The Transition toWhat you need to know for Cardiology

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

Interventional Cardiology• Cardiac Catheterization

• Left, right or both• Document all measurements and precise anatomical site of cardiac

sampling and pressure• Angioplasty report should include the following:

• Vessel treated: Specific coronary artery(s)• Number of coronary vessels treated• Any procedure on vessel bifurcation• Number of vascular stents used and type

• Drug Eluting or Non Drug Eluting• Any platelet inhibitors • Any radiological exam such as aortography• Cardiac mapping

• Atherectomy report• Documentation is the same as Angioplasty

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Acute Coronary Syndrome (ACS)• Be clear on your intended Diagnosis. • Would one of the following better describe

the patient’s condition? - Angina- Unstable Angina- Myocardial Infarction

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Acute Myocardial Infarction (AMI)• Document Type as:

- STEMI or NSTEMI• Document Location:

– Transmural– Anterior Wall– Inferior Wall– Subendocardial– Other site

• Document exact date of recent MI (one occurring within the last 4 weeks) and type:– STEMI and wall of heart affected versus NSTEMI

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Aneurysm• Document Site:

– Aorta, thoracic, abdomen– Upper/Lower extremity– Renal– Iliac– Other specific arteries

• Document with or without:– Rupture – Dissection

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Arterial Embolism, Thrombosis, & Athero-embolism• Document Site:

– Aorta– Upper/Lower extremity– Iliac artery– Other specific arteries

• Document if:– Septic with underlying cause

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Atrial Fibrillation & Atrial Flutter

• For atrial fibrillation, document type as:– Paroxysmal– Persistent or– Chronic

• For atrial flutter, document type as: – Typical or Type I or– Atypical or Type 2

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Cardiac Arrest

• Document cause as due to:– Underlying

cardiac or non-cardiac condition

– Show cause and effect by using words such as “due to” or “secondary to”

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• Document the underlying cause

Cardiogenic Shock

Cardiomyopathy• Document type:

– Dilated– Congestive– Ischemic– Obstructive/Non-obstructive– Hypertrophic– Alcoholic

• Document if due to:– Poisoning– Drug– Other Diseases i.e. gout, hypothyroidism

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Hypertensive Heart & Renal Disease

• Document and link the cardiac and renal conditions to the hypertension

• Document type of CKD:– CKD Stage 1-5 ( not a range)– End Stage (ESRD)

• Document specific heart disease:– Acute on Chronic Systolic Heart Failure– Hypertensive Cardiomyopathy– Persistent Atrial Fibrillation

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Congestive Heart Failure (CHF)• Document severity:

– Acute – Chronic– Acute on chronic

• Document type:– Systolic– Diastolic– Combined systolic & diastolic

• Document etiology, if known, such as due to: Dilated cardiomyopathy

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Coronary Artery Disease (CAD)• Document Site as:

– Native artery and/or– Bypass graft

• Autologous vein• Autologous artery• Nonautologous

• Document if with:– Angina pectoris– Unstable angina pectoris– Angina pectoris and spasm

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Demand Ischemia• Document underlying cause:

– Hypertension– Hypotension– Anemia– Tachycardia– Bradycardia

• Note:– In coding, not equivalent to Type II MI or

NSTEMI. If both diagnosis used, a query may be submitted requesting clarification in the record.19

Hypotension• Document type:

– Shock due to specific cause ( blood loss, sepsis etc.)

– Idiopathic– Orthostatic– Postural– Due to drug-specify drug– Post procedural– Due to hemodialysis– Chronic

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Pulmonary Edema• Document severity

– Acute vs. chronic• Identify underlying cause:

– Heart failure– Chronic Kidney Disease

• Flash pulmonary edema:– i.e. unable to code unless specified as

acute

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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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