The Transition toWhat you need to know for Gynecology

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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• Document site and type:– Cervix: mild,

moderate, or severe– Vaginal: mild,

moderate, or severe– Vulva: mild, moderate,

or severe

Dysplasia

Complications of Surgery• Physician documentation must include the

cause and effect relationship between the procedure 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

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Endometriosis

• Document site:–Ovarian –Fallopian tube–Parametrium–Uterus–Vagina–Specify other

site

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Female Genital Prolapse

• Document type:– Cephocystoc:

midline or lateral– Uterine prolapse:

1st, 2nd degree– Rectocele– Vaginal intercelic

Menstruation Excessive and Frequent• Document:

–With regular cycle

versus–With irregular cycle

• Document if occurring during:–Puberty –Perimenopausal period–Postmenopausal period

• Document if appropriate additional dx of acute/chronic blood loss anemia

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Neoplasms• Document site and laterality such as:

– Ectocervix– Left ovary

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

remission etc.• For secondary sites:

– Document suspected final pathology results• Document final pathology results

– EVEN IF RECEIVED AFTER THE PATIENT IS DISCHARGED WITH A LATE ENTRY DATED AS NEEDED

• Document if neoplasm is benign or malignant

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Urinary Tract Infection (UTI)/CAUTI• If UTI is related to a device, such as Foley catheter

or cystostomy tube, clearly indicate this by using words such as “due to” or “secondary to”.

• Document if Present on Admission• Identify the specific site of the UTI, if known, such

as:–Bladder–Urethra –Kidney

• Document causative organism, when known or suspected, such as E. coli or Candida

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