The Transition toWhat you need to know for Nephrology

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

Chronic Kidney Disease

• Document stage:– Stage 1-5– End stage (ESRD)

• Document etiology, for example:– Diabetic CKD– Hypertensive CKD

• Document if patient is on dialysis

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Acidosis-metabolic, respiratory, lactic

• Link abnormal lab value to clinical diagnosis

Acute Kidney Failure/Injury• Document etiology, if known or suspected, such as:

- Acute tubular, cortical, or medullary necrosis- Postprocedural- Posttraumatic- With transplant kidney

• Be clear on your intended diagnosis. Note that “acute renal insufficiency” results in an “unspecified” code.

• Do not use abbreviations AKI or ARF

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Hypertensive Heart Disease• Document link of cardiac and renal disease

states• Document type of CKD:

– CKD Stage 1-5– End Stage (ESRD)

• Document type of heart failure:– Systolic Heart Failure– Diastolic Heart Failure– Systolic & Diastolic Heart Failure

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Nephritic Syndrome• Document Severity:

– Acute– Rapidly

progressive– Chronic

• Document Manifestation:– Glomerular

Disease– Glomerular

Nephritis11

Nephrotic Syndrome

• Document Manifestation:– Glomerular Lesions– Type Glomerular

Nephritis

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