Why Words Matter - Torrance Memorial Medical Center · 2015-08-18 · ©2015 The Advisory Board...

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Why Words Matter Through an Emergency Medicine Lens

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Key Objectives for Today’s Session

1. Develop understanding of the role documentation plays in determining patient severity of illness

(SOI), risk of mortality (ROM) and physician quality scores

2. Understand definition and key terminology changes in ICD-10-CM and ICD-10-PCS

3. Understand the concepts of linking conditions and manifestations for more accurate depiction of

patient‟s clinical status

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Road Map for Discussion

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Concepts Drive Documentation Requirements

Examples of Diagnoses in ICD-10

Importance of Documentation and Basics of ICD-10-CM/PCS


The Evolution of Clinical Documentation

What was once a tool for communication between providers and clinicians is now the primary data

source to determine quality of patient care. Market forces are leading to Increase in documentation

scrutiny.

Who is the audience for your notes?

Other

Doctors

Care Team

Patients

State

Government

Federal

Government

Insurance

Companies Self


Increased Transparency For Patients

MyCigna.com

HealthGrades- all material and images are sourced from www.healthgrades.com (accessed on 6/18/2012)

Leapfrog- all material and images are sourced from www.leapfroggroup.org (accessed on 6/18/2012)

http://www.healthgrades.com/

http://www.leapfroggroup.org/


Transition from ICD-9-CM to ICD-10-CM/PCS

Per Bill H.R. 4302, “The Secretary of Health and Human Services may not, prior to October 1, 2015,

adopt ICD–10-CM/PCS code sets”.

2011, The Clinical documentation Improvement Specialist's Guide to

ICD-10 p.9 Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPR, C-CDI,

CCDS and Sylvia Hoffman, RN, C-CDI, CCDS.

Benefits and Goals of ICD-10-CM/PCS

• Provides better detail, a more accurate depiction, and improved communication

of patients clinical status

• Allows for more accurate payment for new procedures

• Improves capture of morbidity and mortality data

• Reduces the number of miscoded, rejected and improper claims for

reimbursement


ICD-9-CM vs. ICD-10-CM/PCS: A Comparison

Source: Nichols, J.C. (2011). ICD-10 – Physician impacts. Advisory

Board Applications and Technologies Collaborative; CMS (2013).

ICD-10 Implementation guide for small hospitals 1) Code Volume Expansion in ICD-10-CM/PCS

The main difference between ICD-9-CM

and ICD-10-CM/PCS codes, outside of

structural changes, is the SPECIFICITY of

the code.

ICD-10-CM/PCS codes specify several

components not found ICD-9-CM, such as

causal agent, type, laterality, approach,

episode of care, root operation, etc.

Why so many new codes?

14,000

69,000

4,000

72,000

ICD-9 ICD-10

Diagnosis Codes Procedure Codes


Introduction to ICD-10-CM Diagnosis Coding Structure

ICD-10-CM Codes will Contain 3-7 Alphanumeric Characters with the Following Structure

α # α/#

α/# α/# α/#

Category Sub-categories (Etiology, Anatomic Site, Severity, Laterality,

Complication)

Extension

(3-16 options

depending on

category)

α/#

Key ICD-10-CM Documentation Concepts

Specific anatomical location

Degree (mild, moderate, severe, or

unspecified; total/complete vs.

partial/incomplete)

Type (primary, secondary, unspecified) Episode of Care (Initial, Subsequent,

Sequelae)

Acuity (acute, subacute, chronic, acute

on chronic, or unspecified )

Laterality (Right, Left, bilateral, or

unspecified)

Trimester (1,2,3,unspecified) Number of fetus (1-5, other)


Introduction to ICD-10-PCS Coding Structure

In this exercise, we will dissect the structure of an ICD-10-PCS code

Source: AHIMA; The Advisory Board Company research

α/#

α/# α/# α/# α/#

Body

System

Root

Operation

Body

Part

Approach Device Qualifier

α/#

α/#

1. Section –16 options identifying the general type of procedure. Example:

Medical/Surgical Section represents the vast majority of procedures

reported in an inpatient setting

2. Body System - e.g. circulatory system, respiratory system

3. Root Operation - 31 options, based on the objective of the procedure

4. Body Part - e.g. pericardium, coronary artery, heart, atrium, mitral valve

5. Approach - 7 options, e.g. open, percutaneous, percutaneous endoscopic

6. Device - 4 basic groups: Grafts/prostheses, implants, simple or mechanical

appliances, and electronic appliance

7. Qualifier - e.g. identify destination site in a Bypass, Diagnostic, Full

thickness burn

Physician documentation

required:

• Type and intent of procedure

(root operation)

• Specific anatomic sites

treated

• Approach

• Specific type of device used

• Validate surgical

complications

• Diagnoses that support

inpatient medical necessity

Section



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Key Concepts To Capture in Your Documentation




Remember: Signs, Symptoms & Test Results Must Be Linked to Related

Diagnoses

While important pieces of the medical record, signs, symptoms and test results are not sufficient for

coders to assign a diagnosis.

The attending physician is responsible for:

• Documenting all conditions in the progress notes and discharge summary

• Resolving conflicts in the documentation

• Linking signs and symptoms to diagnoses may increase

SOI and ROM in the inpatient setting. (The terms

„probable‟, „likely‟, or „suspected‟ are all acceptable on the

inpatient record)

• In the ambulatory setting, documentation regarding patient

condition should be to the highest level known, treated or

evaluated

• Abnormal findings (laboratory, x-ray, pathology and other

diagnostic test results) cannot be coded and reported

unless the clinical significance is identified by the treating

provider ICD-10-CM Official Coding Guidelines III.B

Reminder:


Linking Conditions Critical to Capturing Patient Severity

Examples: Linking Diseases

• Hyponatremia with Metabolic Encephalopathy

• E. Coli Sepsis d/t UTI

• Acute on Chronic Hypoxic Respiratory Failure d/t Gram Negative Pneumonia

Use terms like “due to” , “secondary to” or “with”

Note: Lists, commas, and the word “and” do not link conditions

There is a significant increase in the number of “combination codes” available in the ICD-10-CM/PCS

code set. These codes can help capture the highest level of complexity and acuity in the public eye.

Linking clinically relevant conditions, where appropriate, is the key

takeaway for physicians. Coders cannot assume clinical relationships.


Severity of Illness (SOI) and Risk of Mortality (ROM)

Documentation drives SOI and ROM level assignment. These levels are used to measure patient

acuity, and therefore drive expected patient LOS and mortality rate.

Level Assigned SOI/ROM Category

Minor 1

Moderate 2

Major 3

Extreme 4

Breakdown of SOI/ROM and their Implication on Quality Measures

Four mutually exclusive SOI/ROM categories exist (1-4), and are determined

based on a number of factors including primary and secondary diagnoses,

comorbidities, demographics, patient history, treatment/procedure delivered, etc.



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Key Concepts To Capture in Your Documentation




ICD-10-CM/PCS ER Diagnoses & Concepts Covered Today

Let‟s move on to these diagnoses & concepts to help explain what documentation will be like in ICD-

10-CM/PCS.

1 POA 8 Asthma

2 AMI 9 Bronchitis

3 Heart Failure 10 COPD

4 Respiratory Failure 11 Pneumonia

5 Sepsis 12 CKD

6 CVA 13 Pain

7 Tobacco Exposure 14 Substance Abuse


ICD-10-CM/PCS Emergency Department Documentation Basics

In the Emergency Department, be sure to include the following specificity in your documentation

Further Specificity Required in ICD-10-CM/PCS:

ACS → codes to an unspecified acute ischemic heart disease in ICD-10-CM

Urosepsis → no longer defaults to UTI. Document instead, Sepsis d/t UTI

Key Emergency Department Documentation Concepts

Acuity Tobacco dependence or exposure

Context of the injury when external causes Traumatic or non-traumatic

Dysrhythmias captured on rhythm strip

Specify medication complications as

• Adverse effects

• Poisoning

• Under dosing

Laterality Site of injury or problem

For procedures, specify site and link to conditions and or diagnoses justifying the procedure


Present On Admission

Critical to document Present On Admission

Source: The Advisory Board Company research; Health Data

Consulting

If a condition is Present on Admission (POA), document

• All known details

• Type of encounter (initial, subsequent, sequelae) for injuries and poisonings

• Link a complication of medical care to its suspected cause

• Document suspected organism, if known or based on risk factors

Present on Admission (POA) status is a significant driver of quality reporting and risk stratification. Some

conditions (e.g. UTI or pressure ulcer) when not identified as POA, are considered a Hospital-Acquired

Conditions (HACs) and negatively impact quality scores

Note: Make sure infection due to a device is clearly documented as POA if appropriate

• UTI due to indwelling Foley, POA

• MRSA infection due to central venous catheter, POA

• Stage 3 Pressure Ulcer to Buttock, POA

Documentation Examples


Understanding Implications for AMI Changes

Limited time frame for acute designation will require increased specificity

Patient enters ER with

symptoms MD identifies AMI of

the anterior wall

Patient history of STEMI

two weeks ago

Specify in days for accurate code

selection Understand implications for MIs

• Acute MI – within the last 28 days

• Subsequent MI – additional MI within 28

days

• New Acute MI – additional MI after 28 days

• Old MI – MI more than 28 days old

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PMH: Patient suffered a STEMI involving the left circumflex coronary artery two

weeks ago and was discharged home. Same patient is admitted today for a

STEMI of the anterior wall.

“a month ago”

> 28 Days?

≤ 28 Days

Notes


Acute Myocardial Infarction

Initial ST elevation (STEMI) myocardial infarction of anterior wall involving left main coronary artery

Consistent across all AMIs Type and

Site

Specific

artery

Order

Myocardial Infarction

Initial

STEMI

Inferior Wall

STEMI

Anterior Wall

Left main coronary artery

Left anterior descending coronary artery

Other coronary artery

Subsequent

STEMI Unspecified site

STEMI

Other site

NSTEMI

0 I 2 1 1

19


Specify: STEMI or NSTEMI

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Documentation Requirements:

• Specific Wall – i.e. Anterior, Inferior

• Specific Artery – i.e. Left main, Left anterior descending

• Was tPA administered? At transferring facility or current facility?

• Tobacco exposure

• Current complication of STEMI

• Hemopericardium will need further clarification if related to and a complication of

the MI; or unrelated and not a complication of the MI.

• Unless otherwise specified, AMI defaults to STEMI in ICD-10-CM

• Carry all clinically significant information from the cath report / echo report or other testing

results into the progress notes to ensure it will be captured in the coded record

Documentation Teaching Point:


Look Out For These Conditions

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Atherosclerosis, Angina, and Acute Coronary Syndrome (ACS)

Key Points:

• ICD-10-CM assumes Angina pectoris is to due atherosclerosis unless otherwise documented

• Acute coronary syndrome (ACS) sequences to a nonspecific diagnosis of unspecified acute

ischemic heart disease

• Clarifying ACS and Angina (unstable, with spasm, other, unspecified) can impact SOI/ROM

and DRG assignment


A Valid Question

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Some doctors might have noticed

unspecified options for both the

vessel type and angina. Why should

I document them both if a coder can

code without it?

“

”


Specificity Drives Severity

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Which means that vessel type and angina type matter. In some cases, presence of angina serve as a

severity driver

Unspecified Coronary

Bypass Graft

Angina

(Unspecified)

No comorbid condition

(CC) present

Comorbid condition (CC)

present

Comorbid condition (CC)

present

Native Coronary Artery Of

Transplanted Heart

Autologous Vein Coronary

Artery Bypass Graft

Unstable Angina

Pectoris

Angina with

Documented Spasm


Heart Failure Specificity for Severity of Illness

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Link all pieces of an illness to get the highest severity of illness to support tests, procedures or

therapies

Components to Best Practice Documentation

• Specify Acuity: Acute, Chronic or Acute on Chronic Heart Failure

• Specify Type: Systolic, Diastolic, or Combined Systolic and Diastolic

• Clarify the relationship of the hypertension to the heart disease or heart failure

Linking together may impact the severity of illness and risk of mortality of the patient

• Identify, if known, the underlying etiology of the failure

Is it an exacerbation of stable heart failure, due to fluid overload, or due to missed

dialysis

• Echocardiogram Findings

If available, document findings of systolic, diastolic or combined heart failure from the

echo in your progress notes and discharge summary

• Hypertensive heart disease with Acute on Chronic

Diastolic CHF

Heart Failure Combination Code Examples:


CCs and MCCs

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Comorbid Conditions (CCs) and Major Comorbid Conditions (MCCs). To capture severity of illness

(SOI), please specify in your documentation

Major Comorbid Conditions (MCCs) Comorbid Conditions (CCs)

• Systolic heart failure

• Chronic systolic heart failure

• Diastolic heart failure

• Chronic diastolic heart failure

• Combined systolic and diastolic

heart failure

• Heart failure due to hypertension

with CKD Stage 5 or ESRD

• Rheumatic heart failure

• Left ventricular heart failure

• Acute systolic heart failure

• Acute on chronic systolic heart

failure

• Acute diastolic heart failure

• Acute on chronic diastolic heart

failure

• Acute combined systolic and

diastolic heart failure

• Acute on chronic combined

systolic and diastolic heart

failure

• Acute pulmonary edema of lung

without heart disease or heart

failure

CHF→ Systolic Heart Failure (CC) → Acute Systolic Heart

Failure (MCC)

Chest Pain → Unstable Angina (CC) → Probable NSTEMI

(MCC)

Specificity Matters


Heart Failure

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Acute systolic heart failure

Heart Failure

Diastolic

Systolic

Acute

Chronic

Acute on Chronic

Unspecified

Combined Systolic + Diastolic

Unspecific

I 0 5 2

Heart Failure Type of

Heart Failure

1

Severity

If a patient has HTN and CHF, the physician

documentation needs to identify a cause and effect

relationship.

Example: Hypertensive heart disease with

acute systolic heart failure due to medication

noncompliance



Four Types of Atrial Fibrillation

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ICD-10-CM Atrial Fibrillation Documentation Concepts

Paroxysmal

Episodes end spontaneously within 7 days; most episodes last < 24

hours

Persistent*

Episodes last > 7 days and may require electrical or pharmacologic

intervention

Permanent (chronic)

Lasts > than 1 year, regardless of whether cardioversion has been

attempted and has failed or has never been attempted

Unspecified

No documentation of the specificity of the atrial fibrillation → lower

SOI

*Persistent atrial fibrillation is a Comorbid Condition


Making the Case for Additional Specificity

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Leaving out specificity in documentation can lead to improper SOI/ROM and reimbursement

Principal DX: I21.4 NSTEMI

Secondary Dx: I48.x Atrial Fibrillation

Physician A

Physician B

$ 1,572

MS-DRG Dollars

282 – AMI,

discharged

alive, w/o

CC/MCC

Relative Weight: 0.7551

Reimbursement: $3,933

GMLOS: 2.1

MS-DRG Dollars

281 – AMI,

discharged

alive, w/CC

Relative Weight: 1.0568

Reimbursement: $5,505

GMLOS: 3.1

Atrial

Fibrillation I48.9 Atrial Fibrillation ,

unspecified

“ ”

Persistent Atrial

Fibrillation I48.1 Atrial Fibrillation,

Persistent

“ ”

Atrial Fibrillation Scenarios


Documenting Practice: Echocardiogram Evidence

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Be sure to document any of the following complications identified on Echocardiogram

• Aneurysm

• Intracavitary thrombus

• Papillary muscle rupture

• Thrombosis in the atrium, appendage, or

ventricle

• Pericardial effusion

• Right ventricular infarction

• Pseudoaneurysm

• Septal defect: atrial or ventricular

A Comprehensive Chart is Always Best Practice!


Respiratory Failure

ICD-10-CM Respiratory Failure Documentation Concepts

ICD-10-CM Documentation Concepts

Acuity • Acute

• Acute on Chronic

• Chronic

Specificity With

• Hypoxia

• Hypercapnia

• Unspecified

Tobacco Use

Document if patient has

• exposure to environmental tobacco smoke

• history of tobacco use

• occupational exposure to tobacco smoke

Physician Documentation Tips:

• Mild, moderate or severe respiratory distress and respiratory

insufficiency do not equal respiratory failure

• Blood gases and mechanical ventilation are not required

• Clarify the need for continuous home oxygen – dependence on home

oxygen also does not capture severity of illness


Always Document Date & Time of Intubation and Extubation

The duration of intubation and mechanical ventilation must be documented, as it is a direct reflection of the severity

of a patient‟s condition. Mechanical Ventilation greater than 96 hours shifts DRG assignment and SOI/ROM.

Intubation

ICD-10-PCS Documentation Concepts

Root

Operation

Insertion

Body Part

Mouth/throat

Trachea

Approach Via Natural or Artificial Opening

Device Intraluminal Device

Endotracheal Airway

Qualifier None

Example: OBH17EZ - Insertion, Trachea,

Natural Opening, Intraluminal Device, No

Qualifier

Mechanical Ventilation

ICD-10-PCS Documentation Concepts

Root Operation Performance

Body Part Respiratory

Duration <24 consecutive hours

24-96 consecutive hours

>96 hours

Function Ventilation

Qualifier None

Example: 5A1935Z - Performance, Respiratory,

<24 consecutive hours, Ventilation, No Qualifier

Key Documentation Concepts Required for Intubation and Mechanical Ventilation

While date/time of intubation is generally well

documented, always be sure to document the

time of extubation as well.

Don’t Forget Time of Extubation


Sepsis, Severe Sepsis and Septic Shock

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Properly documenting sepsis in ICD-10-CM has a significant impact on severity captured.

Documentation Concepts

Bacteremia vs Sepsis in the coding world

• It is imperative the physician clarifies if the patient has a

systemic infection (sepsis) or only has the finding of bacteria in

the bloodstream

• “Bacteremia” is an abnormal lab finding and is considered a sign

and symptom, it does not represent a systemic process

• “Sepsis” replaces the term “Septicemia” used in ICD-9-CM

Sepsis Documentation Should:

• Link the underlying local infection (e.g. PNA) to the systemic

infection

• Identify the suspected/known organism and any drug resistance

• Clarify if there is associated shock or organ failure

Severe Sepsis is sepsis with documented organ failure.

Documentation required:

• Identification of the suspected/known organism

• Identification of associated organ failure

Example: Acute renal failure due to E Coli sepsis

Septic Shock generally refers to circulatory failure

associated with severe sepsis. Documentation required:

• Identification of the suspected/known organism

• Identification of associated organ failure

SIRS Criteria

Temp < 96.8°F(36°C) or

> 100.4°F (38°C)

Pulse > 90 bpm

RR > 20 breaths/min or

PaCO2 < 32 mmHg

WBC

12,000 or

< 4,000 cells/mm3

or > 10% bands

Septic Shock

Severe Sepsis

Sepsis


Glasgow Coma Scale

1) ¹Indicates MCC designation

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GCS Score can now be captured in ICD-10-CM

GCS Score

Criteria Type

& Points 1 2 3 4 5 6

Eyes Open Never¹ To pain¹ To sound Spontaneous N/A N/A

Best Verbal

Response None¹

Incomprehensible

words¹

Inappropriate

words

Confused

conversation

Oriented;

converses

normally

N/A

Best Motor

Response None¹

Extension to painful

stimuli¹

Abnormal flexion

to painful stimuli

Flexion

withdrawal from

painful stimuli¹

Localizes

painful

stimuli

Obeys

commands

Used in conjunction with:

• Traumatic brain injury

• Acute Cerebrovascular disease

• Other sequelae of cerebrovascular disease

Note

Scale:

• Minor, GCS > 13

• Moderate, GCS 9-12

• Severe, GCS <9

• Report each of the subcategory scores rather

than just the total score

• Some coma diagnoses codes are categorized as

MCCs

Documentation Tip


CVA Documentation

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Key Points

• Acuity

• Laterality

• Identify if hemorrhage or infarction

• Site of non-traumatic intracerebral hemorrhage

• Hemisphere

• Brain stem

• Cerebellum

• Intraventricular

• Multiple localized

• Cerebral infarctions documentation must include:

• Embolism

• Thrombosis

• Stenosis/occlusion

• Artery if known

• Associated symptoms

• Presence of hemiparesis and/or hemiplegia

• Hand dominance of patient (right, left, or ambidextrous)

• tPA administration in a different facility in the last 24 hours


Tobacco Exposure

ICD-10-CM requires documentation of tobacco exposure, specifically for:

• Pulmonary disease

• Diseases of the head, neck, mouth and esophagus

• During pregnancy, birth and puerperium

Document Level of Usage Type of Usage/Exposure

No Use

Exposure • During pregnancy, birth and puerperium

• Environmental tobacco smoke (2nd hand

smoke)

Use • Tobacco use (current)

• Tobacco use (past)

Dependence • Nicotine dependence and source ( e.g.

cigarettes, chewing tobacco, other)

• Nicotine dependence in remission

• With or without other nicotine-induced

disorders


Asthma

ICD-10-CM Documentation Concepts (now aligned with National Heart, Lung, and Blood Institute (NHLBI) guidelines

Document (if present):

• Exercise-induced

bronchospasm

• Cough variant asthma

• Detergent asthma

• Eosinophilic asthma

• Wheezing

Always document tobacco

exposure

Documentation Tip:

J 4 5 1 5 Chronic lower respiratory

diseases

(Asthma)

Type

and

acuity

“With”

Severe persistent asthma with acute exacerbation

Types:

Intermittent

Persistent

Acuity:

Mild

Moderate

Severe

“With”

Uncomplicated

Acute exacerbation

Status asthmaticus


Bronchitis


When documenting Bronchitis or Bronchiolitis, specify:

1. Acuity of condition (acute, chronic, or acute on chronic)

2. Type of condition

• Chronic asthmatic bronchitis

• Chronic obstructive bronchitis, etc.

3. Causal organism

Ex: “bronchiolitis due to Respiratory syncytial virus (RSV)”

Remember: Always document tobacco exposure!

Documentation Tips:


COPD & Emphysema


COPD

• Is the COPD “with”:

• Acute lower respiratory infection

• Or acute exacerbation?

Emphysema

• Specify type:

• Unilateral

• Panlobar

• Centrilobular

Other considerations include:

• Compensatory

• Due to inhalation of chemical gases, fumes, or vapors

• With chronic (obstructive) bronchitis

• Interstitial

• Mediastinal

• Neonatal interstitial

• Surgical (subcutaneous)

• Traumatic subcutaneous

Reminder:

Always document tobacco

exposure


Pneumonia & Influenza

ICD-10-CM Pneumonia & Influenza Documentation Concepts

Pneumonia

Identify the organism

Is it Viral or Bacterial? Name the organism, known or

suspected

Example: “Probable pneumonia due to MRSA”

Remember: Probable, likely and suspected are all

acceptable terms in the inpatient setting

Link any associated conditions

to the pneumonia:

• Influenza with secondary gram negative pneumonia

• Sepsis due to pneumonia

• Acute respiratory failure due to pneumonia

Aspiration Pneumonia Identify if:

• Due to solids or liquids

• Due to anesthesia during L/D

• Due to anesthesia during puerperium

Influenza

Type • Novel influenza virus type A

• Influenza virus

Associated conditions • Pneumonia, specify causative organism if known

• Respiratory illness (laryngitis, pharyngitis, upper

respiratory symptoms)

• GI Illness' – excludes intestinal flu

• Encephalopathy

• Myocarditis

Documentation Tips:

• Both required

documentation of

tobacco

• Do not need a + CXR

or culture


2 J

40

Pneumonia

Pneumonia due to methicillin resistant Staphylococcus aureus

1 5 2

Influenza and Pneumonia

(Bacterial pneumonia) Specific Organism

Pneumonia Bacterial

Staph aureus

MSSA

MRSA

Other

Unspecified

Note:

• When the organism is not identified, the default is

Pneumonia, unspecified

• Documentation of the terms Healthcare Acquired

(HAC) / Hospital Acquired (HAP) / Community-

Acquired (CAP) Pneumonias default to pneumonia,

unspecified

1


Chronic Kidney Disease

Per National Kidney Foundation

Chronic Kidney Disease

Identify the

Stage

Stage I-V

(stages IV-V Impacts SOI/ROM)

Is the CKD related to Hypertension or Diabetes? If so,

document the linkage (“due to”/ “with”)

Transplant

Status

Document if the patient has had a transplant

or

If the patient is a candidate for a transplant

CKD as a Manifestation: Link Diseases

Examples:

• Type 2 DM with diabetic CKD Stage 5

• Hypertensive heart disease with CKD Stage 3 and with chronic diastolic heart

failure

• Hypertension with CKD Stage 4

Use terms like “due to” or “with”

Note: Lists, commas, and the word “and” do not link conditions

Stage I GFR > 90

Stage II GFR 60-89

Stage III GFR 30-59

Stage IV GFR 15-29

Stage V GFR <15


Documenting Pain

ICD-10-CM Documentation Requirements

Documentation Concepts

Clarify if the pain is “Acute” or “Chronic”

Clarify: Is this an admission for inpatient treatment of pain or is an underlying condition

causing the pain?

Example: Admitted for treatment of pain due to bone metastases of breast cancer

Link pain type to the condition.

Example:

• Chronic pain due to…

• Phantom limb pain from R BKA

If pain is from a polyneuropathy, what is the cause?

• Inflammatory or due to diabetes

Is a spinal neurostimulator or intrathecal infusion pump being used to treat the patient?

If so, specify this in documentation.


Pain

Acute pain due to trauma

G 8 9 1 Other disorders of the nervous system Acute

Other disorders of the nervous system

Acute

Post-thoracotomy

Trauma

Post-procedural Chronic

1 Type of

Pain


Substance Abuse Disorders

ICD-10-CM Documentation Requirements

• Alcohol & Other Substances

• Specify the name of the substance (e.g. alcohol, cocaine, opioids, hallucinogens)

• Type of Use:

• Use (e.g. smoked a cigarette today)

• Dependence – “new terminology” was called Addiction

• Is the patient “dependent” on the substance?

• If yes, patient‟s SOI is higher = Comorbid condition (CC)

• Abuse – (e.g. occasional drug user or binge drinker)

• Current status:

• In remission, with intoxication, or with withdrawal

• Document any behavior disorders associated with the substance problem:

• (e.g. anxiety disorder, delirium. hallucinations, sleep disorders etc.)

Blood Alcohol Level (BAL) or Blood Alcohol

• Physician will want to document Blood Alcohol Level (BAL)

Difference in Terminology:


Substance Abuse

Cocaine abuse with intoxication with delirium

F 1 4 1 Mental & behavioral disorders d/t

psychoactive substance use Type of Use

Behavioral

disorder

Cocaine

abuse Intoxication,

uncomplicated

Intoxication with delirium

Intoxication unspecified

Intoxication with perceptual disturbance

dependence

use

2 1


Sequelae (Late Effects)

46

4 Critical Components to Capture for all Sequelae/Late Effects Identified:

1. Document Deficits Present

Can include:

• Cognitive deficits

• Speech & Language deficits

• Aphasia

• Dysphasia (include type)

• Dysarthria

• Fluency disorder

• Stuttering following non-traumatic SAH

• Monoplegia

• Hemiplegia & hemiparesis

2. Document Time Onset for Each

Sequelae

• Is this deficit “new” or “old”?

• Clearly link all deficits to the appropriate event

3. Document Laterality of Deficit “hemiplegia on left side, non-dominant side”

4. Document Patient’s Dominance

• Left-handed

• Right-handed

• Ambidextrous

• There is no time limit on when a sequelae (late effect) codes can be used

• The term “sequelae” replaces the term “late effect” in ICD-10-CM. This diagnosis will require the

provider documentation to link the sequelae to the initial event

Documentation Tip


Case Study Examples

1 Documenting Diagnosis Instead of Symptoms

2 Linking Associated Conditions/Manifestations


Documenting Diagnosis Instead of Symptoms

Patient admitted

for evaluation of

chest pain.

Stress test and

echocardiogram

performed. Both

registered as normal.

Clinical Scenario: Mrs. Smith is a 60 year-old female admitted for the evaluation of chest pain.

The morning of admission she awakes with midsternal chest discomfort associated with nausea.

The patient‟s pain was relieved after receiving nitroglycerin sublingual and a GI cocktail in the

ED.

Final diagnoses should not be symptoms (such as chest pain, nausea, shortness of breath) when a likely or

probably diagnosis is known. In addition, when a diagnosis is “ruled out” it should be documented as such.

Common Insufficient

Documentation

• Chest Pain • Nausea


Chest pain and

symptoms resolved

with GI cocktail.

Placed on a cardiac

monitor and started on

topical nitrates.

Patient

discharged.

Best Practice Documentation

• Chest Pain

probably due to

GERD

• Cardiac Ischemia

was ruled out


Linking Associated Conditions/Manifestations

Clinical Scenario: The patient presented with a complaint of fainting while walking in his yard.

He denies this ever occurred before. He has a history of urinary retention and a chronic

indwelling Foley catheter. VS: HR 45, BP110/60, RR 20, Temp 101. EKG showed severe sinus

bradycardia. Urine culture positive for E Coli.

After further evaluation it was

determined that the patient suffered

from sick sinus syndrome and required

a pacemaker.

Patient started on IV

antibiotics for UTI.

Documentation Tip:

Patient admitted with a

diagnosis of syncope.

Clearly link all conditions that are associated. The important language in this example is “due to.”

Documentation Tip:

Common Insufficient

Documentation

• Syncope • Sick Sinus

Syndrome

• UTI • Pacemaker

Insertion

Best Practice

Documentation

• Syncope due to

Sick Sinus

Syndrome

• Pacemaker

insertion

• UTI due to indwelling Foley, Present on

Admission

2445 M Street NW I Washington DC 20037

P 202.266.5600 I F 202.266.5700 advisory.com

The Engagement Team

Please do not hesitate to contact your team with any

questions or comments.

Rob Byrd

Director

[email protected]

202-266-6132

Samantha Hauger

Partner

[email protected]

202-266-6679

Jill Lindsey

Associate Director

[email protected]

202-568-7141

Matt Ruiz

Senior Associate

[email protected]

202-266-5884

Dr. Sylvia Morris

Senior Medical Director

[email protected]

Why Words Matter - Torrance Memorial Medical Center · 2015-08-18 · ©2015 The Advisory Board...

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Transcript of Why Words Matter - Torrance Memorial Medical Center · 2015-08-18 · ©2015 The Advisory Board...