1 Shatondra Surulere, MBA, RHIA, CCS, CCS‐P, CHTS‐PW, AHIMA Approved Trainer and Ambassador Senior Consultant, Revenue Cycle Consulting ICD‐10 Documentation Preparation and Leveraging Documentation Templates and Coding Queries 2 Presentation Objectives Identify ICD-10 documentation requirements for hospitals and physician practices Gain an understanding of today’s documentation challenges Review key ICD-10 documentation requirements Review ICD-10 documentation improvement strategies
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ICD 10 Documentation Preparation Leveraging … · Physician query questions could be addressed in current tools ... Requirements. 15 The Importance of Specificity Specificity in
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Quality, Joint Commission, infection control, and other requirements are often not incorporated in documentation tools
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ICD-10 Documentation Requirements
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The Importance of Specificity
Specificity in documentation is key, because, in ICD-10, fewer “unspecified” codes exist
Specific documentation benefits
Reduces physician queries and AR delays
Reduces denials/request for medical records
More accurate quality and infection control reporting
Your documentation is, the less queries you will receive from the CDI specialist and the coders
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ICD‐10 … A Refresher in Documentation Requirements
Below are some general documentation tips
that you can begin using now to create a
seamless transition to the new system:
Specific diagnosis
o Document the diagnosis to the
greatest level of specificity
Specific anatomy
o Document the exact body location
Document ALL conditions identified and treated during the encounter
o Secondary diagnosis ARE IMPORTANT
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ICD‐10 … A Refresher in Documentation Requirements
Laterality
Document which side of the body- right or left
o Note: approximately 5,000+ codes have a right and left distinction
Dominant verses non-dominant side
Document dominant verses non-dominant side for all paralytic syndrome conditions
Initial verses recurrent
Document whether the condition is initial or recurrent
Combination codes for conditions and common symptoms or manifestations
o Secondary diagnosis ARE IMPORTANT
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Cardiovascular Example
CAD (coronary arteriosclerosis) is specified as of native vessel, bypass graft, or transplanted heart.
Combination codes to include CAD with angina (unstable, with spasm, other) as well as CAD with ischemic chest pain.
Document exact date of MI New/initial MI: Occurred or diagnosed within the past four
weeks but not previously treated Old MI: Report a "healed or old MI" whether the patient is
currently experiencing problems or not Subsequent MI: subsequent, new MI occurring within the
four-week timeframe of the initial MI Document type of MI
STEMI vs. NSTEMI
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Cardiovascular Documentation Examples
Physician office documentation: “reports history of CAD, HTN, MI, and angioplasty”
o Need additional documentation CAD is present after angioplasty of a native artery (I25.10) or of the bypass (I25.810)
o Documentation regarding the date and specifies of the MI will be required
Inpatient physician documentation: “patient has history of ESRD, CHF, and high blood pressure and
past MI”o There is conflicting documentation on this chart from another
physician, stating that the patient has HTN. HBP and HTN are coded differently, and, if the patient truly has HTN (I10), it should be documented as such, not as HBP (R03.0).
o Documentation regarding the date and specifies of the MI will be required
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Laterality Documentation Examples
For all body parts that can be defined as left, right, or bilateral side(s), the specific “side” must be documented
Physician office documentation “patient complains of hearing
loss (right); large right cerumen impaction” – good example of laterality documentation (H61.21 –impacted cerumen, right ear)
Physician office documentation “patient presents with glaucoma
and senile cataract” – This would need specification for the glaucoma and cataract(s), are they right, left, or bilateral?
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Fracture Documentation Requirements
More information will be required to accurately code fractures in ICD-10 type of fracture specific anatomical site whether the fracture is
displaced or not laterality routine versus delayed healing nonunion and malunions
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Injury Documentation Requirements
Documentation for injuries should include the “encounter type”
Initial encounter
Subsequent encounter for fracture with routine healing
Subsequent encounter for fracture with delayed healing
Sequela of fracture
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Pregnancy/Obstetrics Documentation
All diagnoses related to a patient’s pregnancy should have the trimester in which the problem began documented (1st
trimester up to 13 weeks, 6 days; 2nd trimester 14 weeks 0 days to 27 weeks 6 days; 3rd trimester 28 weeks 0 days to delivery) Inpatient physician documentation:
H&P – “patient is 29 weeks pregnant, presents with new onset of malnutrition, low weight gain since week 20, and edema of the legs which is new.”
This is an example of good documentation regarding obstetrics. The codes for this patient would be:
o O25.13 – malnutrition in pregnancy, 3rd trimester
o O12.03 – gestational edema, 3rd trimester
o O26.12 – low weight gain in pregnancy, second trimester
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Tobacco Use/Exposure Documentation
The medical record documentation should include information regarding the patient’s history impact to current encounter and treatment
Tobacco use/abuse codes now specify what type of tobacco (cigarettes, chewing tobacco, etc.)
Any patient with a respiratory diagnosis and/or cardiac diagnosis should have documentation of current and/or past tobacco smoke exposure/abuse
Identify your most common diagnoses and procedures and pull a sample of medical records by physician.
Conduct an ICD-10 documentation gap analysis. Identify gaps and trends
By disease
Specialty
Physician
Start with the Documentation
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Step 3: Work Flow Optimization
Consider work flow re-design sessions
Evaluate dashboards Documentation issues by disease
Physician query trends
A/R delays due to non-specific and/or missing documentation
Identify opportunities to utilize technology Enhance tracking, trending and reporting to capture
trends and delays
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Step 4: Develop Future State Tools
A successful conversion to ICD-10 will require a review of current tools to identify enhancements to facilitate capture documentation required for code assignment CPOE Templates EHR Templates Physician Query Forms
Identify ICD-10 specific documentation requirements Engage Physicians to identify opportunities to enhance
compliance and acceptance A few things to consider
Work flow re-design sessions Utilizing an ICD-10 Approved Trainer
Start NOW!
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ICD‐10 Mitral Valve Disorder Code Revisions
ICD-9 Code
ICD-9 Descriptions ICD-10 Code ICD-10 Description
424.0Mitral Valve Disorders
I34.0Nonrheumatic mitral (valve) insufficiency
I34.8Other nonrheumatic mitral valve disorders
Mitral Valve DisordersDocumentation Specificity Required for Code Assignment
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Problem List/CPOE Templates
Problem Non-Specific Documentation Specific Documentation
Hypertension, heart disease, kidney disease
1) HTN; 2) CAD; 3) CKD
Hypertensive heart and CKD, stage 4, w/out heart failure