ICD-10 Tips for All Specialties - Crozer-Keystone Health System - PA

ICD-10 Tips for All Specialties

Following are documents containing key information for physician documentation in the ICD-10 environment. It is important that physicians focus on the inclusion of this specific information in their documentation. In several cases below, two tips sheets in the form of PDFs are included within a category for your information. Please start to use this information when you document now!

Please click the titles below to view this important information.

Documentation of Acute Myocardial Infarction

It is important for providers to understand the elements necessary for the documentation of Acute Myocardial Infarctions in ICD-10. Please use the tip sheets below as guides when you document this condition.

Documentation Tip Sheet

Advisory Board Documentation Tip Sheet

You may also view the information below.

Document the following:

Type of MI
  • ST elevation MI (STEMI)
  • Non-ST elevation MI (NSTEMI)

Site of MI (including wall and vessel)

Anterior Wall

  • Left Main Coronary Artery
  • Left Anterior Descending Artery
  • Other coronary artery Anterior wall

Inferior Wall

  • Right Coronary Artery
  • Other coronary artery of Inferior wall

Posterior Wall MI

  • Left circumflex coronary artery
  • Right coronary artery
  • Other coronary artery of Posterior wall

Unspecified

Septal Wall MI

  • Left Anterior Descending Artery
  • Other coronary artery of Septal wall

Lateral Wall MI

  • Left anterior descending artery
  • Left circumflex artery
  • Other coronary artery of Lateral wall

Episode of Care

Initial - within four week timeframe (28 days)

Subsequent - care for a subsequent, new MI, occurring within four week (28 days) timeframe of the initial MI

Complications

List all complications related to the MI.

Documentation of Anemia

Please use the enclosed information as a guide when documenting this condition. You may also view the information below.

Cause of Anemia:

  • Chronic anemia secondary to malignancy
  • Chronic anemia secondary to CKD
  • Acute blood loss anemia secondary to acute GI bleed
  • Acute post-operative blood loss anemia (if greater-than-expected blood loss during surgery)
  • Chronic idiopathic anemia

Type of Anemia:

  • Iron Deficiency
  • Pernicious
  • Aplastic
  • Sickle Cell
  • Blood Loss Anemia

Acuity:

  • Acute
  • Chronic
  • Acute on Chronic

Documentation of Asthma

In ICD-10, the provider will be required to grade asthma by its severity and whether it is intermittent or persistent. Please use the tip sheets below as guides when you document this condition.

Documentation Tip Sheet

Advisory Board Documentation Tip Sheet

You may also view the information below.

There are 3 severity categories: Mild, Moderate and Severe. The “Mild” category is further classified as Mild Intermittent or Mild Persistent.

Asthma Types

Mild Intermittent:

  • Mild Intermittent, uncomplicated
  • Mild Intermittent with acute exacerbation
  • Mild Intermittent with status asthmaticus

Mild Persistent:

  • Mild persistent, uncomplicated
  • Mild persistent with acute exacerbation
  • Mild persistent with status asthmaticus

Moderate Persistent:

  • Moderate persistent, uncomplicated
  • Moderate persistent with acute exacerbation
  • Moderate persistent with status asthmaticus

Severe Persistent:

  • Severe persistent, uncomplicated
  • Severe persistent with acute exacerbation
  • Severe persistent with status asthmaticus

ICD-10 CHANGE:

Documentation of a history of tobacco use, tobacco dependence, exposure to environmental tobacco smoke is also important.

    Documentation of Atrial Fibrillation and Atrial Flutter

    In ICD-10 further specificity of atrial fibrillation and atrial flutter will be required. Please use the enclosed information as a guide when documenting this condition. You may also view the information below.

    Atrial Fibrillation

    • Paroxysmal
    • Persistent
    • Chronic

    Atrial Flutter

    • Typical
    • Atypical

    Documentation of Clinical Examples

    Please use the tip sheet below as a guide when you document this condition.

    Documentation Tip sheet

    You may also view the information below.

    Temporary and intraoperative pacemakers:

    Root operation is classified as Performance, given that the device completely takes over physiological function by extracorporeal means. Additional characters specify intermittent vs. continuous use of the device.

    Cardioversions:

    Root operation is classified as Restoration, as the purpose of the procedure is to return or attempt to return a physiological function to its original state by extracorporeal means.

    Example: Code: 5A2204Z

    Description: Restoration of Cardiac Rhythm, Single

    Note: Failed cardioversion procedures are also included in the definition of Restoration will code the same as successful procedures.

    Documentation of Congestive Heart Failure

    Please use the tip sheets below as guides when you document this condition.

    Documentation Tip Sheet

    Advisory Board Documentation Tip Sheet

    You may also view the information below.

    The documentation concepts necessary to describe Congestive Heart Failure in ICD-9 will not change in ICD-10.

    The two important concepts to remember when documenting Congestive Heart Failure are Acuity and Type.

    In certain cases, the type may no be known. Therefore, it is acceptable to document what you know and update your documentation as test results become available, e.g., echocardiogram results, ejection fraction.

    Acuity: Acute, chronic, acute on chronic

    Type: Systolic, Diastolic, Combined Systolic and Diastolic

    Document associated conditions such as aortic valve disease, CAD cardiomyopathy (type), mitral valve disease (stenosis, insufficiency).

    Documentation of the CVA

    Please use the tip sheets below as guides when you document this condition.

    Documentation Tip Sheet

    Advisory Board Documentation Tip Sheet

    You may also view the information below.

    • Location, Vessel and Laterality
      Pre-cerebral: vertebral, basilar, carotid
      Cerebral: anterior, middle, posterior
      Cerebellar: right, left, anterior, posterior, middle
    • Cause
      Traumatic, non-traumatic
      Hemorrhage, embolism, thrombosis, occlusion, stenosis, infarction
    • Acuity
      Acute vs. Old
    • Deficits- hemiplegia, exp. Aphasia
      Residuals from an old CVA?
      New deficits
    • What is the patient’s dominant side?
    • Was thrombolytic agent used?

    Example: Instead of documenting “CVA” you will now document “acute, L middle cerebral artery occlusion with resulting R hemiplegia and expressive aphasia in a R handed patient. TPA used.”

    Documentation of Debridement

    It is important for providers to understand the elements necessary for the documentation of excisional vs. non-excisional debridement. Please use the enclosed information as a guide when documenting this condition. You may also view the information below.

    1. Excisional debridement involves the cutting away of tissue/necrosis/slough and falls under the “Excision” definition in ICD-10.
    2. Non-excisional debridement is defined as the non-operative brushing, irrigating, scrubbing, or washing away of devitalized tissue. It falls under the “Extraction” definition in ICD-10.
      Either can be performed at the bedside, in the ER or in the OR.

    Key Documentation Concepts:

    • Location of the debridement (e.g., right ankle, left wrist)
    • Condition requiring debridement (e.g., ulcer, necrosis, abscess)
    • Instrument used (e.g., scissors, scalpel, curette, water jet, etc. If blade is used please note size)
    • Method used (e.g. ,irrigating, brushing, cutting)
    • Depth of the debridement noting the deepest layer: skin, subcutaneous, fascia, muscle, bone
    • Description of the tissue removed
    • Descriptor: incisional or excisional

    Documentation of Diabetes Mellitus

    Please use the enclosed information as a guide when documenting this condition. You may also view the information below.

    Specificity in diabetes documentation may increase severity of illness of the patient.

    Document
    Potential Specifications
    Type of Diabetes

    DM Type 1

    DM Type 2

    DM due to underlying condition (e.g., Cushing's syndrome)

    Drug/chemical induced DM (Document the drug/chemical)

    Gestational DM

    Use of Insulin

    Long term

    Current

    Any manifestations or complications related to DM Example: Hyperglycemia, Hyperosmolarity, Nephropathy, Retinopathy, Gastroparesis

    Physician Documentation Example:

    • Type 1 diabetes with mild no proliferative diabetic retinopathy with macular edema
    • Type 1 diabetes with ketoacidosis without coma

    ICD-10-CM allows the capture of related conditions with one code instead of multiple codes.

    Documentation of the Diagnosis

    Signs, symptoms and ill-defined conditions are not to be used as principal diagnoses when a related definitive diagnosis has been established. Please use the enclosed information as a guide when documenting this condition.

    Please document the definitive diagnosis for these signs and symptoms, when determined:

    • Chest pain
    • Abdominal pain
    • Back pain
    • Syncope
    • Dizziness
    • Headache
    • Shortness of breath
    • Nausea and vomiting
    • Seizure
    • Fever

    Documentation of Fractures

    Please use the enclosed information as a guide when documenting this condition. You may also view the information below.

    • Laterality: Right, left
    • Displaced vs. Non-displaced
    • Mechanism of injury
    • Etiology of Fracture
      Traumatic, pathologic, osteoporosis, neoplastic disease
    • Closed or open (use Gustillo-Anderson classification for open fractures)
    • Type of Fracture
      Comminuted, greenstick, oblique, segmental, spiral, transverse, compression, burst, etc.
    • Note Injury to Surrounding Tissue
    • Encounter Type
      Initial encounter for fracture (type)
      Subsequent encounter for fracture with routine healing
      Subsequent encounter for fracture with delayed healing
      Subsequent encounter for fracture with nonunion
      Subsequent encounter for fracture with malunion
      Sequela

    Example: Instead of documenting fractured R arm, you will now document “Fell while running, traumatic, acute, closed, transverse right distal radial fracture with surrounding soft tissue hematoma and swelling.”

    Documentation of Diseases of the Genitourinary System

    Diseases of the genitourinary system are documented by their laterality, location, underlying cause or organism, and specific presence of disease, such as acute kidney or acute renal failure, chronic kidney disease and the presence of hematuria or hydonephrosis. Please use the enclosed information as a guide when documenting this condition You may also view the information below.

    Acuity
    Acute, Chronic
    Laterality Right, left, bilateral
    Location Kidney, ureter, bladder
    Underlying cause or organism (if known) Calculus, stricture, sepsis, indwelling Foley catheter, ARF due to dehydration, Staph Aureus

    In addition:

    • Specify presence of acute kidney vs. acute renal failure.
    • Include the stage for chronic kidney disease.
    • Indicate the presence of hematuria.
    • Indicate the presence of hydronephrosis.

    Documentation of Glasgow Coma Scale

    Please use the tip sheet below as a guide when documenting this condition.

    Advisory Board Documentation Tip Sheet

    You may also view the information below.

    Criteria Type & Points 1 2 3 4 5 6
    Eyes Open Never* To pain* To sound Spontaneous N/A N/A
    Best Verbal Response None* Incomprehensible words* Inappropriate words Confused conversation Oriented; converses normally N/A
    Best Motor Response None* Extension to painful stimuli* Abnormal flexion to painful stimuli Flexion withdrawal from painful stimuli* Localizes painful stimuli Obeys commands
    Documentation Tip:
    • Report each of the subcategory scores rather than just the total score.
    • Some coma diagnoses codes are categorized as MCCs.

    GCS is used in conjunction with:

    Traumatic brain injury

    Acute cerebrovascular disease

    Or other sequelae of cerebrovascular disease

    Scale:

    Severe, GCS< 9

    Moderate, GCS 9 - 12

    Minor, GCS > 13

    Documentation of Head Trauma/Coma

    It is important for providers to understand the elements necessary for the documentation of head trauma/coma in ICD-10. Please use the enclosed information as a guide when documenting this condition. You may also view the information below.

    Key Documentation Concepts

    Mechanism of Injury

    Encounter Type: Initial, Subsequent, Sequela

    Level of Consciousness

    • Document Glasgow Coma scale score (evaluation of eye opening, verbal response, motor response) AND the time the score was rendered, e.g., pre-hospital, upon arrival to the ER, on admission, or 24 hours or more after admission.
    • If loss of consciousness - document length of time patient was unconscious (if known)

    Associated Injuries

    Skull Fracture

    • Location, laterality, displaced or non-displaced

    Intracranial Injury

    • Portion of the brain involved, specific artery/vessel
    • Presence of cerebral edema

    Documentation of Inflammatory Diseases of the Female Pelvic Organs

    Inflammatory diseases of the female pelvic organs are documented by their laterality, specific conditions, including salpingitis and oophoritis, vaginitis and vulvitis and pelvic inflammatory diseases and peritonitis. In addition, these diseases are documented by the identification of an infectious agent, abscess vs. cellulitis and pelvic adhesions. Also documented are underlying diseases such as herpes, chlamydia and cancer. Please use the enclosed information as a guide when documenting this condition. You may also view the information below.

    Acuity

    Acute, Sub-acute, Chronic

    Laterality Right, left, bilateral
    Specific conditions Salpingitis and oophoritis, vaginits and vulvitis, pelvic inflammatory disease and peritonitis
    Identify the following:
    • Infectious agent
    • Abscess vs. cellulitis
    • Pelvic adhesions - differentiate between post infective and post procedural
    Underlying disease Herpes, chlamydia, cancer

    Documentation of Mechanical Ventilation

    Please use the tip sheet below as a guide when documenting this condition.

    Advisory Board Documentation Tip Sheet

    You may also view the information below.

    Always Document Date and 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 the DRG assignment and SOI/ROM.

    Intubation
    Mechanical Ventilation
    ICD-10-PCS Documentation Concepts ICD-10-PCS Documentation Concepts
    Root Operation: Insertion Root Operation: Performance
    Body Part: Mouth/throat & Trachea Body Part: Respiratory
    Approach: Via natural or artificial opening

    Duration: <24 consecutive hours

    24-96 consecutive hours

    >96 hours

    Device: Intraluminal device or endotracheal airway
    Qualifier: None

    Example: OBH17EZ - Insertion, Trachea, Natural Opening, Intraluminal Device, No Qualifier

    Documentation of Pneumonia

    Important Concepts to Include in Your Documentation of Pneumonia

    Please use the tip sheets below as guides when you document this condition.

    Documentation Tip Sheet

    You may also view the information below.

    Acuity - Acute or chronic

    Laterality - Left, Right, Bilateral

    Location - Upper lobe, middle lobe, lower lobe

    Cause (if known) - Community acquired, hospital acquired, aspiration, ventilator associated, chemical, bacterial, viral, associated with HIV-AIDS, etc.

    Organism (if known) - A positive sputum culture is not required for you to document the type of pneumonia you "suspect" you are treating; for example: "suspect gram neg. pneumonia."

    Document Associated Issues - Abscess, cavitation, empyeme, sepsis, respiratory failure (acute, chronic or acute on chronic hypoxic/hypercapnic)

    Remember: It is acceptable to use terms such as "Probable," "Suspected," or "Possible" in the medical record, i.e., "Suspect Pseudomonas" or "Probable gm. neg. Pneumonia." Avoid using "versus" as it posses a problem with coding.

    It is acceptable to document "rule out," but remember to document in your notes if and when you have ruled out a condition.

    Documentation of "Present on Admission"

    Present on Admission (POA) is defined as any diagnosis present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter - including emergency department, observation or outpatient surgery - are considered "POA."

    Please use the tip sheets below as guides when you document this condition.

    Documentation Tip Sheet

    Advisory Board Documentation Tip Sheet

    You may also view the information below.

    Some of the conditions which might fall into this category and should be noted in your documentation as 'Present on Admission include:

    • Fractures/dislocations
    • Burns
    • Intracranial bleeding
    • Pressure Ulcers
    • Catheter associated urinary tract infections
    • Object left in during surgery
    • Surgical site infection
    • Vascular catheter infections
    • DVT
    • Uncontrolled diabetes
    • Sepsis

    Documentation of Procedures

    To assist you in understanding the key definitions related to documenting procedures in ICD-10, enclosed is a list of terms to be used in your documentation. Please use the enclosed information as a guide when documenting this condition. You may also view the information below.

    Alteration Modifying the anatomic structure of a body part without affecting the functions of the body part
    Bypass Altering the route of passage of the contents of a tubular body
    Change Taking out or off a device from a body part and putting an identical or similar device in or on the same body part without cutting or puncturing the skin or mucus membrane.
    Control Stopping or attempting to stop, postprocedural bleeding.
    Creation Making a new genital structure that does not take over the function of a body part.
    Destruction Physical eradication of all or a portion of a body part by the direct use of energy, force or a destructive agent.
    Detachment Cutting off all or part of the upper or lower extremities.
    Dilation Expanding an orifice or the lumen of a tubular body part.
    Division Cutting into a body part without draining fluids and/or gases from the body part in order to separate or transect a body part..
    Drainage Taking or letting out fluids and/or gases from a body part.
    Excision Cutting out or off, without replacement, a portion of the body.
    Extirpation Taking or cutting out solid matter from a body part.
    Extraction Pulling or stripping out or off all or a portion of a body part by the use of force.
    Fragmentation Breaking solid matter in a body part into pieces.
    Fusion Joining together portions of an articular body part rendering the articular body part immobile.
    Insertion Putting in a non-biological appliance that monitors, assists, performs or prevents a physiological function, but does not physically take the place of the body part.
    Inspection Visually and/or manually exploring a body part.
    Map Locating the route of passage of electrical impulses and/or locating functional areas in a body part.
    Occlusion Completely closing an orifice or the lumen of a tubular body part.
    Reattachment Putting back in or on all or a portion of a separated body part to its normal location or other suitable location.
    Release Freeing a body part from an abnormal physical constraint by cutting or by use of force.
    Removal Taking out or off a device from a body part.
    Repair Restoring, to the extent possible, a body part to its normal anatomic structure and function.
    Replacement Putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part.
    Reposition Moving to its normal location or other suitable location all or a portion of a body part.
    Resection Cutting out or off, without replacement, all of a body part.
    Restriction Partially closing an orifice or the lumen of a tubular body part.
    Revision Correcting, to the extent possible, a portion of a malfunctioning device or the position of a displaced device.
    Supplement Putting in or on biological or synthetic material that physically reinforces and/or augments the function of a body part.
    Transfer Moving, without taking out, all or a portion of a body part to another location to take over the function of all or a portion of the body part.
    Transplantation Putting in or on all or a portion of a living body part taken from another individual or animal to physically take the place and/or function of all or a portion of a similar body part.

    Documentation of Respiratory Failure

    Please use the tip sheet below as a guide when documenting this condition.

    Advisory Board Documentation Tip Sheet

    You may also view the information below.

    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
    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.

    Documentation of Sepsis

    Please use the tip sheets below as guides when you document this condition.

    Documentation Tip Sheet

    Advisory Board Documentation Tip Sheet

    You may also view the information below.

    Document these key pieces of information:

    • Was the sepsis present on admission?
    • Is the sepsis with or without shock?
    • The causal agent or presence of underlying systemic infection, if known (bacterial, fungal, candida) e.g.
      Sepsis due to MRSA pneumonia or MRSA pneumonia with sepsis
      Sepsis due to a post procedural infection
      In unknown agent or source – document “sepsis, unknown source”
    • Associated organ dysfunction when documenting severe sepsis, e.g.

      Severe sepsis due to MRSA pneumonia with resulting acute respiratory failure

      If more than one organ is affected--document individually

    ICD-10 CHANGE:

    There is no longer a code for SIRS due to an infectious process. There are two categories for SIRS of a noninfectious origin, one without acute organ dysfunction and one with acute organ dysfunction.

    Remember: In ICD-10 there is no such thing as urosepsis.

    Specificity in documentation clearly defines your patient’s severity of illness and risk of mortality. Accurate documentation is the key!

    Documentation of TIA

    Please use the tip sheet below as a guide when documenting this condition. 

    Advisory Board Documentation Tip Sheet

    You may also view the information below.

    Transient Ischemic Attack
    ICD-10-CM Documentation Concepts
    If known, specify TIA as one of the following:
    • Vascular syndrome
    • Carotid artery syndrome (hemispheric)
    • Multiple and bilateral precerebral artery syndrome
    • Vertebro-basilar artery syndrome
    • Amaurosis fugax
    • Transient global amnesia
    • Past history of (PHO) TIA or cerebral infarction without residual deficits
    Document any syndromes observed:
    • Anterior, Middle or Posterior cerebral artery syndromes
    • Brain stem stroke syndrome
    • Cerebellar stroke syndrome
    • Pure motor lacunar syndrome
    • Pure sensory lacunar syndromes
    • Other lacunar syndromes

    Link diagnosis to underlying cerebrovascular disease process or imaging findings.

    Documentation Tip:

    Look for any associated stenosis: if present, it will move the MS-DRG and impact SOI/ROM.

    Documentation of Tobacco Use

    Please use the tip sheet below as a guide when documenting this condition.

    Advisory Board Documentation Tip Use

    You may also view the information below.

    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.g, cigarettes, chewing tobacco, other)
    • Nicotine dependence in remission with or without other nicotine-induced disorders

    Contacts

    ICD-10 Questions Related to Inpatient Documentation

    If you have questions about ICD-10 related to inpatient documentation, please contact:

    Lisa Stackhouse, RN, CDI Manager

    Lisa.Stackhouse@crozer.org
    Phone: 610-284-8523

    Alternative Contact:

    ICD10Help@crozer.org

    ICD-10 Questions Related to Professional Billing or Office Practices

    If you have questions about ICD-10 related to professional billing or office practices, please contact your practice administrator.