The Transition toWhat you need to know for Pulmonary Medicine

Date | Presenter Information

Tools Available

Twitter @AdvocateICD10

Flat Screens in lounges

AMGDoctors.com

How can we reach our

physicians?

Intranet

Email BlastsPhysician Relations

Team

Website

APP Newsletter

Pocket Cards

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Ongoing Support for ICD-10Physician Advisors

Clinical Informatics

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-Public Reporting-Reimbursement-Physician Scorecards-Quality Improvement

What’s in it for me?• Better reflection of the quality of the care you

provided to your patient• A more accurate assessment of the Severity of Illness

(SOI) i.e. how sick your patient was during the hospitalization

• Improves your publicly reported quality measure scores

• Supports the improvement of your patient’s clinical outcomes and safety

• Enables a better capture of SOI (severity of illness) and ROM (risk of mortality)

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What should be documented?

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ReimbursementAdmit

• HPI: tell “the story”

• PMH: all chronic conditions in as much detail as available (e.g., Chronic Systolic CHF)

• PSH: all surgeries (e.g., left hip arthroplasty)

• Assessment and Plan:• Differential diagnosis• Working diagnoses• Other conditions being

treated

Daily

• Rule out or confirm differential diagnosis based on test results, imaging results and response to empiric treatment.

Discharge

• All treated/resolved diagnoses should be documented.

• For diagnoses that are documented as suspected, possible, probable at the time of discharge should be listed in the discharge summary.

No Matter How Obvious it is to the Clinician• It is not appropriate for the coder to report a diagnosis based on abnormal findings:

– Laboratory

– Pathology

– Imaging

• A query must be sent to document a definitive diagnosis

• Only a physician can establish a cause and effect relationship between a diagnosis such as gastroparesis and diabetes

• Possible, probable and suspected conditions can be reported, but ONLY if documented at the time of discharge (for inpatient records)

• Outpatient Surgical and Observation Records: Enter as much information as known at the time.

Patient with shortness of breath and lung nodule. Coded to shortness of breath and lung nodule.

Patient with shortness of breath and lung nodule, suspected lung cancer with pathology pending. Coded to shortness of breath and lung nodule.

We would not code a possible condition as an established diagnosis on outpatient records.

What Coders are Unable to Assume

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Key Changes Needed to Support ICD-10 Coding

Acidosis- Metabolic, Respiratory, Lactic

• Link abnormal lab value to clinical diagnosis

• Respiratory acidosis: specify acute, chronic etiology

• Metabolic acidosis etiology

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Pleural Effusion• Document cause

or etiology of pleural effusion: e.g. malignant

• Document neoplasm linked to malignant pleural effusion

Asthma• Document Severity and type:

– Mild intermittent– Mild persistent– Moderate persistent– Severe persistent

• Document Status:– Uncomplicated– w/ acute exacerbation– w/ status asthmaticus

• Document if present with COPD/bronchitis, bronchiolitis/other

Chronic Obstructive Pulmonary Disease (COPD)

• Document if present with acute lower respiratory tract infection + casual organism, when known/suspected, such as:– Pseudomonas pneumonia– Acute Bronchitis and organism known/suspected

• Document if present with: – Acute exacerbation

• Document if present with respiratory failure and severity:– Acute respiratory failure– Chronic respiratory failure– Acute on chronic respiratory failure– Cause– Present on Admission

• Document if oxygen-dependent

Emphysema• Document type:

– Unilateral– Panlobular– Centrilobular– Other type

• Document if oxygen dependent

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Neoplasms• Document if neoplasm is benign or malignant• Document site and laterality such as:

– Lung– Prostate– Kidney– Breast– Colon

• Differentiate between primary and secondary (metastatic) site– Document primary site and if it is still present, treated, resolved

in remission• For secondary sites:

– All sites; Document final pathology results• Document final pathology results

– EVEN IF RECEIVED AFTER THE PATIENT IS DISCHARGED WITH A LATE ENTRY DATED AS NEEDED

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Pneumonia• Document type:

– Aspiration pneumonia– Ventilator associated pneumonia– Viral pneumonia– Bacterial pneumonia

• Document causative organism, when known or suspected:– Klebsiella pneumonia– Gram negative pneumonia

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Pulmonary Embolism• Document type, such as:

– Saddle– Septic

• Document cor pulmonale if present and whether it is:– Acute or Chronic

• Specify if PE is: – Chronic (still present) versus– Resolved– Note that “history of PE” is ambiguous

• Document if anti-coagulant therapy is for active treatment or prophylactic

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Pneumothorax• Document:

- Acute, Chronic- Spontaneous, primary, secondary, tension- Traumatic, post procedural/operation- Underlying pulmonary disease Present on Admission

• Document type– Aspiration pneumonia – Ventilator associated pneumonia– Viral pneumonia– Bacterial pneumonia

• Document causative organism, when known or suspected– Klebsiella pneumonia– Gram negative pneumonia15

Pulmonary• Document severity

– Acute or chronic• Document cause

– Shock– Surgery (thoracic vs. non-thoracic surgery)– Trauma– Newborn

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Respiratory Failure• Document severity:

– Acute– Chronic– Acute on chronic

• Document type:– Hypoxic– Hypercapnic– Hypoxic and Hypercapnic

• Document if associated with COPD• Document if Present on Admission (POA)• Post-procedural

– Acute post-procedural Respiratory failure– Acute on chronic post-procedural respiratory failure

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Sleep Apnea• Document type

– Central sleep apnea– Obstructive – Congenital central alveolar hypoventilation– Specify if associated with alveolar

hypoventilation and obesity

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