Tips on ICD-10 Clinical Documentation for Providers
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1 Tips on ICD-10 Clinical Documentation for Providers
2 Objectives To reinforce quality clinical documentation guidelines To provide examples of documentation necessary to support ICD-10 To outline the granularity of ICD-10 2
3 The Inpatient and Outpatient Medical Severity of illness Record Must Support: Publically reported data Quality Indicators Enough information for the coder to apply the correct code 3
4 Documentation Principles for ALL Settings: Inpatient and Outpatient Each encounter includes: Reason for encounter Relevant history Physical examination findings Prior diagnostic test results Assessment Clinical impression or diagnosis Medical Plan of Care 4
5 Documentation Principles: Inpatient and Outpatient Rationale for ordering diagnostics and ancillary services Health risk factors identified Patient s progress Patient s response to treatment Revisions of diagnosis documented based on clinical results All codes reported on the claim form must be supported in the medical record 5
6 Documentation Establishes CAUSE-and-EFFECT Relationship Type 2 diabetes with diabetic nephropathy Anemia due to chemotherapy Anemia due to acute/chronic blood loss 6
7 Documentation is Always CONSISTENT One time mention of diagnosis is not enough for coding purposes Treated diagnosis are always Inpatient - Assessed throughout the patient s stay - DAILY Outpatient - Assessed every visit until resolved Inpatient or Outpatient - Cannot be coded from the problem list 7
8 Inpatient Case Study CHIEF COMPLAINT: Anxious Male who presents to the ED for detox. Has been referred by parole office for inpatient detox and eventual placement into rehab. He admits to binge drinking the past two weeks, mainly beers. When he does quit he begins to shake and becomes extremely anxious. Denies seizure activity. His last drink was 10 pm last night. Review of Systems and Physical Exam all normal Uses the problem list in the admission H&P 8
9 Alcohol Withdrawal Protocol Nausea/Vomiting Anxiety Paroxysmal Sweats Tactile disturbances Visual disturbances Tremors Agitation Orientation and clouding of sensorium Auditory disturbances Headache 9
10 Active Problems on Problem List Date of Encounter June 10, 2013 HTN (added on Feb 25, 1997) Non-compliant to HTN meds (Added on May 30, 1997) Type 2 Diabetes Mellitus (Added on April 15, 2005) Asthma (Added on Nov. 24, 2008) Seasonal Allergies (Added on Mar 30, 2010) Alcohol Abuse (added on Mar 30, 2010) Noncompliance (Last updated on April 29, 2013) 10
11 Day 2: Clinical Assessment by Provider Blood pressure: 145/94 Pain: 0 Height: Not done while inpatient Weight: lb BMI: 37.8 Pulse: 65 Respirations: 18 Temperature: 97.2 Last Accucheck: 190 Lungs clear Heart-reg Abdomen-soft, nontender Extremities-no edema Neuro-no deficits Assessment/Progress: Alcohol Dependency, detox clinically stable. On AWA protocol with librium DM type 2 uncontrolled Doctors Orders/Plan: 1) Continue present management, awaiting rehab placement (Present management includes Glipizide PO and Sliding Scale Insulininformation gathered from Medication Administration Record) 11
12 Laterality New Features of ICD-10 Combination codes like: K57.21 Diverticulitis of large intestine with perforation and abscess with bleeding Combination codes for poisoning: T42.3x2S Poisoning by barbiturates, intentional harm, sequela Obstetric codes identify Trimester of Care O26.02 Excessive weight gain in pregnancy, second trimester New clinical concepts like under dosing, blood type, blood alcohol level 12
13 ICD-10 Requires: Specificity BE SPECIFIC Location of the fracture Fracture of shaft of the humerus S42.30 requires specification to the 7th digit 13
14 ICD-10 Requires: Laterality Laterality (Left, Right, Bilateral) S Unspecified fracture of shaft of humerus, right arm 14
15 ICD-10 Requires: Clinical Detail Greenstick Transverse Oblique Spiral Comminuted Segmental Displaced Nondisplaced 15
16 ICD-10 Requires: Clinical Detail (cont.) 16
17 ICD-10 Requires: Type of Encounter, 7th Digit A=Initial encounter for closed fracture B=initial encounter for open fracture D=Subsequent encounter for fracture with routine healing G=Subsequent encounter for fracture with delayed healing K=Subsequent encounter for fracture with malunion S=Sequela Final Code S42.341A Displaced spiral fracture of the humerus, right arm, initial encounter 17
18 ICD-10 Requires: Location & Depth Example: The local Skilled Nursing facility sends over an elderly lady with a urinary tract infection who has become septic. During your admission assessment of the patient you turn the patient over and see that there is stage 2 pressure ulcer on the right lower back. 18
19 ICD-10 Requires: Location & Depth (cont.) L Pressure ulcer of right lower back, stage 2 Was this present on Admission? 19
20 ICD-10 Codes that Need More Specificity: Inpatient OR Outpatient Diabetes Type: Type 1 Type 2 Chemical or drug induced Other: Secondary, post procedure Diabetes due to underlying conditions; such as: Congenital rubella Cushing s syndrome Cystic fibrosis Malignant neoplasm Malnutrition Pancreatitis and other diseases of the pancreas 20
21 ICD-10 Codes that Need More Specificity: Inpatient OR Outpatient Diabetes- Complications Ketoacidosis Kidney complications Ophthalmic complications Neurological complications Circulatory complications Other specified complications: Arthropathy Neuropathy Skin complications Oral complications Hypoglycemia with /without coma 21
22 Documentation Establishes a Cause-and- Effect Relationship Between Two Conditions Example: Patient admitted with non-healing wound on foot Clinical Indicators A1c=8.6 Type 2 Diabetes on problem list Is this Type 2 Diabetes with foot ulcer E
23 Type 2 Diabetic Foot Ulcer E11.6 Type 2 Diabetes with other specified complications E11.62 Type 2 Diabetes with skin complications E Type 2 Diabetes with Foot Ulcer 23
24 Coding Note: Use Additional Code to Identify Site of Ulcer (L97.4-L97.5) L97.4=Non-pressure chronic ulcer of heel and mid-foot(15 options) Location: unspecified, right heel and mid-foot, left heel and mid-foot Severity of ulcer Limited to breakdown of skin With fat layer exposed With necrosis of muscle With necrosis of bone Unspecified severity 24
25 L97.5 Non-Pressure Ulcer of Other Part of Foot (15 Options) Location Other part of foot Unspecified Right Left Severity Other part of foot Limited to breakdown of skin With fat layer exposed With necrosis of muscle With necrosis of bone Unspecified severity 25
26 Outpatient Case Study 38 year-old Native American female is seen in Ophthalmology for ongoing diabetes related eye problems She had onset of Type 1 Diabetes Mellitus at age 13 She has no renal, hepatic, or peripheral vascular involvement, no elevated lipids or triglycerides Last A1c was
27 Outpatient Case Study (cont.) Stable, mild nonproliferative diabetic retinopathy for many years with no visual acuity problems She is now four months post-delivery of a healthy baby girl During her pregnancy her retinopathy advanced to moderate nonproliferative She developed signs of macular edema in her right eye 27
28 Outpatient Case Study (more) Fundoscopy performed reveals stable areas of microaneurysms in left eye and no evidence of macular edema. Exam of right eye shows microaneurysms and retinal hemorrhage, thickening, and focal edema consistent with macular edema. Near and far visual acuity remains at 20/30 in each eye. Patient is advised that she is not a candidate for treatment at this time. She is reminded to see her Primary Care provider regularly. Return in three months for monitoring of her retinopathy and macular edema. 28
29 Diagnosis E10.3 Type 1 Diabetes with ophthalmic complications E10.33 Type 1 Diabetes with moderate nonproliferative diabetic retinopathy E Type 1 Diabetes with moderate nonproliferative diabetic retinopathy with macular edema 29
30 RECAP of Required Documentation Be specific Consistent throughout inpatient stay or outpatient encounters All cause and effects are connected Higher more complex codes are used If you treat something, explain why and the patient s response to treatment 30
31 Parting Words... If YOU didn t write it...it didn t happen. 31
32 References American Health Information Management Association. Managing an Effective Query Process. Journal of AHIMA, 79(10): Department of Health and Human Services, CMS, ICD-10-CM Classification Enhancements, April 2013 Alcohol Withdrawal Protocol and other clinical resources: gsys 32
33 Credits and Contact This slide set was created by Fran Kosik, a contractor with the IHS ICD-10 national team, and reviewed and edited by her peer ICD-10 approved trainers. This presentation is for use by IHS, Tribal, and Urban sites. If using slides individually, please credit the IHS ICD-10 National Team. For additional information, contact Janice Chase, IHS ICD-10 Federal Lead at: Janice.Chase@ihs.gov 33
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