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NEUROLOGY AND NEURO SURGERYand 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.
3 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
Table of contents Alzheimer's 4
Anemia 5
BMI – high 6
BMI –low 7
Cardiac Arrest 8
Cerebral Edema 9
Coma 10
CVA 11
Debridement 12
Degenerative Disc Disease 13
Dementia 14
Diabetes 15
Dysphasia 16
Encephalopathy 17
Headache/ Migraine 18
Heart failure- acute 19
Heart failure-chronic 20
Hypertension 21
Hyponatremia 22
Level of consciousness 23
Meningitis 24
Mental Status- Altered 25
Metabolic—acidosis/ alkalosis 26
Mood Disorder 27
Neoplasm 28
Non pressure ulcer 29
Malnutrition 30
Personal Injury 31
Pneumonia- Aspiration 32
Pneumonia- Hypostatic /passive/ stasis 33
Pneumonia-Specificity 34
Pressure Ulcer 35
Renal Failure—acute 36
Renal failure-chronic 37
Respiratory failure 38
Respiratory failure post op 39
Sepsis 40
Shock 41
Substance abuse 42
TIA 43
Urosepsis 44
UTI 45
Weakness 46
Hospital specific
Documentation Specialists contact info 47-54
4 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Alzheimer’s
ICD10 Documentation Needed
Identify onset, behavior disturbances and with dementia or associated delirium
[ ] Alzheimer’s disease
[ ] Early onset [ ] Late onset [ ] Unspecified [ ] Other
[ ] Alzheimer’s disease with behavioral disturbances
[ ] Aggressive [ ] Combative [ ] Violent [ ] Unspecified
[ ] Other_______
[ ] Alzheimer’s disease with dementia
[ ] Acute [ ] Sub acute [ ] With wandering
[ ] Alzheimer’s disease with associated delirium
5 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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
6 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
BMI > 40 with associated diagnosis of:
[ ] Morbid (Severe) Obesity
[ ] Overweight
[ ] Obesity (unspecified)
ICD10 Documentation Needed
Morbidly Obese
[ ] Morbid (Severe) Obesity
[ ] Due to excess calories
[ ] Familial
[ ] Endocrine
[ ] with Alveolar Hypoventilation (Pickwickian syndrome)
[ ] Drug-induced (Name of drug: _____)
7 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
BMI < 19 with associated diagnosis of: (check one)
[ ] Underweight
[ ] Protein Calorie Malnutrition:
[ ] Mild [ ] Moderate [ ] Severe
[ ] Unspecified
[ ] Cachexia
[ ] Emaciation due to malnutrition
ICD10 Documentation Needed
Same as ICD 9
8 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Cardiac Arrest
ICD10 Documentation Needed
Identify underlying cause, post procedure or intra-op arrest
[ ] Underlying cardiac condition (specify)___________
[ ] Underlying other condition (specify)______
[ ] Cause unspecified
[ ] Post procedural cardiac arrest following cardiac surgery
[ ] Post procedural cardiac arrest following other surgery
[ ] Intra-operative cardiac arrest during cardiac surgery
[ ] Intra-operative cardiac arrest during other surgery
[ ] Any associated diagnoses / conditions________
9 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Cerebral edema
[ ] Cerebral edema / Vasogenic edema
[ ] Compression of brain
[ ] Findings not significant
[ ] Radiologic finding only
[ ] Does not apply to this patient
ICD10 Documentation Needed
Same as ICD 9
10 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Coma
ICD10 Documentation Needed
Identify specificity
[ ] Coma / Comatose
[ ] Persistent vegetative state
[ ] Stupor
[ ] Drowsiness
[ ] Somnolence
[ ] Catatonic stupor
[ ] Semicoma
[ ] Associated injury (skull fracture, intracranial injury) _________________________________
[ ] Glasgow coma score_____________
Eye opening describe ________
Verbal response describe _________ Motor functioning describe_________
11 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
CVA
ICD10 Documentation Needed
Identify Laterality, type, location and manifestations
[ ] CVA -- Laterality: [ ] Right [ ] Left [ ] Bilateral [ ] Unspecified
[ ] Hemorrhage (non-traumatic): Please specify Artery: _____________________[ ] Subarachnoid[ ] Intracerebral[ ] Extradural[ ] Subdural: [ ] Acute [ ] Subacute [ ] Chronic
[ ] Cerebral Infarction [ ] Cerebral [ ] Pre-Cerebral Please specify Artery: ___________
[ ] Thrombosis[ ] Embolism[ ] Unspecified occlusion or stenosis[ ] Venous Thrombosis[ ] Other Cerebral Infarction[ ] Cerebral Infarction Unspecified (Stroke NOS)
[ ] Occlusion / Stenosis without Cerebral Infarction[ ] Pre-Cerebral Artery: [ ] Vertebral [ ] Carotid [ ] Other Pre-Cerebral
Artery[ ] Cerebral Artery: [ ] Middle [ ] Anterior [ ] Posterior[ ] Cerebellar [ ] Other Cerebral Artery [ ] Unspecified Cerebral Artery
[ ] Manifestations / Residual Effects[ ] Hemiplegia [ ] Right [ ] Left [ ] Unspecified[ ] Dysphagia
12 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
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
ICD10 Documentation Needed
Same as ICD 9
13 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Degenerative Disc Disease
ICD10 Documentation Needed
Identify Location and if with Myelopathy/Neuritis/Radiculopathy/Radiulitis
[ ] Degenerative Cervical Disc Disease
Specify level of spine: ___________
[ ] With Myelopathy [ ] With Neuritis, Radiculopathy, Radiculitis
[ ] Other/Unspecified
[ ] Degenerative Sacrococcygeal Disc Disease
[ ] Degenerative Lumbar Disc Disease
[ ] With Myelopathy [ ] With Neuritis, Radiculopathy, Radiculitis
[ ] Other/Unspecified
[ ] Degenerative Thoracic Disc Disease
[ ] With Myelopathy [ ] With Neuritis, Radiculopathy, Radiculitis
[ ] Other/Unspecified
[ ] Degenerative Thoraco-Lumbar Disc Disease
[ ] With Myelopathy [ ] With Neuritis, Radiculopathy, Radiculitis
[ ] Other/Unspecified
[ ] Degenerative Lumbosacral Disc Disease
[ ] With Myelopathy [ ] With Neuritis, Radiculopathy, Radiculitis
[ ] Other/Unspecified
14 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Dementia
ICD10 Documentation Needed
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: ___________________
15 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Diabetes
ICD10 Documentation Needed
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
16 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Dysphagia
ICD10 Documentation Needed
IDENTIFY PHASE, TYPE and ACUITY
Phase: [ ] Oral [ ] Oropharyngeal [ ] Pharyngeal [ ] Pharyngoesophageal
Type: [ ] Cervical [ ] Functional[ ] Hysterical [ ] Nervous [ ] Neurogenic[ ] Siderpenic [ ] Spastica
Following Non-Traumatic: [ ] SAH [ ] Intracerebral Hemorrhage[ ] Intracranial Hemorrhage[ ] CVA
Acuity: [ ] Acute [ ] Chronic [ ] Acute on Chronic
[ ] Other specified Dysphagia:___________
[ ] Unspecified Dysphagia
17 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Encephalopathy
ICD10 Documentation Needed
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
18 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Migraine
ICD10 Documentation Needed
IDENTIFY SPECIFICITY
[ ] With Aura [ ] With Refractory Migraine[ ] Intractable[ ] Persistent[ ] Other __________________
[ ] With CVA [ ] Hemiplegic [ ] Intractable[ ] With Status Migrainosus[ ] Menstrual[ ] Cyclical vomiting[ ] Periodic Headache Syndrome[ ] Ophthalmologic
Headache IDENTIFY SPECIFICITY
[ ] Tension[ ] Primary thunderclap[ ] Associated with sex, cough, exertion[ ] Cluster[ ] Post-traumatic[ ] New daily persistent[ ] Vascular[ ] Drug- induced[ ] Other_________________________
19 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
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
ICD10 Documentation Needed
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
20 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
CHRONIC HEART FAILURE
[ ] Chronic Systolic Heart Failure
[ ] Chronic Diastolic Heart Failure
[ ] Chronic Systolic and Diastolic Heart Failure
ICD10 Documentation Needed
SAME as ICD 9 with the addition of etiology
Etiologies:
[ ] Hypertension
[ ] Valvular disease
[ ] Rheumatic heart disease
21 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Hypertension
[ ] Malignant Hypertension
[ ] Accelerated Hypertension
[ ] Benign Hypertension
[ ] Unspecified Hypertension
ICD10 Documentation Needed
Same as ICD 9
22 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Hyponatremia
ICD10 Documentation Needed
Identify specificity
[ ] Hyponatremia, unknown cause
[ ] Hyponatremia due to Sodium Deficiency
[ ] Hyponatremia due to SIADH (Syndrome of Inappropriate Secretion of Antidiuretic Hormone)
[ ] Insignificant lab value
23 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Level of Consciousness[ ] Coma / Comatose
[ ] Encephalopathy, type: ____________________________
[ ] Persistent vegetative state
[ ] Stupor
ICD10 Documentation Needed
Same as ICD 9
24 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Meningitis
ICD10 Documentation Needed
Identify Type, Organism and Present on Admission
[ ] Viral Meningitis
[ ] Specify organism (i.e. adenovirus, enterovirus, measles, etc.) ___________
[ ] Bacterial Meningitis - Acute
[ ] Specify organism (i.e. gram negative, staph, strep, e coli, etc.)___________
[ ] Due to (please specify cause) _________
[ ] Aseptic - Acute
[ ] Late effect
[ ] Septic
[ ] Present on Admission [ ] Yes [ ] No
[ ] Unable to determine
25 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Altered Mental Status
ICD10 Documentation Needed
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
26 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Acidosis/Alkalosis
ICD10 Documentation Needed
Identify Type of Acidosis or Alkalosis
[ ] Acidosis:
[ ] Metabolic [ ] Respiratory
[ ] Lactic [ ] Renal
[ ] Alkalosis:
[ ] Metabolic [ ] Respiratory
27 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Mood Disorder
ICD10 Documentation NeededIDENTIFY Type, Status and SeverityType (check appropriate):
[ ] Manic
[ ] Bipolar [ ] Manic [ ] Depressive [ ] Mixed
[ ] Major Depressive Disorder
[ ] With Psychosis
[ ] Persistent Mood Disorder
[ ] Without Psychosis
Status:
[ ] Single past episode
[ ] Current episode
[ ] In remission [ ] Partial [ ] Full
[ ] With Psychosis
[ ] Without Psychosis
Severity:
[ ] Mild
[ ] Moderate
[ ] Severe
[ ] Unspecified
28 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Neoplasm
ICD10 Documentation Needed
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 ____________________________________
29 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Non Pressure Ulcer
ICD10 Documentation Needed
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
30 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Malnutrition
[ ] Under-nutrition / Malnutrition:
[ ] Mild [ ] Moderate
[ ] Severe [ ] Unspecified
[ ] Protein Calorie Malnutrition:
[ ] Mild [ ] Moderate [ ] Severe
[ ] Unspecified
[ ] Marasmus
[ ] Nutritional Edema
[ ] Other Malnutrition (please specify) _______________________________
ICD10 Documentation Needed
Same as ICD 9
31 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Injury
ICD10 Documentation Needed
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.) ______________________________
32 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Aspiration Pneumonia
ICD10 Documentation Needed
IDENTIFY SPECIFICITY and any associated illnesses
[ ] Aspiration Bronchitis[ ] Pneumonia secondary to______ (specify organism / underlying disease)[ ] Community Acquired (simple) Pneumonia[ ] Healthcare / Hospital Acquired Pneumonia (outside facility / prior hospitalization) [ ] Ventilator associated[ ] Radiation induced
[ ] Associated illness: [ ] Respiratory failure [ ] Sepsis [ ] Underlying lung disease [ ] Other specify)_____
[ ] Pneumonia of unknown etiology[ ] Infiltrates without evidence of Pneumonia
33 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Hypostatic Passive/ Stasis Pneumonia
[ ] Hypostatic Passive/ Stasis Pneumonia
[ ] Pneumonia due to (specify organism/ underlying disease)_____________
[ ] Ventilator-associated
[ ] Radiation induced
[ ] Associated illness:
[ ] Respiratory Failure
[ ] Underlying lung disease
[ ] Other (specify)________________
ICD10 Documentation Needed
Same as ICD 9
34 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
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
ICD10 Documentation Needed
Similar to ICD 9
35 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Pressure Ulcer
ICD10 Documentation Needed
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)
36 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
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 ________
ICD10 Documentation Needed
Same as ICD 9
37 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
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
ICD10 Documentation Needed
Same as ICD 9
38 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Respiratory Failure
ICD10 Documentation Needed
IDENTIFY TYPE, ACUITY and ETIOLOGY
Acute Respiratory Failure: [ ] with Hypoxia [ ] with Hypercapnia
Acute On Chronic Respiratory Failure: [ ] with Hypoxia [ ] with Hypercapnia
Acute Respiratory Failure caused by: _____ (etiology)
[ ] Acute Respiratory Insufficiency following [ ] trauma [ ] other
39 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Post op Respiratory Issues
ICD10 Documentation Needed
Identify Acuity and surgery type
[ ] Post-op Acute pulmonary insufficiency
[ ] Thoracic surgery [ ] Non-Thoracic surgery
[ ] Post-op Acute respiratory failure
[ ] Thoracic surgery [ ] Non-Thoracic surgery
[ ] Post-op Chronic pulmonary insufficiency
[ ] Post-op Chronic respiratory failure
[ ] Hypoxia
[ ] Respiratory failure not related to surgical procedure
[ ] Acute [ ] Chronic [ ] Acute on Chronic
40 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Sepsis
ICD10 Documentation Needed
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.) _______________________
41 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
SHOCK
[ ] Hypovolemic shock
[ ] Hemorrhagic shock
[ ] Cardiogenic shock
[ ] Septic shock (Circulatory failure associated with severe sepsis, represents organ failure)
ICD10 Documentation Needed
Same as ICD 9
42 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Substance Abuse
ICD10 Documentation Needed
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
43 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
TIA
ICD10 Documentation Needed
Identify TIA TYPE
[ ] TIA Stenosis / Syndrome related to:
[ ] Vertebro-Basilar Artery
[ ] Carotid Artery
[ ] Multiple / Bilateral Pre-Cerebral Artery
[ ] Cerebral / Pre-cerebral occlusion / stenosis
[ ] Small vessel disease of the brain / cerebral vascular disease
[ ] Transient Global amnesia
[ ] Amaurosis Fugax
[ ] Other TIA
[ ] Unspecified TIA (spasm of cerebral artery, transient cerebral ischemia)
44 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
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)
ICD10 Documentation Needed
Same as ICD 9
45 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
UTI
ICD10 Documentation Needed
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
46 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Weakness
ICD10 Documentation Needed
Identify due to and laterality
[ ] Weakness due to __________
[ ] Hemiparesis [ ] Hemiplegia
Laterality
(please check all that apply):
[ ] Right side [ ] Left side
[ ] Upper extremity [ ] Lower extremity
[ ] Dominant side [ ] Non-dominant side
47 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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
48 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
Sts. Mary and Elizabeth
Clinical Documentation Specialists Mickey Decker– 502-361-6125
Cheryl Brooks-502-361-6549
Annette Majors- 502-361-6495
Manager- Sandy Hodge- Bowman 502-409-2673
Supervisor- Kristen Boles 859-421-1542
Questions—contact your Clinical Documentation Specialists at your hospital
49 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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
Manager- Sandy Hodge- Bowman 502-409-2673
Supervisor- Kristen Boles 859-421-1542
Questions—contact your Clinical Documentation Specialists at your hospital
50 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
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
Manager- Sandy Hodge- Bowman 502-409-2673
Supervisor- Kristen Boles 859-421-1542
Questions—contact your Clinical Documentation Specialists at your hospital
51 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
St. Joe East
Clinical Documentation Specialists Kimberly Gilbert-Morrison—502-316-5220
Kelly Geers—502-750-2329
Manager- Sandy Hodge- Bowman 502-409-2673
Supervisor- Kristen Boles 859-421-1542
Questions—contact your Clinical Documentation Specialists at your hospital
52 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
Flaget
Clinical Documentation Specialist Cheryl Mitchell—502-350-5247
Manager- Sandy Hodge- Bowman 502-409-2673
Supervisor- Kristen Boles 859-421-1542
Questions—contact your Clinical Documentation Specialists at your hospital
53 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
St Joe London
Clinical Documentation Specialists Katrina Henson—606-330-6759
Sherry Mills—606-330-6000
Manager- Sandy Hodge- Bowman 502-409-2673
Supervisor- Kristen Boles 859-421-1542
Questions—contact your Clinical Documentation Specialists at your hospital