family practice and other common documentation tips icd 10 documentation specificity needed based on...

FAMILY PRACTICEand 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 Alzheimer's 5

Anemia 6

Aplastic Anemia 7

Atrial Fib 8

BMI – high 9

BMI –low 10

Cardiac Arrest 11

Cellulitis 12

Cerebral Edema 13

Chest pain 14

Cirrhosis of Liver 15

Colitis 16

Coma 17

Crohn’s Disease / Regional Enteritis 18

CVA 19

Debridement 20

Degenerative Disc Disease 21

Dementia 22

Diabetes 23

Diverticulitis 24

Dysphasia 25

Encephalopathy 26

Esophagitis 27

Functional Quadriplegia 28

Gastroparesis 29

Gastrointestinal Ulcer- Upper 30

GERD 31

Gout 32

Headache/ Migraine 33

Heart failure- acute 34

Heart failure-chronic 35

Hepatitis 36

HIV-AIDS 37

Hypertension 38

Hyponatremia 39

Influenza 40

Level of consciousness 41

Lymphoma 42

Meningitis 43

Mental Status- Altered 44

Metabolic—acidosis/ alkalosis 45

Mood Disorder 46

Myocardial Infarction 47

Neoplasm 48


Table of Contents cont

Respiratory- Emphysema 67

Respiratory failure 68

Respiratory failure post op 69

Sepsis 70

Shock 71

Sickle Cell Disease 72

Substance abuse 73

TIA 74

Urosepsis 75

UTI 76

Weakness 77

Hospital specific

Documentation Specialists contact info 78-85

Neutropenia 49

Non pressure ulcer 50

Malnutrition 51

Osteomyelitis 52

Pain 53

Pancreatitis 54

Personal Injury 55

Pneumonia- Aspiration 56

Pneumonia- Hypostatic /passive/ stasis 57

Pneumonia-Specificity 58

Pressure Ulcer 59

Prostatitis 60

Pulmonary embolism 61

Renal Failure—acute 62

Renal failure-chronic 63

Respiratory-asthma 64

Respiratory- Bronchitis 65

Respiratory- COPD 66


ICD10 documentation specificity needed

ICD9 Documentation

Alzheimer’s

ICD10 Documentation Needed

Identify onset, behavior disturbances and with dementia or associated delirium

[ ] Alzheimer’s disease

[ ] Early onset [ ] Late onset [ ] Unspecified [ ] Other

[ ] Alzheimer’s disease with behavioral disturbances

[ ] Aggressive [ ] Combative [ ] Violent [ ] Unspecified

[ ] Other_______

[ ] Alzheimer’s disease with dementia

[ ] Acute [ ] Sub acute [ ] With wandering

[ ] Alzheimer’s disease with associated delirium



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:


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

BMI > 40 with associated diagnosis of:

[ ] Morbid (Severe) Obesity

[ ] Overweight

[ ] Obesity (unspecified)


Morbidly Obese

[ ] Morbid (Severe) Obesity

[ ] Due to excess calories

[ ] Familial

[ ] Endocrine

[ ] with Alveolar Hypoventilation (Pickwickian syndrome)

[ ] Drug-induced (Name of drug: _____)



ICD9 Documentation

BMI < 19 with associated diagnosis of: (check one)

[ ] Underweight

[ ] Protein Calorie Malnutrition:

[ ] Mild [ ] Moderate [ ] Severe

[ ] Unspecified

[ ] Cachexia

[ ] Emaciation due to malnutrition


Same as ICD 9



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

Colitis


Identify Site, Type and ComplicationsSite (if applicable):

[ ] Small Intestine [ ] Large Intestine [ ] Other site __

Type:

[ ] Colitis due to radiation

[ ] Ulcerative Colitis

[ ] Infectious Colitis

[ ] Toxic Colitis

[ ] Ischemic Colitis

[ ] Colitis due to ___________________

[ ] Chronic Colitis

Complications:

[ ] Rectal Bleeding

[ ] Intestinal Obstruction

[ ] Fistula

[ ] Abscess

[ ] Other complication _________________

[ ] Unspecified complication



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

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

Degenerative Disc Disease


Identify Location and if with Myelopathy/Neuritis/Radiculopathy/Radiulitis

[ ] Degenerative Cervical Disc Disease

Specify level of spine: ___________

[ ] With Myelopathy [ ] With Neuritis, Radiculopathy, Radiculitis

[ ] Other/Unspecified

[ ] Degenerative Sacrococcygeal Disc Disease

[ ] Degenerative Lumbar Disc Disease



[ ] Degenerative Thoracic Disc Disease



[ ] Degenerative Thoraco-Lumbar Disc Disease



[ ] Degenerative Lumbosacral Disc Disease





ICD9 Documentation

Dementia


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: ___________________



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

Dysphagia


IDENTIFY PHASE, TYPE and ACUITY

Phase: [ ] Oral [ ] Oropharyngeal [ ] Pharyngeal [ ] Pharyngoesophageal

Type: [ ] Cervical [ ] Functional[ ] Hysterical [ ] Nervous [ ] Neurogenic[ ] Siderpenic [ ] Spastica

Following Non-Traumatic: [ ] SAH [ ] Intracerebral Hemorrhage[ ] Intracranial Hemorrhage[ ] CVA

Acuity: [ ] Acute [ ] Chronic [ ] Acute on Chronic

[ ] Other specified Dysphagia:___________

[ ] Unspecified Dysphagia



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

Esophagitis


IDENTIFY SPECIFICITY

[ ] Eosinophilic Esophagitis[ ] Esophagitis with GERD / Reflux[ ] Candida Esophagitis[ ] Ulcerative Esophagitis[ ] Esophagitis Unspecified[ ] Other Esophagitis



ICD9 Documentation

Functional Quadriplegia

[ ] Functional quadriplegia (complete immobility)

[ ] Immobilization syndrome (impaired mobility)


Same as ICD 9



ICD9 Documentation

Gastroparesis


Identify if related to diabetes and if underlying disease

[ ] Gastroparesis related to Diabetes

[ ] Gastroparesis in underlying disease/process (please state: ______________)



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

GERD


IDENTIFY GERD WITH OR WITHOUT ESOPHAGITIS

Gastro esophageal reflux disease (GERD) with Esophagitis

Gastro esophageal reflux disease (GERD) without Esophagitis



ICD9 Documentation

Gout


IDENTIFY Type, joint involved and acuity

Specify the type/cause of gout:

[ ] Drug-induced [ ] Secondary

[ ] Idiopathic [ ] Syphilitic

[ ] Lead-induced [ ] Primary

[ ] With renal impairment (specify the specific renal disease/disorder, including acuity and/or state)____

Specify the specific joint involved _ [ ] Right [ ] Left

Specificity acuity of gout:

[ ] Acute

[ ] Chronic – with or without tophus

[ ] Gout attack

[ ] Gout flare



ICD9 Documentation

Migraine



[ ] 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

CHRONIC HEART FAILURE

[ ] Chronic Systolic Heart Failure

[ ] Chronic Diastolic Heart Failure

[ ] Chronic Systolic and Diastolic Heart Failure


SAME as ICD 9 with the addition of etiology

Etiologies:

[ ] Hypertension

[ ] Valvular disease

[ ] Rheumatic heart disease



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

Influenza


IDENTIFY Organism and associated factors

[ ] Influenza caused by ______ (specify organism)

[ ] Influenza-associated Encephalopathy

[ ] Influenza-associated Pneumonia



ICD9 Documentation

Level of Consciousness[ ] Coma / Comatose

[ ] Encephalopathy, type: ____________________________

[ ] Persistent vegetative state

[ ] Stupor


Same as ICD 9



ICD9 Documentation

Lymphoma


IDENTIFY Anatomical Site, Type and Cell Type

Anatomical Site: _______________________)

Type:

[ ] Hodgkins (Cell type: _________)

[ ] Follicular (Cell type: _________)

[ ] Non-Follicular (Cell type: _________)

[ ] Mature T/NK Cell (Cell type: _________)

[ ] Other Specified/ Unspecified Non-Hodgkin’s (Cell type: ___________________)

[ ] Other Specified T/NK Cell (Cell type: _____)

[ ] Unspecified



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



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

Mood Disorder

ICD10 Documentation NeededIDENTIFY Type, Status and SeverityType (check appropriate):

[ ] Manic

[ ] Bipolar [ ] Manic [ ] Depressive [ ] Mixed

[ ] Major Depressive Disorder

[ ] With Psychosis

[ ] Persistent Mood Disorder

[ ] Without Psychosis

Status:

[ ] Single past episode

[ ] Current episode

[ ] In remission [ ] Partial [ ] Full

[ ] With Psychosis

[ ] Without Psychosis

Severity:

[ ] Mild

[ ] Moderate

[ ] Severe

[ ] Unspecified



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

Neoplasm


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 ____________________________________



ICD9 Documentation

Neutropenia


Identify Cause

[ ] Congenital

[ ] Secondary to chemotherapy (list chemotherapeutic drug: __________)

[ ] Drug induced (list drug: ________________)

[ ] Due to infection (infection site: _______ Organism: _________________________)

[ ] Cyclic


[ ] 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

Osteomyelitis


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



ICD9 Documentation

Pain


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



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

Hypostatic Passive/ Stasis Pneumonia

[ ] Hypostatic Passive/ Stasis Pneumonia

[ ] Pneumonia due to (specify organism/ underlying disease)_____________

[ ] Ventilator-associated

[ ] Radiation induced

[ ] Associated illness:

[ ] Respiratory Failure

[ ] Underlying lung disease

[ ] Other (specify)________________


Same as ICD 9



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

Prostatitis


Identify acuity, bacterial vs viral and organism if know

[ ] Acute Prostatitis:

[ ] Bacterial (organism __________ if known)

[ ] Viral (organism ______________if known)

[ ] Chronic Prostatitis:

[ ] Bacterial (organism ________ if known)

[ ] Viral (organism ____________if known)



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 DocumentationChronic Renal Failure[ ] Chronic Renal Failure (CRF) / Chronic Kidney Disease (CKD)

Stage: _______ (I to V or ESRD—see below)

Dialysis dependent [ ] Yes [ ] No

CKD- National Kidney Foundation Guidelines for CKD Staging

Stage I Kidney damage with normal or increased GFRGFR > 90

Stage II Kidney damage with mildly decreased GFRGFR 60-89

Stage III Kidney damage with moderately decreased GFR GFR 30-59

Stage IV Kidney damage with severely decreased GFRGFR 16-29

Stage V Kidney failure GFR<15

ESRD End Stage Renal Disease On dialysis


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

Post op Respiratory Issues


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



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

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



ICD9 Documentation

Weakness


Identify due to and laterality

[ ] Weakness due to __________

[ ] Hemiparesis [ ] Hemiplegia

Laterality

(please check all that apply):

[ ] Right side [ ] Left side

[ ] Upper extremity [ ] Lower extremity

[ ] Dominant side [ ] Non-dominant side


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

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





St Joe Main


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


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




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