] Obesity (unspecified)
ICD10 Documentation Needed
Morbidly Obese
[ ] Morbid (Severe) Obesity
[ ] Due to excess calories
[ ] Familial
[ ] Endocrine
[ ] with Alveolar Hypoventilation (Pickwickian syndrome)
[ ] Drug-induced (Name of drug: _____)
6 ©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
ICD10 Documentation Needed
Same as ICD 9
7 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Cellulitis
ICD10 Documentation Needed
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
8 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Cleft Palate
ICD10 Documentation Needed
Identify Type, Laterality and any associated diagnosis
[ ] Hard [ ] Medial [ ] Soft [ ] Uvula
[ ] Hard with Soft
[ ] Cleft Lip Involvement
[ ] Unilateral Cleft Lip
[ ] Bilateral Cleft Lip
[ ] Median Cleft Lip
[ ] Associated diagnosis/conditions (please specify): ___________________
9 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
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
ICD10 Documentation Needed
Same as ICD 9
10 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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: ___________________
11 ©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
12 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Foot Deformity
ICD10 Documentation Needed
IDENTIFY SPECIFICITY
(for any deformity marked below specify):
[ ] Congenital [ ] Acquired
[ ] Talipes equinovarus [ ] left [ ] right [ ] bilateral
[ ] Talipes calcaneovarus [ ] left [ ] right [ ] bilateral
[ ] Metatarsus varus [ ] left [ ] right [ ] bilateral
[ ] Talipes calcaneovalgus [ ] left [ ] right [ ] bilateral
[ ] Pes planus [ ] left [ ] right [ ] bilateral
[ ] Pes cavus [ ] left [ ] right [ ] bilateral
[ ] Vertical talus deformity [ ] left [ ] right [ ] bilateral
[ ] Other foot deformity (please specify): _________
[ ] Associated diagnosis/conditions (please specify): __
13 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Bone fracture
ICD10 Documentation Needed
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
14 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Neoplasm
ICD10 Documentation Needed
Identify Site, Laterality, Type, Malignancy and associated conditions
Site: Identify:_______________
Laterality: [ ] Right [ ] Left [ ] Bilateral
Type: [ ] Primary [ ] Secondary
[ ] 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 ____________________________________
15 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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 [ ] No
16 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Malnutrition
[ ] Under-nutrition / Malnutrition:
[ ] Mild [ ] Moderate
[ ] Severe [ ] Unspecified
[ ] Protein Calorie Malnutrition:
[ ] Mild [ ] Moderate [ ] Severe
[ ] Unspecified
[ ] Marasmus
[ ] Nutritional Edema
[ ] Other Malnutrition (please specify) _______________________________
ICD10 Documentation Needed
Same as ICD 9
17 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Open Fraction
ICD10 Documentation Needed
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.
18 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Osteomyelitis
ICD10 Documentation Needed
Identify site, acuity and if related to diabetes
Osteomyelitis site: ____________
[ ] Acute osteomyelitis directly related to diabetes mellitus
[ ] Acute osteomyelitis unrelated to diabetes mellitus
[ ] Chronic osteomyelitis directly related to diabetes mellitus
[ ] Chronic osteomyelitis unrelated to diabetes mellitus
19 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Pain
ICD10 Documentation Needed
Identify acuity and cause
[ ] Acute Pain
[ ] Trauma
[ ] Post- Thoracotomy
[ ] Post- operative / post-procedural
[ ] Other __________________
[ ] Chronic pain
[ ] Trauma
[ ] Post-Thoracotomy
[ ] Post-operative / post-procedural
[ ] Other __________________
[ ] Neoplasm pain
20 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Injury
ICD10 Documentation Needed
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.) ______________________________
21 ©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
ICD10 Documentation Needed
Similar to ICD 9
22 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Pressure Ulcer
ICD10 Documentation Needed
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)
23 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Post op Respiratory Issues
ICD10 Documentation Needed
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 [ ] Chronic [ ] Acute on Chronic
24 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Sepsis
ICD10 Documentation Needed
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.) _______________________
25 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
SHOCK
[ ] Hypovolemic shock
[ ] Hemorrhagic shock
[ ] Cardiogenic shock
[ ] Septic shock (Circulatory failure associated with severe sepsis, represents organ failure)
ICD10 Documentation Needed
Same as ICD 9
26 ©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)
ICD10 Documentation Needed
Same as ICD 9
27 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
UTI
ICD10 Documentation Needed
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
28 ©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
29 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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
Questions—contact your Clinical Documentation Specialists at your hospital
30 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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
Questions—contact your Clinical Documentation Specialists at your hospital
31 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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
Questions—contact your Clinical Documentation Specialists at your hospital
32 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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
Questions—contact your Clinical Documentation Specialists at your hospital
33 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
Flaget
Clinical Documentation Specialist Cheryl Mitchell—502-350-5247
Manager- Sandy Hodge- Bowman 502-409-2673
Supervisor- Kristen Boles 859-421-1542
Questions—contact your Clinical Documentation Specialists at your hospital
34 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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
Questions—contact your Clinical Documentation Specialists at your hospital
35 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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
Questions—contact your Clinical Documentation Specialists at your hospital