The Transition toWhat you need to know for Pediatrics Newborn

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

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Ongoing Support for ICD-10Physician Advisors

Clinical Informatics

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-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)

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What should be documented?

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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

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Key Changes Needed to Support ICD-10 Coding

Newborn affected by Maternal Condition• Document specific maternal condition

– Drug use– Alcohol use– Tobacco use– Infection (GBS positive)– Diabetes Pre existing or Gestational– Hypertension Pre existing or

Gestational– Incomplete Cervix

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Baby turned blue and began choking after feeding, ALTE not further specified

• Document apparent life-threatening event (ALTE) with obstructive apnea due to GERD

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Cleft Lip• Document:

– Bilateral– Median– Lateral

• Document if present with cleft palate

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• Document:– Hard palate– Soft palate– Hard palate with soft

palate– Uvula

• Document :– Bilateral– Median– Unilateral

• Document if present with cleft lip

Cleft Palate

Meconium Aspiration• Document any associated respiratory

conditions:– Pneumonia– Respiratory Distress Syndrome

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Neonatal Jaundice• Document Etiology

– Isoimmunization (Rh, ABO, other hemolytic diseases)

– Preterm delivery– Physiologic

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Post-operative Care after Congenital Heart Surgery

• Physician must document if cardiac condition is still present and under active treatment or if it was surgically corrected

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Outcome of Delivery (Newborn Status)

• Document if :– Single birth– Twin birth– Multiple births

• Document for each baby if: – Live born– Stillborn

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Omphalitis ofNewborn

• Document with or without mild hemorrhage

Failure To Thrive• Document if newborn is 28 days

or less– Prematurity (Gestational age

between 28-36 completed weeks of gestation)

– Extreme immaturity (Gestational age less than 28 completed weeks of gestation)

• Document failure to thrive, malnutrition – Poor feeding, decreased

urine output, fussiness, failure to gain weight

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• A code for prematurity cannot be assigned based solely on the documentation of completed weeks.

• Physician must state that the infant is premature

Prematurity

Feeding Problems of Newborn• Instead of “feeding problems” or “feeding

difficulty” be more specific, for example:– Regurgitation and rumination– Slow feeding– Underfeeding– Overfeeding– Difficulty with breast feeding– Vomiting– Other

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Sepsis of Newborn• Document if

confirmed or suspected

• Document if ruled out• Document organism

known or suspected– Streptococcus– Staphylococcus– E. Coli– Anaerobes

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• If prophylactic antibiotics are given to a newborn pending cultures, physicians must document whether sepsis was ruled in or ruled out based on clinical results

Congenital Adrenal Hyperplasia

• Document if salt losing (codes to enzyme deficiency

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Croup

• Document Type:– Bronchial– Diphtheritic– Stridulous

Spina Bifida• Document Location:

– Cervical– Thoracic– Lumbar– Sacral– Occulta

• Document with or without hydrocephalus

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Intraventricular Hemorrhage (IVH)

• Specify– Grade 1– Grade 2– Grade 3– Grade 4

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