OBSTETRICS and GYNECOLOGY - Tahoe Forest … and GYNECOLOGY ... liver enzymes and LP = Low platelet count> Syndrome ... Abnormal Findings on Antenatal Screening of Mother

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OBSTETRICS and GYNECOLOGY

INSTEAD OF PLEASE CONSIDER ALSO INCLUDING:

ICD 10 Themes: e.g. Acute on Chronic Systolic Heart Failure

Acuity/Severity/Type/Staging

Acute/Chronic/Acute on Chronic

Mild, Moderate, Severe

Systolic, Diastolic, Combined

Stage I, II, III, IV

e.g. Malignant neoplasm of lower lobe right bronchus

Anatomy/Site Specificity

Location of tumor

Bone/Joint/Muscle involved

e.g. Decubitus Ulcer, Stage 3, Right Buttocks, Present on Admission

Laterality

Right/Left/Bilateral/Overlapping (see Neoplasm re overlaps two or more contiguous (next to each other) sites)

e.g. Hypertensive heart disease with chronic systolic heart failure

Manifestations – LINK IT!

Associated or Related Conditions

‘With’/‘Secondary’ to/’Due to’

‘Evidence of’ and causative organism

Use ‘no organism isolated’, instead of ‘negative culture’

e.g. Likely Sepsis secondary to UTI; Evidence of Bacterial Pneumonia (‘Evidence of’ in outpt setting can be captured as a diagnosis)

Etiology – ‘DUE TO’ WhAt?

‘LIKELY’ suspects….Who dun it?

Possible, Probable, Suspected (Inpt Only)

Evidence of, As Evidenced by (Outpt Setting and Inpt Setting)

e.g. Drug Poisoning/Adverse Effect Episode of Care/Incidence of Encounter (Trauma/Fractures/Medication.Chemical Event(Drug Poisoning))

Initial/Subsequent/Sequela

Antepartum/Post Partum/Delivered (Changed to Trimester…okay for MD to put in Gestational Weeks, Coder will convert)

Time Frame: Trimester/Weeks of Gestation

1st = < 14 wks, 0 days

2nd = 14 wks, 0 days to 28 weeks, 0 days

3rd = 28 wks, 0 days until delivery)

ALWAYS INCLUDE ON EACH ENCOUNTER

Top Diagnosis Codes by Specialty:

Late Pregnancy

Time Frame:

Post Term is > 40 weeks – 42 weeks;

Prolonged is > 42 weeks

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Cesarean Section, Indication for Etiology: Repeat (Previous)/ Breech/ Cephalopelvic Disproportion (CPD); etc

Delivery with Laceration Stage: 1st, 2nd, 3rd, 4th Degree Tear

Anatomical Site: Perineal/Anal Sphincter

Procedure: Description of how/what repaired

Obstructed Labor Etiology:

Malposition or Malpresentation: Incomplete Rotation of Head/Breech, Face, Brow, Shoulder, or Compound Presentation/Other, i.e. Footling or Incomplete Breech Presentation

Maternal Pelvic Abnormality, i.e.: Deformed Pelvis/Contracted Pelvis/Pelvic Inlet Contraction/Pelvic Outlet and Mid-Cavity Contraction/Fetal Pelvic Disproportion/Abnormality of pelvic organ, e.g. congenital malformation of uterus or cervical incompetence/Other

Other Etiology: Shoulder Dystocia/Locked Twins/Unusually Large Fetus

Abnormal Fetal Heart Rate or Rhythm Type: Bradycardia/Decelerations/Irregularity/Tachycardia etc

Advanced (Elderly) Maternal Age Delivery Time Frame: Trimester/Weeks of Gestation

(≥ 35yrs) Type: Primigravida/Multigravida

Breech Type: Complete; Incomplete (Footling); Frank

Cord (Nuchal) Entanglement/Around Neck Etiology:

Around Neck, With or Without Compression

Entanglement, With or Without Compression

Other Etiologies: Prolapse of Cord/Short Cord/Vasa Previa/Vascular lesion of cord/Other

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Postpartum Hemorrhage Type: Third Stage (associated with retained placenta);

Other Immediate (following delivery of placenta or uterine atony);

Delayed and Secondary (retained portions of placenta after 1st 24 hours of delivery)

Delayed Delivery after ROM Type: Spontaneous/Artificial or Other (Coded as Premature ROM)

Time Frame:

With Onset of Labor

after or within 24 hours

Trimester/Weeks of Gestation: Full Term (after 37 completed Weeks of Gestation)

Pre – Term (before 37 completed Weeks of Gestation)

Primary Uterine Inertia Type: Primary (Failure of Cervical Dilation) /Secondary (Arrested Active Phase of Labor)

Time Frame: Trimester/Weeks of Gestation

Prolonged Second Stage of Labor Stage: First Stage/ Second Stage/ Delayed Delivery of second twin, etc.

Time Frame: Trimester/Weeks of Gestation

Precipitate Labor Time Frame: Trimester/Weeks of Gestation

Abnormal Glucose Tolerance Etiology: Diabetes Mellitus/Hypoglycemia/Antenatal Screening/Complicating Pregnancy/Glycosuria/Other

Time Frame: Trimester/Weeks of Gestation

Early Onset Delivery Time Frame: Trimester/Weeks of Gestation

Onset of Delivery after 37 weeks, planned C Section Time Frame: Trimester/Weeks of Gestation

Etiology: Breech/Distress/Cephalopelvic disproportion/Failed (e.g. forceps)/Malposition/Hemorrhage (intrapartum)/Planned, Other

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Pre-eclampsia Severity: Mild-Moderate or Severe

Indicate if with HELLP <HE = Hemolysis, EL = Elevated liver enzymes and LP = Low platelet count> Syndrome

Time Frame: Trimester/Weeks of Gestation

Abortion, Spontaneous Type: Spontaneous/Induced

Manifestation: Complete/Incomplete

Complications: Genital tract and pelvic infection/Delayed or excessive hemorrhage/Embolism/Shock/Renal Failure/Metabolic Disorder/Damage to Pelvic Organs/Other Venous/Cardiac Arrest/Sepsis/UTI/Other/

Hyperemesis (Note: Coders canNOT code ‘↓’ ‘↑’, must state the imbalance i.e. hyponatremia) Re: Hyperemesis Gravidarum - definition of early vs.

late pregnancy changed to 20 weeks (from 22 weeks)

Manifestations: With dehydration/electrolyte imbalance/Severe (with metabolic disturbances)

Specify the metabolic disturbance, i.e. Acute Renal Failure, Hypovolemia

Specify the electrolyte imbalance i.e. Hyponatremia/Hypokalemia etc

Severity: Mild/Severe

Anemia Acuity: Acute/Chronic

(Acute Blood Loss Anemia does not reflect a complication of surgery, unless surgeon states it’s a complication and there is a cause and effect relationship; May state ‘expected’/’inherent’; Documentation of ‘Post-op Anemia’ is not enough, instead ‘Post Operative Anemia due to Acute Blood Loss’)

Etiology: Blood Loss; Iron Deficiency; Chemotherapy; Neoplastic; Aplastic, etc

Incidental to Pregnant State vs. Impacting Pregnancy

State “Does not affect or complicate the pregnancy” if incidental, otherwise will code as ‘impacting the pregnancy’

e.g. Pregnant patient with burn of hand, “Burn of hand does not affect or complicate the pregnancy”

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Gestational Hypertension vs. Gestational Edema and Proteinuria without Hypertension (Findings of edema and proteinuria explain an increase in number of office visits and complexity of patient you are treating.)

Type: Gestational Edema and Proteinuria With Gestational Hypertension Without Gestational Hypertension

Pre-Existing vs. Pregnancy Induced Conditions State ‘pre existing’ vs. ‘pregnancy induced’ i.e. Gestational Hypertension

Abnormal Findings on Antenatal Screening of Mother

Type: Hematological/Biochemical/Cytological/Ultrasonic/Radiological/Chromosomal and Genetic/Other/Unspecified

Multiple Gestation - # placenta/# amniotic sacs

(Clarify which fetus related to problem, as applicable, Fetus 1 or Fetus 2)

For Twins: -Monochorionic/Monoamniotic -Monochorionic/Diamniotic -Dichorionic/Diamniotic, or -Unable to determine number of placenta and number of amniotic sacs

Early Pregnancy Time Frame: Changed to 20 weeks (from 22 weeks)

Emphasized with: Hyperemesis Gravidarum/Abortions/Fetal Deaths/Hemorrhage

Pre-term Labor Time Frame: Prior to 37 weeks

Uterine Leiomyoma (Fibroid Tumor) Anatomical Site: Submucousal/Intramural/Subserosal/Unspecified

Dysmenorrhea Type: Primary/Secondary/Psychogenic/Other

Diabetes Type: Type 1 or Type 2 ; Drug or Chemical Induced; or Gestational

Terms i.e. ‘uncontrolled’ or ‘inadequately controlled’ code to ‘hyperglycemia’…even if recent ‘hypoglycemia’…..specifically use Hypoglycemia or Hyperglycemia instead. Or if used, stipulate if not hyperglycemic.

Control Status (Insulin):

With: Hypoglycemia/Hyperglycemia

Insulin Use

Associated Diagnosis/Conditions: i.e. ulcers

(be clear in note if patient has only an abnormal Manifestations or Secondary related problems

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glucose tolerance test but no diagnosis of diabetes) (document LINK to Diabetes): i.e. neuropathy; nephropathy; retinopathy; ketoacidosis

Depression Acuity: Acute/Chronic/Recurrent/Single Episode

Severity: Mild/Moderate/Severe

Type: Anxious/Bipolar/Atypical/Post-Partum

CAUTION: ‘Unspecified Depression’ codes to MAJOR Depressive Disorder….is it actually a LESS severe disorder i.e. Adjustment Disorder; Anxiety Depression..please be specific

Etiology: Dementia; Head Injury; Multiple Sclerosis; Stroke; Pregnancy;

Manifestations: Anxiety/Suicidal Ideation/Somatization

Remission Status: Partial/Complete

Nutritional Anemia Type: i.e. if nutritional due to iron deficiency: Sideropenic iron deficiency anemia; Iron deficiency due to inadequate dietary iron intake

Vitamin B12 type i.e. Due to intrinsic factor deficiency; Vitamin B12 malabsorption

Folate Deficiency type: i.e. Due to diet; Drug induced

Other Nutritional Types: i.e. Protein deficiency

Anemia in Chronic Disease Link to Chronic Disease i.e. -Anemia due to chronic kidney disease -Anemia due to colon cancer

Neutropenia Type: Agranulocytosis/Other Drug Induced/Congenital/Cyclic

Etiology: Cancer Chemotherapy/Infection etc.

If Drug-induced: - Specify Drug - Purpose of drug’s use (e.g. chemotherapy) - Specify the malignancy (e.g. Cytoxan for primary

malignancy upper-inner quadrant of left breast

Associated Conditions (e.g. infection)

Adverse Effect (e.g. fever or mucositis)

Thrombocytopenia Classification: -Idiopathic -Primary -Secondary -Congenital or Hereditary -Heparin Induced

Secondary Thrombocytopenia: - Underlying Condition (e.g. alcohol induced)

Specify Hemorrhagic Conditions (e.g. qualitative platelet defects)

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Pancytopenia Definition - Anemia (e.g. Hct < 32%); and, - Thrombocytopenia (e.g. PPC < 150K); and, - Neutropenia (e.g. ANC < 1,500)

–

Physician must describe underlying cause and what individual component has been treated

- e.g. Platelets for thrombocytopenia - PRBC transfusion for acute blood loss anemia

Etiology - Malignancy (Specify Malignancy) - Drug induced (Specify specific drug) - ‘Pancytopenia due to antineoplastic

chemotherapy’ or - ‘Pancytopenia secondary to Cisplatin and

disease’ , Or - ‘Pancytopenia due to HIV disease.’

Complications of Surgery Affected Body System

Specific Condition

Timeframe: Intra operatively or Post operatively

(Punctures or lacerations that are unavoidable or inherent to the procedure are not complications. When NOT a complication…include the medical decision making and characterize the event as ‘intentional’, ‘unavoidable’, or ‘inherent’ to the procedure)

Link Complication to Diagnosis: ‘due to’/’secondary to’ etc… There is no timeframe/deadline for a Postoperative Complication (current condition due to previous surgery or procedure)

NOT Complications Document: Inherent, Expected, Intended

Avoid ‘Accidental/Complication/Unavoidable/Slip/ Iatrogenic/Unintended’ etc when it is not a complication. Avoid using ‘Post operative’ when not a complication; if used, include that it was ‘intended, expected, inherent’ etc.

Additional Terms that suggest non-accidental: to facilitate; necessary; required; intentional; integral; routinely expected

Procedure Coding System (PCS) – New with ICD 10

Pre-operative/Post Operative Diagnosis State difference b/w pre and post dx, as applicable

Link ‘findings’ with post operative diagnosis

Procedure Performed Be Explicit, including unplanned

Post op drains/tubes – Specify type of drain/tube

Be specific re ‘intent’ of surgery i.e. Excision/Biopsy etc

Types of Anesthesia/Estimated Blood Loss (EBL)/Transfusions

-Site infused (Central/Peripheral) - Type & Volume of Fluid (Fresh/Frozen/Autologous)

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Procedure – Coder needs ALL elements addressed in order to be able to assign a code…..physician can use their own language for coder to translate, yet all information needs to be available. Coders must have a clear understanding of the ‘intent’ of the procedure..it will help the coder properly assign the appropriate code.

-Intent of the Procedure - Excision (partial removal i.e. biopsy)/Resection (total removal)/Drain fluid/Inspect i.e. endoscopy etc. -Approach—Specify technique used to reach the site i.e. open, percutaneous, use of scopes etc -Prose for steps and technique, not the name of procedure -Laterality of incision/Relative Location -Anatomical site – Be specific re site/Body Cavity (instead of quadrants)/How much of body part removed (all, partial, or measurements) - Devices Used Intraoperatively – material or appliance that remains in the body after the procedure is completed. i.e. Biological or synthetic material (i.e. joint prosthesis, intrauterine device; Therapeutic material (i.e. radioactive implant); Mechanical or electronic appliances ( i.e. orthopedic pin, pacemaker) etc. -Intraoperative Grafting – source and destination site -Modality of Guidance -Specimens – specify if sent to pathology are intended to diagnose and help treatment decisions following the procedure. -Medications applied at Surgical Site -Closure – type/area -Complications

Procedure Documentation:

Lymph Node Removal Differentiate between removal of: -One or more (portion) lymph nodes Versus -Removal of an entire chain of lymph nodes

Anatomical Site: Head; Right/Left Neck; Right/Left Axillary; Mesenteric; Right/Left inguinal etc

Lysis of Adhesions

Anatomical Site of each organ or body part RELEASED/FREED, i.e.

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(The body part value coded, is the body part being freed, not the tissue being manipulated or cut to free the body part.)

-Greater Omentum -Lesser Omentum -Mesentery

Etiology: i.e. previous surgery; chronic infection/inflammation; preventing access to surgical site

(Adhesions that exist without being organized or without causing any symptoms or without increasing the difficulty of performing the operative procedure will not be coded separately.)

Amount: Extensive; Numerous etc

Timeframe: i.e. Extensive lysis; Tedious lysis; long time to lyse

Secondary Conditions:

Urinary Tract Infection Acuity: Acute or Chronic

e.g. ‘Chronic Cystitis with hematuria’; ‘Acute Urethritis due to E.Coli’; ‘Acute on Chronic Pyelonephritis due to foley cathether with Candida’

Specific Site: Bladder (Cystitis)/Urethra (Urethritis)/Kidney (Pyelonephritis)

Manifestations: Hematuria etc.

Causative Organism i.e. E Coli or Candida

IF related to a device i.e. foley catheter, state ‘due to’ or ‘secondary to’

Cysts Anatomical Site: Corpus Luteum/Paratubal etc

Laterality: Right/Left/Bilateral

Causative Agent: Bacterial or Viral

Causative Organism: (if known)

Manifestation: Hydrosalpinx etc

Etiology: Hemorrhagic etc

Obesity BMI 19 or less = Indicates Malnutrition

BMI 25 – 29.9 = Overweight

(BMI can be taken from Nursing Documentation; MD needs to document the diagnosis and etiology/manifestation correlating to BMI)

BMI 30.0 – 39.9 = Obesity

BMI = ≥ 40 = Morbid Obesity (state Etiology: Excess Calories ; Other and Manifestation: Alveolar Hypoventilation, as applicable)

Etiology: Excess Calories (for Morbid Obesity); Drug Induced; Endocrine; Familial; Constitutional; etc

Manifestation: Alveolar Hypoventilation (for Morbid Obesity)

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Malnutrition BMI 19 or less = Indicates Malnutrition

Acuity: Acute (< 3 mo); Chronic (>3 mo)

Severity: Mild/Moderate/Severe

(BMI can be taken from Nursing Documentation; MD needs to document the diagnosis and etiology/manifestation correlating to BMI)

Type: Protein Calorie; Protein Energy

Etiology: Renal Disease; Pregnancy Related; Diabetes; Following Gastrointestinal Surgery, etc

Utilize Dietician’s Assessment to assist you with diagnosis. To review MNT Nutrition Evaluation in CPSI, Go to <chartlink> <C/H Section tab> <MNT Nutrition Evaluation, page 1 and 2.

Manifestations: Insufficient Energy Intake; Unintentional Weight Loss; Significant Edema or Ascites; Diminished Functional Capacity; Cachexia; Dehydration;

Hypotension Etiology: Postural; Orthostatic (chronic); Neurogenic (Orthostatic); Postoperative; Drug-induced; Cardiogenic; Idiopathic; etc

Non Pressure Ulcer Wound Acuity: Chronic

Laterality

Severity/Depth of Tissue Involved: Skin Breakdown; Fat Layer Exposed; Muscle Necrosis; Bone Necrosis; Unspecified Severity

Etiology: Diabetes; Infection (specify); Other (specify)

Present on Admission, if applicable

Pneumonia Type: Healthcare Associated/Aspiration/Ventilator Associated/Radiation Induced

CAUTION: CAP-Community Acquired PNA- defaults to a ‘simple pna’ with low severity; if documented, please also include if it is Viral or Bacterial (and other items listed from list on right, as applicable) to capture the true severity.

Causative Agent: Viral or Bacterial

Causative Organism (if known)

Associated Illnesses: influenza/ lung abscess/Sepsis

Common Secondary Conditions: Acute Respiratory Failure; Exacerbation of COPD, etc.

Clinically significant diagnostic results from Lab and Radiology in the medical record. i.e. if elevated white count; infiltrate on CXR

History of Tobacco Use, Present or Past

Respiratory Failure Acuity: Acute/Chronic/Acute on Chronic

(Chronic RF is very common in pt with severe COPD) CAUTION: ‘Respiratory Distress’ and ‘Respiratory

Manifestation: With Hypoxia or With Hypercapnia, or both

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Insufficiency’ are vague and symptomatic of underlying condition – is the intended diagnosis Respiratory Failure OR what is other underlying condition?

Etiology: if known (i.e. due to COPD Exacerbation; Pneumonia; Surgery, Trauma, etc)

Sepsis Type: Sepsis/Severe Sepsis/Septic Shock

(fyi: negative or inconclusive blood cultures do not preclude a diagnosis of sepsis in patients with clinical evidence of the condition)

Causative Organism (if known)

(fyi: Bacteremia is a non specific diagnosis and indicates the presence of bacteria in the blood, but does not indicate the bacteria are pathological or has any resulting systemic illness needing treatment.)

Underlying Systemic Infection (the source of infection) i.e. Sepsis due to UTI

(fyi: Urosepsis is non descriptive term and is NOT synonymous with sepsis and there is no default for coders…please .use ‘Sepsis due to UTI’ instead) (fyi: Sepsis Syndrome is a non specific term..avoid using it)

Any Associated Organ Dysfunction i.e. Acute Renal Failure; Acute Respiratory Failure; Encephalopathy

SIRS Infectious or Non-infectious (If ‘non-infectious’ specify what ‘due to’, i.e. ‘SIRS due to Burn’)

Always document the Etiology!! With severe Sepsis or Without Sepsis

With or Without Organ Dysfunction

(Does NOT code to Sepsis, unless stated ‘with sepsis’)

Defaults to the underlying infectious process i.e. Pneumonia

Underdosing Intentional vs. Unintentional

Reason for Underdosing i.e. financial hardship or Age related dementia

Episode of Care: Initial/Subsequent/Sequela

Tobacco Use Use/Dependence/Contact with Second Hand Exposure (Acute or Chronic)

Current/No longer Use Tobacco/Never

Type of Tobacco Product: Cigarette/Chewing Tobacco/Nicotine

If Dependence: Uncomplicated/In remission/With withdrawal/With other Nicotine induced disorder

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ADDITIONAL DOCUMENTATION TIPS

Radiology Tests Ordered

‘Better info given →Better outcome on Report’

Reason for Exam –Be Specific as to what looking for - Anatomical Site Specificity/Where specifically the

problem is…i.e. ‘tender over T9’ instead of ‘back pain’

- Indication for Xray, i.e. Lt Pleuritic Chest Pain; Orthopnea; SOB at rest

- Why doing exam/What are you looking for? i.e. re Cancer…’Looking for Metastasis

- AVOID: R/O, Pre –Op, Vague terms i.e. cough, dizzy. Instead state, fever, shakes, chills so Radiologist can help you capture Pneumonia if present.

- Example of Reason for Exam: ‘Pt fell of ladder, pain medial aspect Lt ankle x 3 days’ instead of ‘ankle pain’; OR, ‘Pt with fever, chills, productive cough green sputum x 2 days’ instead of, ‘cough’.

Chronic Conditions/Secondary Diagnosis Capture the Severity!!!

Avoid stating ‘History of’ ……Instead document what you are doing for Chronic Conditions now! Examples of documentation showing link between the additional disease and this admission’s evaluation, treatment, or monitoring:

Hypertensive Heart Disease and Chronic Kidney Disease (CKD), stage 3 (Strict I & O, Monitor BP)

Chronic Systolic Heart Failure (Echo, Lasix 40 mg)

Hypokalemia (K+ repleted)

Acute Blood Loss Anemia (2 U PRBC’s)

Indicate “Present on Admission” (POA) status, as applicable

A diagnosis without documentation of being present on admission could be inadvertently considered a hospital-acquired condition (HAC). Example: Pneumonia not definitively diagnosed until hospital day two but suspected, probable, or likely on admission should be noted as such. This allows coders to most accurately report the condition as being POA as opposed to hospital-acquired.

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AVOID Signs and Symptoms as Diagnosis Definitive diagnoses are preferred in the inpatient setting and support a higher evaluation and management (E/M) fee. In the inpatient setting, coders can capture ‘probable’, ‘likely’, ‘suspected’, or presumed diagnoses when patients present with the signs and symptoms of the diagnoses being ruled out…. as long as those diagnoses are restated in the discharge summary and have not been ruled out during the stay.

Discharge Summary Wrap it all up!!

For all ‘Rule Out’ situations: Rule it in!/ Rule it Out!/or state ‘Resolved’

Avoid Conflicting with previous documentation substantiated in the record……Caution: If primary physician subsequent dictation conflicts with previous ‘consult’ note, the primary physician’s diagnosis is taken.

INCLUDE: Reason for hospitalization: Chief Complaint; including description of the initial diagnostic evaluation Significant Findings: -Admitting Diagnosis - reason for hospitalization -Discharge Diagnosis - significant findings/diagnoses -As well as those conditions resolved during hospitalization -List all possible and probable diagnoses as well -Hospital Course (procedures performed and findings/surgical findings/test results/treatment rendered/consults) -Discharge Disposition – pt condition at discharge -Education -Follow up needed -Diet -Medications – discharge meds; changes; discontinued meds -Discharge Instructions (instructions to patient and family, including follow up)

References: 3M physician video; CMS Road to 10; Coding Guidelines; 3M Doc tips; AHIMA ACDIS ICD 10 Webinar 12.2014; ACDIS ICD 10 CDI Bootcamp 2014; ICD 10 CM for Hospitals; Precyse Doc Talks ;Optum ICD 10

Check out www.tfhd.com/icd10