The Transition toWhat you need to know for Orthopedics

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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Fractures Pathological

• Specify whether etiology is:– Osteoporosis (senile

vs. disuse)– Osteopenia– Neoplastic– Some other disease

• Document site and laterality

• If COMPRESSION fracture, clarify if traumatic or pathological

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Fracture, Cancer• Document site, laterality

and etiology– Due to neoplasm

(specify primary of secondary)

– Due to trauma• Document neoplasm linked

to fracture

Fractures Traumatic Vertebral• Document:

– Level of vertebral column, for example L1

– Displaced versus nondisplaced

– Part of vertebra fractured, for example, posterior arch

• Document type of fracture, for example:– Type II dens fracture of the 2nd

cervical vertebra– Type III spondylolisthesis of

2nd cervical vertebra– Stable versus unstable burst

fracture– Zone I-III or Type 1-4 sacral

fracture10

• Document the healing process– Routine– Delayed– Nonunion– Malunion

• Indicate the encounter type– Initial– Subsequent– Sequela

Fractures Traumatic• Document:

– Open versus closed– Displaced versus nondisplaced– Name of specific bone and

specific site on bone– Orientation of fractures, such

as transverse, oblique, spiral

and‒ Laterality

• For open fractures of the forearm, femur, and lower leg, document type as– Type I, II, IIIA, IIIB, or IIIC

according to Gustilo classification

• For physeal fractures, document– Type I, II, III, IV according

to Salter Harris classification11

• For sacral fractures, document:– Zone I, II, III

and‒ Minimally versus severely

displaced

or‒ Type 1, 2, 3, 4

• Document the healing process– Routine– Delayed– Nonunion– Malunion

• Indicate the encounter type‒ Initial ‒ Subsequent‒ Sequela

Intervertebral Disc Disorders• Document site as:

– Cervical– Thoracic– Lumbar– Sacral– Other

• Document any associated:– Disc Displacement– Disc Degeneration– Myelopathy– Radiculopathy– Sciatica

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Osteoarthritis• Document type, for example:

– Primary– Posttraumatic– Other Secondary

• Document site, for example:– Hip– Knee– Shoulder

• Document laterality– Right– Left– Bilateral

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Spinal Column Injury or Disease• For conditions of the spinal column,

document site affected as– Occipito-atlanto-axial– Cervical or cervical-thoracic– Thoracic or thoracolumbar– Lumbar or lumbosacral– Sacral or sacrococcygeal

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Spondylosis• Document by type

– Anterior spinal artery compression syndrome– Vertebral artery compression syndrome– Other spondylosis

• Document site as– Occipito-atlanto-axial– Cervical or Cervical-thoracic– Thoracic or Thoracolumbar– Lumbar or Lumbosacral– Sacral or Sacrococcygeal

• Document if with– Myelopathy– Radiculopathy

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