The Transition to What you need to know for Cardiothoracic Surgery Date | Presenter Information.

The Transition toWhat you need to know for Cardiothoracic Surgery

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

2

Ongoing Support for ICD-10Physician Advisors

Clinical Informatics

3

-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)

4

What should be documented?

5

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

6

Key Changes Needed to Support ICD-10 Coding

Anemia in Chronic Disease

• Document the chronic disease and link it to the anemia, for example:– Anemia due to chronic

kidney disease-specify stage of CKD

– Anemia due to a specific neoplasm

– Anemia due to chemotherapy

• Document neoplasm as primary secondary

Anemia, Blood Loss

• Document, when appropriate:– Anemia due to acute

blood loss– Anemia due to

chronic blood loss – Acute on chronic

anemia– Postoperative

anemia due to acute blood loss

Pulmonary Embolism• Document type, such as:

– Saddle– Septic

• Document cor pulmonale if present and whether it is:– Acute or Chronic

• Specify if PE is: – Chronic (still present) versus– Resolved– Note that “history of PE” is ambiguous

• Document if anti-coagulant therapy is for active treatment or prophylactic

9

Acute Myocardial Infarction (AMI)• Document Type as:

- STEMI or NSTEMI• Document Location:

– Transmural– Anterior Wall– Inferior Wall– Subendocardial– Other site

• Document exact date of recent MI (one occurring within the last 4 weeks) and type:– STEMI and wall of heart affected versus NSTEMI

10

Cardiac Arrest

• Document cause as due to:– Underlying cardiac

or non-cardiac condition

– Show cause and effect by using words such as “due to” or “secondary to”

11

• Document the underlying cause

Cardiogenic Shock

Coronary Artery Disease (CAD)• Document Site as:

– Native artery and/or– Bypass graft

• Autologous vein• Autologous artery• Nonautologous

• Document if with:– Angina pectoris– Unstable angina pectoris– Angina pectoris and spasm

12

ECHO, EKG, CXR, and Laboratory

Results

• Document diagnosis based on clinical findings as well as diagnostic study results in progress notes and the discharge summary indicating the clinical significance of the diagnosis

13

• Specify actual diagnosis

Hypernatremia, Hypokalemia, Hypocalcemia, Hypermagnesemia

Congestive Heart Failure (CHF)• Document severity:

– Acute – Chronic– Acute on chronic

• Document type:– Systolic– Diastolic– Combined systolic & diastolic

• Document etiology, if known, such as due to:– Dilated cardiomyopathy– Other

14

Hypotension• Document type

– Blood loss acute/chronic and cause

– Idiopathic– Orthostatic– Postural– Due to drug-specify

drug– Post procedural – Due to hemodialysis

15

Excessive Bleeding After Surgery

• Document underlying cause:– intraoperative

hemorrhage– postoperative

hemorrhage– acute blood loss

anemia

Atrial Fibrillation & Atrial Flutter• For atrial fibrillation, document type as:

– Paroxysmal – Persistent or – Permanent

• For atrial flutter, document type as: – Typical or Type I or– Atypical or Type 2

• For both, document if condition is a complication of surgery

16

Ventricular Tachycardia

• Document diagnosis in progress notes if agree with diagnosis

17

Ileus

• Document if condition is a complication of surgery or is an expected outcome

Venous Embolism Thrombosis, Phlebitis, and Thrombophlebitis

• Document location:– Portal vein– Hepatic vein– Vena cava,

superior, inferior– Thoracic vein– Renal vein – Deep vein of

lower extremity– Femoral vein– Iliac vein– Tibial vein– Superficial vessel

of upper extremity18

• Document location continued:– Deep vein of upper

extremity– Antecubital vein– Basilic vein– Cephalic vein – Radial vein– Ulnar vein– Axillary vein– Subclavian vein– Inner jugular

• Document severity:‒ Acute chronic

• Document laterality‒ Right ‒ Left‒ Bilateral

• Document device if underlying cause‒ PICC‒ Central line‒ AV Graft

Respiratory Failure• Document severity:

– Acute– Chronic– Acute on chronic

• Document type:– Hypoxic– Hypercapnic– Hypoxic and hypercapnic

• Document if associated with COPD• Post-procedural

– Acute post-procedural Respiratory failure– Acute on chronic post-procedural respiratory failure

19

Pneumonia• Document type:

– Aspiration pneumonia– Ventilator associated pneumonia– Viral pneumonia– Bacterial pneumonia

• Document causative organism, when known or suspected:– Klebsiella pneumonia– Gram negative pneumonia

20

21