The Transition toWhat you need to know for General Surgery/Trauma

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

Anemia, Blood Loss

• Document, when appropriate:– Anemia due to acute

blood loss– Anemia due to chronic

blood loss – Postoperative anemia

due to acute blood loss

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Appendicitis • Document severity:

– Acute– Chronic– Recurrent– Relapsing– Subacute

• Document if with:– Peritoneal

abscess– Peritonitis– Gangrene– Perforation

Complication of Surgery• Physicians documentation must include the

cause and effect relationship between the care provided and the condition that may be considered a complication.

• Physician documentation must indicate that condition is a complication.

• The physician may be asked for clarification if the complication is not clearly documented as either a complication or as an expected outcome

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Neoplasms• Document if neoplasm is benign or malignant• Document site and laterality such as:

– Lung– Prostate– Kidney– Breast– Colon– Other anatomic sites

• Differentiate between primary and secondary (metastatic) site– Document primary site and if it is still present

• For secondary sites:– Document suspected and final pathology results– EVEN IF RECEIVED AFTER THE PATIENT IS DISCHARGED

WITH A LATE ENTRY DATED AS NEEDED

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Obesity• Document etiology:

– Due to excess calories or nutritional

– Due to drugs– Other, for example, due

to thyroid or pituitary disorder

• Specify if morbidly obese• Document BMI• Document if:

– With alveolar hypoventilation/ hypoventilation syndrome

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Ascites• Document if ascites is

malignant• Document neoplasm

linked to malignant ascites

Crohn’s Disease• Document anatomical site:

– Large intestine– Small intestine– Small and large intestine

• Document any associated complications, such as: – Bleeding – Intestinal obstructions– Fistula– Abscess– Perforation

• Don’t use the term “inflammatory bowel disease.” Use of this term when your intended diagnosis is Crohn’s disease may understate severity of illness and risk of mortality

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Encephalopathy• Document acute/chronic• Document type:

– Metabolic– Toxic– Alcoholic– Septic– Hepatic– Anoxic

• Document cause:– Infection– Electrolyte imbalance– Substance abuse and

resulting disease – Viral hepatitis

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Hernia• Document site and

laterality:– Bilateral inguinal

hernia– Femoral hernia– Umbilical hernia– Ventral hernia– Diaphragmatic/hiatal

hernia• Document if with:

– Gangrene– Obstruction– Gangrene and

obstruction

Gastritis• Document severity:

– Acute– Chronic

• Document underlying cause:– Alcohol induced – Diet deficiency– Viral– Allergic

• Document associated complications– bleeding

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Pancreatitis• Document severity:

– Acute– Chronic

• Document etiology and show cause and effect:– Idiopathic cute

pancreatitis– Acute pancreatitis due

to alcohol abuse– Gallstones or biliary– Drug induced

Hepatic Failure

• Document type:– Acute– Subacute– Chronic

• Document if with hepatic coma

• Document etiology, for example:– Due to alcohol or

drugs

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Irritable Bowel Syndrome

• Document if with diarrhea

• Document if psychogenic

Peptic Ulcer Disease

• Document severity:– Acute – Chronic

• Document site:– Duodenal– Esophagus– Gastric– Other

• Document underlying cause:– Alcohol– Drug or chemical

• Document if associated with:– Perforation– Hemorrhage– Perforation and hemorrhage

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Gastrointestinal Bleed

• Document etiology and show cause and effect, for example:– Acute GI bleed due to

bleeding esophageal varices– Acute GI bleed due to

hemorrhoids– Acute GI bleed due to

gastritis• Document where blood was

observed:– Rectal– Hematochezia– Hematemesis

Ulcerative Colitis• Use the following terms to further define the anatomical site:

– Pancolitis– Proctitis– Rectosigmoiditis

• Document any associated complications:– Bleeding– Intestinal obstruction– Fistula– Abscess– Perforation

• Don’t use the term “inflammatory bowel disease.” Use of this term when your intended diagnosis is Ulcerative Colitis may understate severity of illness and risk of mortality

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