Clinical Documentation ICD-10

Importance of Clinical documentation for accurate ICD-10 coding

ICD-10 is not the coding but its improved Patient care which is documented Descriptive documentation to support accurate coding is the base of reimbursement from the insurances

If physicians don't document their care, it can't be captured or coded

Proper documentation has the potential to improve:

Patient care,
Clinical data Timely and appropriate claims payment

What needs to be documented?

Basic concepts such as:

Laterality (Right, Left, Bilateral, Unilateral) Anatomical locations Trimester

Type of diabetes
Known complications or comorbid conditions Description of severity, acute or chronic or other known parameters

Major Modifications

Revised diabetes mellitus codes

(5th digits from ICD-9-CM will not be used)

Expanded codes (e.g., injury, diabetes)

Added trimesters to obstetrical codes (5th digits from ICD-9-CM will not be used)

Added code extensions for injuries and external causes of injuries Laterality Left Versus Right Area specified in cases of Neoplasm

Examples

Malignant neoplasm, of central portion of breast Malignant neoplasm of central portion of right female breast Malignant neoplasm of central portion of left female breast

Most Commonly Encountered Disease/Problems taken as example

DIABETES HEART DISEASE (CAD, A-FIB, CHF etc.) PAIN (BACK, LOWER BACK, LIMBS UPPER OR LOWER) OSTEOARTHRITIS CHRONIC KIDNEY DISEASE PULMONARY DISEASE

Examples on the following slides

Must/Preferable to dictate
DIABETES
Type I or Type II diabetes - Must dictate Onset - Preferable if dictated When did it start? - Preferable if dictated

HEART DISEASE (CAD, A-FIB, CHF etc.) Coronary Artery Disease (CAD):
Native Artery involved Preferable if dictated Status post bypass graft Preferable if dictated

PAIN, OSTEOARTHRITIS, OSTEOPENIA, OSTEOPROSIS, ARTHRITIS,

CHRONIC KIDNEY DISEASE

Stage 1 to 6 (end stage) Must dictate
Dependence on Dialysis Must dictate

Anatomical location
Which anatomical structure - Must dictate Proximal, distal, medial, lateral, central, peripheral, superior, inferior, anterior, posterior Preferable if dictated

Laterality
Right side or left side Must dictate

Severity
Mild, moderate or severe Preferable if dictated

Example for -PULMONARY DISEASE

Temporal Factors: Must dictate
Acute / Chronic / Intermittent / Persistent

Severity: Must dictate

Mild / Moderate / Severe

Asthma: Must dictate

Acute / Chronic / Allergic / Exacerbation

COPD: Must dictate

With exacerbation

Bronchitis specific: Must dictate

Simple / Mucopurulent / Mixed simple and Mucopurulent / Tracheobronchitis

To be dictated by Provider
Dictated currently ICD-9 Condition described : DIABETES
HISTORY OF PRESENT ILLNESS: The patient is an 86 years old female with history of diabetes. At last visit, we had discussed about going up on her Lantus every three days, but it seems like the patient did not do that and she is still taking Lantus 17 to 20 units and she also continued to take NovoLog Mix 70/30 in the morning and with supper. She states that her blood sugar at suppertime is staying around 188 to 200 and fasting blood sugar is 127, but she did not bring those readings with her. Her last hemoglobin A1c was checked in January and it was high at that time. She is complaining of constipation. She has been taking over-the-counter medication, but it is not helping
ASSESSMENT: 1.Uncontrolled diabetes 2.Constipation.

To be dictated now ICD-10 Condition described : DIABETES

HISTORY OF PRESENT ILLNESS: The patient is an 86 years old female with history of diabetes. At last visit, we had discussed about going up on her Lantus every three days, but it seems like the patient did not do that and she is still taking Lantus 17 to 20 units and she also continued to take NovoLog Mix 70/30 in the morning and with supper. She states that her blood sugar at suppertime is staying around 188 to 200 and fasting blood sugar is 127, but she did not bring those readings with her. Her last hemoglobin A1c was checked in January and it was high at that time. She is complaining of constipation. She has been taking over-the-counter medication, but it is not helping
ASSESSMENT: 1.Uncontrolled diabetes - Type I / Type II 2.Constipation.

DX
Uncontrolled Diabetes

ICD-9
250.02 (Uncontrolled Diabetes Type 2 /
non-insulin dependent)

ICD-10
E11.65 (Type 2 Diabetes with
hyperglycemia)

Uncontrolled Diabetes Type 1 / insulin-dependent

250.03 (Uncontrolled Diabetes Type 1 /

insulin dependent)

E10.65 (Type 1 Diabetes with

hyperglycemia)

Diabetes

250.00 (Diabetes Type 2, not stated as

uncontrolled)

E11.9 (Type 2 Diabetes without

complications)

Diabetes - Type 1 / Insulindependent

250.01 (Diabetes Type 1 (juvenile type)

/ insulin-dependent, not stated as uncontrolled)

E10.9 (Type 1 Diabetes without

complications)

To be dictated by Provider
Dictated currently ICD-9
Condition described : HEART DISEASE (CAD)

To be dictated now ICD-10 Condition described : HEART DISEASE (CAD)

ASSESSMENT AND PLAN: The patient is an individual who has CAD with/without - stable/unstable - other/unspecified etc angina, status post bypass graft, has dropped about 4 pounds since last time, status post multiple surgeries in the past, obesity, the patient has a history of anxiety, neuropathy, hypertension, intervertebral disk disease, hypertriglyceridemia, atrial fibrillation, GERD, and insulin-dependent diabetes mellitus.

ASSESSMENT AND PLAN: The patient is an individual who has CAD, has dropped about 4 pounds since last time, status post multiple surgeries in the past, obesity, the patient has a history of anxiety, neuropathy, hypertension, intervertebral disk disease, hypertriglyceridemia, atrial fibrillation, GERD, and insulin-dependent diabetes mellitus.

DX
CAD-unspecified type of vessel, native, or graft

ICD-9
414.00 I25.10

ICD-10

125.110 (CAD-native artery with unstable angina) I25.111 (CAD-native artery with unstable angina with
documented spasm)

CAD-native coronary artery

414.01

I25.118 (CAD-native artery with other forms of angina pectoris) I25.119 (CAD-native artery with unspecified angina pectoris) I25.700 (Atherosclerosis of coronary artery bypass graft, unspecified,
with unstable angina pectoris

CAD with bypass graft unspecified type

414.05

I25.701 (Atherosclerosis of coronary artery bypass graft, unspecified,

with angina pectoris with documented spasm)

I25.708 (Atherosclerosis of coronary artery bypass graft, unspecified,

with other forms of angina pectoris)

I25.709 (Atherosclerosis of coronary artery bypass graft, unspecified,

with unspecified angina pectoris

To be dictated by Provider
Dictated currently ICD-9
Condition described : PAIN
ASSESSMENT: The patient has UTI and history of kidney stones. The patient has chronic kidney disease. The patient has tobacco abuse. The patient has chronic pain of leg

To be dictated now ICD-10

Condition described : PAIN
ASSESSMENT: The patient has UTI and history of kidney stones. The patient has chronic kidney disease. The patient has tobacco abuse. The patient has chronic pain of right/left upper/lower leg

Condition described : OSTEOARTHRITIS

ASSESSMENT: This is an individual with chronic kidney disease, hypertension, insomnia, depression, chronic pain syndrome, knee pain, and gout. The patient is accompanied by her daughter. There is also underlying restless legs syndrome, COPD which is severe, degenerative joint disease, and osteoarthritis

Condition described : OSTEOARTHRITIS

ASSESSMENT: This is an individual with chronic kidney disease, hypertension, insomnia, depression, chronic pain syndrome, knee pain, and gout. The patient is accompanied by her daughter. There is also underlying restless legs syndrome, COPD which is severe, degenerative joint disease, and osteoarthritis of knee right/left

DX
Pain of Leg Pain of Right Leg Pain of Left Leg Pain of Thigh

ICD-9

ICD-10
M79.606 (Pain in Unspecified Leg) M79.604 (Pain in Right Leg) M79.605 (Pain in Left Leg) M79.659 (Pain in Unspecified Thigh)

729.5 (Pain in Limb) Pain of Right Thigh Pain of Left Thigh Pain of Lower Leg Pain of Right Lower Leg Pain of Left Lower Leg M79.651 (Pain in Right Thigh) M79.652 (Pain in Left Thigh) M79.669 (Pain in Unspecified Lower Leg) M79.661 (Pain in Right Lower Leg) M79.662 (Pain in Left Lower Leg)

To be dictated by Provider
Dictated currently ICD-9 To be dictated now ICD-10

Condition described : CHRONIC KIDNEY DISEASE

ASSESSMENT: The patient is a 73-year-old who was recently in the hospital for volume overload, has chronic kidney disease as well as CHF, certainly does have multiple other issues including hyperlipidemia, CAD, hypertension, seasonal allergic rhinitis, is being followed by Dr. abcdef of renal. We will certainly get Dr. xyz to see him for his CHF

Condition described : CHRONIC KIDNEY DISEASE

ASSESSMENT: The patient is a 73-year-old who was recently in the hospital for volume overload, has chronic kidney disease stage 3 , etc. / end-stage / on dialysis as well as CHF, certainly does have multiple other issues including hyperlipidemia, CAD, hypertension, seasonal allergic rhinitis, is being followed by Dr. abcdef of renal. We will certainly get Dr. XYZ to see him for his CHF

DX
Chronic Kidney Disease

ICD-9
585.9 (CKD, stage unspecified)

ICD-10
N18.9 (CKD, stage unspecified)

CKD-Stage 1 CKD-Stage 2

585.1 (CKD, stage 1) 585.2 (CKD, stage 2) (mild)

N18.1 (CKD, stage 1) N18.2 (CKD, stage 2) (mild)

CKD-Stage 3

585.3 (CKD, stage 3) (moderate)

N18.3 (CKD, stage 3) moderate)

CKD-Stage 4

585.4 (CKD, stage 4) (severe)

N18.4 (CKD, stage 4) severe)

CKD-Stage 5

585.5 (CKD, stage 5)

N18.5 (CKD, stage 5)

CKD, end stage

585.6 (End Stage Renal Disease)

N18.6 (End Stage Renal disease)

Thank You
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