plastic surgery and other common documentation tips icd 10 documentation specificity needed based on...

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.


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


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



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

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

Cleft Palate


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): ___________________



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

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

Foot Deformity


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): __



ICD9 Documentation

Bone fracture


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



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

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

Open Fraction


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.



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

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

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

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

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 [ ] 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


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



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

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





St. Joe East

Clinical Documentation Specialists Kimberly Gilbert-Morrison—502-316-5220

Kelly Geers—502-750-2329





Flaget

Clinical Documentation Specialist Cheryl Mitchell—502-350-5247





St Joe London

Clinical Documentation Specialists Katrina Henson—606-330-6759

Sherry Mills—606-330-6000





St. Joe Mt. Sterling

Clinical Documentation Specialists Lori Barry—859-497-5458




plastic surgery and other common documentation tips icd 10 documentation specificity needed based on...

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