urology and other common documentation tips icd 10 documentation specificity needed based on conifer...

UROLOGYand 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

Debridement 7

Dementia 8

Diabetes 9

Encephalopathy 10

Heart failure- acute 11

Heart failure-chronic 12

HIV-AIDS 13

Hypertension 14

Hyponatremia 15

Mental Status- Altered 16

Metabolic—acidosis/ alkalosis 17

Neoplasm 18

Non pressure ulcer 19

Malnutrition 20

Personal Injury 21

Pneumonia-Specificity 22

Pressure Ulcer 23

Prostatitis 24

Renal Failure—acute 25

Renal failure-chronic 26

Respiratory- COPD 27

Respiratory- Emphysema 28

Sepsis 29

Shock 30

Substance abuse 31

Testicular Torsion 32

Urosepsis 33

UTI 34

Hospital specific

Documentation Specialists contact info 35-42


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

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

Encephalopathy


IDENTIFY Acuity, Etiology and Severity

Acuity: [ ] Acute [ ] Subacute [ ] Chronic

Etiology:

[ ] Hypertensive [ ] Metabolic

[ ] Toxic [ ] Toxic Metabolic

[ ] Hepatic[ ] Hypoxic

[ ] Septic [ ] Alcohol

[ ] Drugs (specify)_______________

[ ] Post procedural (specify)______________

Severity: [ ] with coma [ ] without coma



ICD9 Documentation

ACUTE HEART FAILURE

[ ] Acute Systolic Heart Failure

[ ] Acute Diastolic Heart Failure

[ ] Acute Systolic and Diastolic Heart Failure

ACUTE ON CHRONIC HEART FAILURE

[ ] Acute On Chronic Systolic Heart Failure

[ ] Acute On Chronic Diastolic Heart Failure

[ ] Acute On Chronic Systolic and Diastolic Heart Failure


SAME as ICD 9 with the addition

OTHER ETIOLOGIES OF HEART FAILURE

[ ] Heart Failure Due To Valvular Disease

[ ] Right Heart Failure / Acute Cor Pulmonale

[ ] Right Heart Failure / Chronic Cor Pulmonale

[ ] Rheumatic Heart Disease

[ ] Endocarditis (valvular)

[ ] Myocarditis

[ ] Pericarditis



ICD9 Documentation

CHRONIC HEART FAILURE

[ ] Chronic Systolic Heart Failure

[ ] Chronic Diastolic Heart Failure

[ ] Chronic Systolic and Diastolic Heart Failure


SAME as ICD 9 with the addition of etiology

Etiologies:

[ ] Hypertension

[ ] Valvular disease

[ ] Rheumatic heart disease



ICD9 Documentation

HIV-AIDS

[ ] HIV infection/disease symptomatic related condition

[ ] AIDS

[ ] Non-HIV related condition

[ ] Asymptomatic HIV infection status

[ ] Non-specific serologic evidence of HIV


Similar to ICD 9



ICD9 Documentation

Hypertension

[ ] Malignant Hypertension

[ ] Accelerated Hypertension

[ ] Benign Hypertension

[ ] Unspecified Hypertension


Same as ICD 9



ICD9 Documentation

Hyponatremia


Identify specificity

[ ] Hyponatremia, unknown cause

[ ] Hyponatremia due to Sodium Deficiency

[ ] Hyponatremia due to SIADH (Syndrome of Inappropriate Secretion of Antidiuretic Hormone)

[ ] Insignificant lab value



ICD9 Documentation

Altered Mental Status


IDENTIFY SPECIFICITY

Altered Mental Status:[ ] Delirium

[ ] Mild Cognitive Impairment [ ] Drug-Induced Delirium [ ] Mental Disorder (Specify): __________ [ ] Other (Specify): ________

Altered Level of Consciousness: [ ] Coma [ ] Somnolence [ ] Persistent Vegetative State [ ] Stupor (Catatonic)[ ] Transient Alteration of Awareness

Encephalopathy:[ ] Alcoholic [ ] Due to Drugs [ ] Hepatic [ ] Hypertensive [ ] Anoxic / hypoxic[ ] Other (Specify): ___________ [ ] Metabolic / Septic [ ] Traumatic [ ] Hypoglycemic



ICD9 Documentation

Acidosis/Alkalosis


Identify Type of Acidosis or Alkalosis

[ ] Acidosis:

[ ] Metabolic [ ] Respiratory

[ ] Lactic [ ] Renal

[ ] Alkalosis:

[ ] Metabolic [ ] Respiratory



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

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

Prostatitis


Identify acuity, bacterial vs viral and organism if know

[ ] Acute Prostatitis:

[ ] Bacterial (organism __________ if known)

[ ] Viral (organism ______________if known)

[ ] Chronic Prostatitis:

[ ] Bacterial (organism ________ if known)

[ ] Viral (organism ____________if known)



ICD9 Documentation

Acute Renal Failure (ARF) / Acute Kidney Injury (AKI)

[ ] Prerenal Azotemia (dehydration, shock, CHF, renal obstruction, creatinine responds to IV fluid)

[ ] Acute Tubular Necrosis (ATN) (nephrotoxicity, extended decreased renal perfusion, increasing creatinine (0.5 / day) not responding to fluids, low urine output)

[ ] Acute Interstitial Nephritis (AIN) (nephritis in which the interstitial connective tissue is chiefly affected)

[ ] Acute cortical necrosis

[ ] Acute medullary necrosis

[ ] Acute kidney injury

[ ] traumatic injury [ ] Nontraumatic injury

[ ] Other Etiology or underlying conditions related to the diagnosis of ARF/ AKI:________________

[ ] Acute on Chronic Renal Failure please specify Type of ARF (above) and Stage of CKD ________


Same as ICD 9



ICD9 DocumentationChronic Renal Failure[ ] Chronic Renal Failure (CRF) / Chronic Kidney Disease (CKD)

Stage: _______ (I to V or ESRD—see below)

Dialysis dependent [ ] Yes [ ] No

CKD- National Kidney Foundation Guidelines for CKD Staging

Stage I Kidney damage with normal or increased GFRGFR > 90

Stage II Kidney damage with mildly decreased GFRGFR 60-89

Stage III Kidney damage with moderately decreased GFR GFR 30-59

Stage IV Kidney damage with severely decreased GFRGFR 16-29

Stage V Kidney failure GFR<15

ESRD End Stage Renal Disease On dialysis


Same as ICD 9



ICD9 Documentation

COPD


Identify Acuity

[ ] Acute exacerbation of COPD

[ ] Acute exacerbation of Asthma

[ ] COPD – Chronic and stable



ICD9 Documentation

Emphysema


Identify Acuity and Type

Acuity:

[ ] Acute exacerbation of Emphysema

[ ] Chronic and stable Emphysema

Type:

[ ] Unilateral:

[ ] Sawyer-James Syndrome

[ ] Unilateral Hyper-Lucent Lung

[ ] Unilateral Pulmonary Artery Functional Hypoplasia

[ ] Pan lobular

[ ] Centrilobar



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

Substance Abuse


Identify substance, status, complication and any induced disorders

Substance(s):

[ ] Alcohol [ ] Opioid [ ] Cannabis

[ ] Sedative, Hypnotic, Anxiolytic [ ] Cocaine

[ ] Other stimulant [ ] Hallucinogenic

[ ] Inhalant-related [ ] Other psychoactive drug: __________

[ ] Unspecified drug

Status: [ ] Use [ ] Abuse [ ] Dependence

Complications:

[ ] Intoxication [ ] Withdrawal [ ] In remission [ ] Uncomplicated

[ ] Other complication: ____________ [ ] Unspecified complication

Substance-Induced Disorders:

[ ] Psychosis: [ ] Delirium [ ] Delusions [ ] Hallucinations

[ ] Perceptual Disturbances: [ ] Anxiety Disorder [ ] Sexual Dysfunction

[ ] Sleep Disorder

[ ] Unspecified substance-induced disorder

[ ] Other substance-induced disorder: ________________________________

[ ] No substance-induced disorder



ICD9 Documentation

Testicular Torsion


Identify Extra or Intra vaginal and site

[ ] Extravaginal:

[ ] Epididymis

[ ] Spermatic Cord

[ ] Testicle/Testis

[ ] Intravaginal:

[ ] Epididymis

[ ] Spermatic Cord

[ ] Testicle/Testis



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




urology and other common documentation tips icd 10 documentation specificity needed based on conifer...

Documents

conifer icd

conifer health solutions

common documentation

diagnosis codes

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procedure codes

deepest layer of debridement

radiotherapy chronic