SJPE ICD10 Preparation Series

Asthma & AnemiaJuly 15, 2015

77 Days Left to

prepare for ICD10’s arrival!

Agenda

• Optum Fast Finder Tools• .ICD10 smart text • Problem List Calculator• Anemia and Asthma Documentation Tips• Top 20 Medical PC Diagnoses • Top 25 Diagnosis Report Handout to Providers

Clinical Documentation Challenges

• Over 1/3 of the expansion of ICD-10 codes is due to the addition of laterality (left, right, bilateral). Physicians and other clinicians likely already note the side when evaluating the clinically pertinent anatomical site(s).

• Ensuring sufficient documentation to support code assignment while allowing providers to document in clinical, (not coding) terms

• Need good clinical documentation-o NOT a greater volume of documentation

Documentation Focus Areas for ICD-10

Disease type

Disease acuity

Disease stage

Site specificity

Laterality

Terminology Changes

ICD9 TermAmputation

Anastomosis

Arthrodesis

Arthroscopy, Cystoscopy

Aspiration

Bunionectomy

Cesarean Section

Tonsillectomy

Debridement

ICD10 TermDetachment

Bypass

Fusion

Inspection, Endoscopic Approach

Drainage

Resection of Metatarsal

Extraction of products of Conception

Resection of Tonsils

Excision, Extraction, Irrigation, Extirpation

Provider Tools

• CMS - Road To 10 site http://www.roadto10.org/• Hyperlink to ICD10 Fast Finder Documents via EPIC• Problem List Calculator (aka Diagnosis Calculator)• .ICD10 Smart Text Phrases• Precyse University – Online Courses o (email Celeste Helinski - Celeste.Helinski@sjhsyr.org to

obtain access via Healthstream)

Optum Fast Finder tools

SJPE has purchased a number of Optum ICD10 Fast Finder tools, by specialty to share with providers/staff.

These tools will be provided to Practice Managers in addition to Coding Staff.

*Key tool for Family Practice is the Primary Care Fast Finder tool. (This will be sent following the webex.)

Sample of Fast Finder tool

Problem List Calculator

IT has been building a

Problem List Calculator

for high volume diagnoses

(aka Diagnosis Calculator)

Anemia via Diagnosis Calculator (preferred method for Ambulatory visits)

Anemia via Diagnosis Calculator (2)

.ICD10 smart texts

IT has also been building .ICD10 smart texts

to assist in documentation building.

Ie. ICD10 a will bring up a list of diagnoses

built that begin with the letter “a”

Anemia .ICD10 Smart Text(preferred method for IP related

visits)

Documentation Concepts

Anemia & Asthma

Anemia

• Be Specific! Anemia is a nonspecific term. o Is the patient anemic due to blood loss? o Where are they bleeding?

Your documentation should be specific, for example:

“acute blood loss anemia 2◦ to GI hemorrhage from bleeding duodenal ulcer”.

Anemia documentation Elements

• Include in documentation if Anemia is due to:• Nutrition or mineral deficits resulting in a nutritional

anemia• A neoplasm (primary and/or secondary)• Related to or due to “chemo or radiotherapy treatments• Any “cause-and effect” relationship between the

intervention and the blood or immune disorder• The specific drug if anemia is drug-induced

Anemia documentation elements cont.

• Documentation of Anemia should include the type of anemia:• Nutritional• Hemolytic• Aplastic• Due to blood loss• Other (please specify)

Anemia ICD10 Codes

Anemia documentation guidance from CMS

Road to 10 Anemia reference link:

http://www.roadto10.org/action-plan/phase-2-train/clinical-scenarios-family-practice/

Asthma

Documentation Requirements:

Must include the relationship between Asthma and other chronic/acute conditions such as COPD, Bronchitis, acute lower respiratory infections and/or exposure to or use of Tobacco (if present) in addition to the severity, and form or type.

Asthma documentation elements

Severity• Mild intermittent• Mild persistent• Moderate persistent• Severe persistent

With• Acute lower

respiratory infection• COPD• Chronic obstructive

bronchitis• Exacerbation• Status asthmatics

Asthma documentation

elements cont.

As well as the Form or Type• Cough variant• Childhood• Exercise induced bronchospasm• Extrinsic allergic• Idiosyncratic• Intrinsic non allergic• Late-onset• Mixed• Other (specify)

Asthma ICD10 Codes

Next Week’s Topic:

Diabetes Coding in ICD10

7/22/15