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JUMP START DOCUMENTATION &

PHYSICIAN EDUCATION WITH A CDI AUDIT

AHIMA San Diego 2014

Introduction: Overview & Goals

� Documentation is the cornerstone to disease and treatment information

� As with ICD-9, ICD-10 code assignment relies solely upon physician documentation of diagnoses and procedures

� “Documentation” is mentioned over 70 times in the ICD-10-CM guidelines document.

� “Querying” is referred to over 20 times in the guidelines document

� ICD-10 is a clinical classification system that is sophisticated enough, and specific enough, to keep up with the changes in medicine and with regulations

2

Value of Clinical Documentation Audit

Each assigned code should be compared, contrasted, and analyzed to:� Confirm presence of clinical documentation as expected

�Assess quality and content of clinical documentation to support assigned codes

�Evaluate assigned codes vs. the application of final ICD-10 codes based on a coding professional’s manual review of the clinical documentation

Value of Clinical Documentation Audit- continued

Clinical documentation review allows your organization to understand the possibilities related to:

� Current coding and documentation practices

� Strengths and opportunities to ensure that the impact of the transition to ICD-10 is positive in terms of accuracy and appropriate reimbursement.

CDI Audit Worksheet Sample

ORIGINAL (ICD-9) HRS (ICD-9) HRS (ICD-10)

Reviewer Scenario Number Admit Date: Disch Date: FinClass MS-DRG DRG Description MS-DRG DRG Description MS-DRG DRG Description Service

HRS HRS024 6/24/13 6/26/13 HMO 470

MAJOR JOINT REPLACEMENT OR

REATTACHMENT OF LOWER EXTREMITY

W/O MCC

470


REATTACHMENT OF LOWER EXTREMITY W/O

MCC

470


REATTACHMENT OF LOWER EXTREMITY

W/O MCC

DIAGNOSES

Code Type SEQ# CLIENT ICD-9 CODE CLIENT ICD-9 DESCRIPTION HRS ICD-9 CODE HRS ICD-9 DESCRIPTION HRS ICD-9 COMMENTS HRS ICD-10 CODE HRS ICD-10 CODE DESCRIPTIONDocumentation Impact

CodeDocumentation Impact Description Reviewer Comments

DxAdmitting / First-

Listed Dx71536

Osteoarthrosis, localized, not specified

whether primary or secondary, lower leg71536

Osteoarthrosis, localized, not

specified whether primary or

secondary, lower leg

M179 Osteoarthritis of knee, unspecified 000No Impact; Documentation Supports

Code

Dx Principal Dx 71536Osteoarthrosis, localized, not specified

whether primary or secondary, lower leg71536

Osteoarthrosis, localized, not

specified whether primary or

secondary, lower leg

M179 Osteoarthritis of knee, unspecified 002Insufficient Documentation (Disease:

Type)

To support a more specific ICD-10 codeassignment, the type of

OA should be documented. i.e. Primary, post traumatic,

secondary

Dx 2 2449 Unspecified acquired hypothyroidism 2449 Unspecified acquired hypothyroidism E039 Hypothyroidism, unspecified 002Insufficient Documentation (Disease:

Type)

To support a more specific ICD-10 codeassignment, the type of

hypothyroidism should be documented. i.e., postinfectious,

due to iodine deficiency

Dx 3 4019 Unspecified essential hypertension 4019 Unspecified essential hypertension I10 Essential (primary) hypertension 000No Impact; Documentation Supports

Code

Dx 4 53081 Esophageal reflux 53081 Esophageal reflux K219Gastro-esophageal reflux disease without

esophagitis000

No Impact; Documentation Supports

Code

Dx 5 2724 Other and unspecified hyperlipidemia 2724 Other and unspecified hyperlipidemia E785 Hyperlipidemia, unspecified 002Insufficient Documentation (Disease:

Type)

To support a more specific ICD-10 code assignment, the type

of hyperlipidemia should be documented. i.e., Mixed, Type A-

D

Dx 6 V1582 Personal history of tobacco use V1582 Personal history of tobacco use Z87891 Personal history of nicotine dependence 000No Impact; Documentation Supports

Code

Dx 7 #N/A #N/A #N/A #N/A














PROCEDURES

Code Type SEQ# CLIENT ICD-9 CLIENT ICD-9 DESCRIPTION HRS ICD-9 HRS ICD-9 DESCRIPTION HRS ICD-9 COMMENTS HRS ICD-10 CODE HRS ICD-10 CODE DESCRIPTIONDocumentation Impact

CodeDocumentation Impact Description Reviewer Comments

PxPrincipal / First-

Listed Px8154 Total knee replacement 8154 Total knee replacement 0SRT0J9

Replace R Knee Jt, Femoral w Synth Sub,

Cement, Open000

No Impact; Documentation Supports

Code

Px 2 #N/A #N/A #N/A #N/A











Clinical Documentation Audit

Key Findings Legend (Snapshot)

Impact

Code

ICD-10

Documentation

Objectives

Explanation Example

001 Insufficient

Documentation

(Disease: Acuity)

ICD-10-CM code that will replace the ICD-9-CM code used for the

same reimbursement will need more specific disease identification

The acuity of respiratory failure should be documented. i.e., acute, chronic or acute on chronic. The acuity of bronchitis should be documented. i.e., acute or chronic

002 Insufficient

Documentation

(Disease: Type)

ICD-10-CM has more than one disease category under a broad

disease category. (i.e.. Diabetes-Type 1, Type 2, secondary, drug or

chemical induced).

The type of iron deficiency anemia should be documented. i.e., due to chronic blood loss, due to inadequate iron intake. The type of hypothyroidism should be documented. i.e., due to medication, due to infectious process, post-surgical.

003 Insufficient

Documentation

(Disease: Stage)

ICD-10-CM has stages or levels of disease, such as mild intermittent,

late onset early onset, intractable or not intractable, stages of disease

kidney or pressure ulcer, post and pre.

Chronic kidney disease should be documented. i.e., Stage I-V, end stage. The phase of the dysphagia should be documented. i.e., oral, oropharyngeal, pharyngeal, pharyngoesophageal, cervical.

004 Insufficient

Documentation

(Laterality)

Codes that are assigned in ICD-10 based on laterality The laterality of the acute osteomyelitis of the hand should be documented. i.e. right, left, bilateral.

005 Insufficient

Documentation (Site

Specificity)

Codes that are assigned in ICD-10-CM based on documented site The site of the furuncle should be documented. i.e., abdominal wall, back, chest wall, groin. The site of Crohn's disease should be documented. i.e., colon, duodenum, ileum, jejunum. The site of the abdominal pain. i.e., LLQ, pelvic or perineal, periumbilical, RLQ, epigastric, LUQ, RUQ.

006 Insufficient

Documentation

(Combination codes)

Combination codes are single codes in ICD-10-CM that are used to

classify: two diagnoses, a diagnosis with an associated secondary

process (manifestation), a diagnoses with an associated

complication

The documentation should include any manifestations of the acute respiratory failure. i.e., with hypercapnia or with hypoxemia. The documentation should include any manifestations of Crohn's disease. i.e., abscess, fistula, intestinal obstruction, rectal bleeding.

How Can You Prepare?

Begin physician education and add the following to queries:

� Asthma

� Severity/Acuity

� Myocardial Infarction

� Specific site

� Major Depression

� Severity/Acuity

How Can You Prepare? continued

..add the following to queries:�Differentiation between general and focal seizures� General seizures require type specificity

� Identify intractable (treatment-resistant) seizures

� Trimester of pregnancy�Default to the trimester when the complication occurred, not the discharge trimester when an admission crosses trimesters

� Identification of the substance related to adverse effect, poisoning, or toxic effect

10

How Can You Prepare? continued

…add the following to queries:

� Glasgow (Coma Scale) � Need a score from each of the three assessment areas, NOT a total score

� Eye opening

� Verbal response

� Motor response

� Gustilo Open Fracture Classification � I, II, III, IIIA, IIIB, or IIIC

11

How Can You Prepare?-continued

…add the following to queries:

�Approach

�Laterality

�Root operation

12

How Can You Prepare?-continued

What policies and procedures need revision?� ICD-10-CM/PCS have new Coding Clinic advice

What documentation templates need revision?� Operative reports

� History and physicals

� Query forms

13

Conclusion /Next Steps

There is much still to do…

� Start Small

� Pick your Battles

� Encourage Teamwork

� Inventory your Query Library

14

Kim Carr

RHIT, CCS, CDIP, CCDS,

AHIMA-Approved ICD-10-CM/PCS Trainer

Director, Clinical Documentation

1777 Reisterstown Road, Suite #330

Baltimore, Maryland 21208

Phone (410) 653-0194

[email protected]

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