ICD 10 Documentation Specificity –Nephrology and Common Documentation Tips -- based on Conifer ICD 10 CDI Queries
2 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD 10 Documentation Specialty Introduction
ICD 10 is being mandated by CMS. Compliance date is set at October 2015. ICD-9 Diagnosis Codes = 14,000 ICD-10 Diagnosis Codes = 69,000 ICD-9 Procedure Codes = 3,800 ICD-10 Procedure Codes = 71,000
The CDI team is here to help with inpatient provider documentation specificity needed in I-10.
Based on Conifer ICD 10 Updated queries, the attached pages will assist with the documentation needed in I-10.
3 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
Table of contents Anemia 4
BMI – high 5
BMI –low 6
Cirrhosis of Liver 7
Coma 8
Debridement 9
Dementia 10
Diabetes 11
Encephalopathy 12
Functional Quadriplegia 13
Gout 14
Heart failure- acute 15
Heart failure-chronic 16
HIV-AIDS 17
Hypertension 18
Hyponatremia 19
Lymphoma 20
Mental Status- Altered 21
Metabolic—acidosis/ alkalosis 22
Mood Disorder 23
Neoplasm 24
Non pressure ulcer 25
Malnutrition 26
Pain 27
Pneumonia- Aspiration 28
Pneumonia-Specificity 29
Pressure Ulcer 30
Prostatitis 31
Renal Failure—acute 32
Renal failure-chronic 33
Respiratory failure 34
Respiratory failure post op 35
Sepsis 36
Shock 37
Substance abuse 38
Testicular Torsion 39
Urosepsis 40
UTI 41
Hospital specific
Documentation Specialists contact info 42-49
4 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Anemia[ ] Acute blood loss anemia
[ ] Post-op anemia related to acute blood loss
[ ] Anemia:
[ ] Aplastic [ ] Nutritional
[ ] Drug induced (specify)________
[ ] Hemolytic: [ ] Hereditary [ ] Acquired
[ ] Autoimmune [ ] Non-autoimmune
[ ] Enzyme disorder
[ ] Anemia due to Neoplasm:
[ ] Primary [ ] Secondary
[ ] Due to Chemotherapy
[ ] Due to Radiotherapy
[ ] Chronic anemia – other etiology:
ICD10 Documentation Needed
Same as in ICD 9
5 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 DocumentationBMI > 40 with associated diagnosis
of:
[ ] Morbid (Severe) Obesity
[ ] Overweight
[ ] Obesity (unspecified)
ICD10 Documentation NeededMorbidly Obese
[ ] Morbid (Severe) Obesity
[ ] Due to excess calories
[ ] Familial
[ ] Endocrine
[ ] with Alveolar Hypoventilation (Pickwickian syndrome)
[ ] Drug-induced (Name of drug: _____)
6 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 DocumentationBMI < 19 with associated
diagnosis of: (check one) [ ] Underweight
[ ] Protein Calorie Malnutrition:
[ ] Mild [ ] Moderate [ ] Severe
[ ] Unspecified
[ ] Cachexia
[ ] Emaciation due to malnutrition
ICD10 Documentation Needed
Same as ICD 9
7 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 DocumentationCirrhosis of Liver
ICD10 Documentation NeededIdentify if alcoholic or non-alcoholic, if
congenital, biliary obstructive, laennec’s and if portal
[ ] Alcoholic [ ] Non-alcoholic
[ ] Congenital ____ (underlying disease)
[ ] Biliary / Obstructive:
[ ] Primary [ ] Secondary
[ ] Laennec’s:
[ ] Alcoholic with: [ ] dependence
[ ] non-dependence
[ ] Non-alcoholic
[ ] Portal: [ ] Alcoholic [ ] Non-alcoholic
8 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 DocumentationComa
ICD10 Documentation NeededIdentify specificity[ ] Coma / Comatose
[ ] Persistent vegetative state
[ ] Stupor
[ ] Drowsiness
[ ] Somnolence
[ ] Catatonic stupor
[ ] Semicoma
[ ] Associated injury (skull fracture, intracranial injury) _________________________________
[ ] Glasgow coma score_____________
Eye opening describe ________
Verbal response describe _________ Motor functioning describe_________
9 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation Debridement[ ] Excisional Debridement:
[ ] Excised [ ] Removed [ ] Cut away [ ] Other: ________Depth / layer: (deepest layer of debridement): [ ] Skin/SubQ [ ] Fascia [ ] Muscle [ ] Bone
Margins: (please specify): ___ / __ x __ x ___ Instruments used: [ ] Scissors [ ] Scalpel [ ]
Curette [ ] Tweezers/forceps [ ] Soft tissue clipper [ ] Other: _____
[ ] Non-excisional Debridement - Removal by flushing, brushing, or washing
[ ] Incision and Drainage only (No Debridement):
Depth: [ ] Skin & Sub Q only [ ] Into soft tissue[ ] Escharectomy
ICD10 Documentation NeededSame as ICD 9
10 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation Dementia
ICD10 Documentation NeededIdentify type and accompanying behaviorsType of Dementia (check all appropriate):
[ ] Vascular (due to cerebrovascular infarct or HTN)
[ ] Frontotemporal [ ] Pick’s Disease
[ ] In Substance Use/Abuse/Dependence
Specify substance: ____________________
[ ] With Lewy Bodies (in Parkinson’s Disease)
[ ] In other specified diseases (such as Alzheimer’s,, Parkinson’s, or other degenerative nervous system disease)
[ ] Unspecified (such as Senile or Pre-senile)
[ ] Unable to determine type of Dementia
Accompanying Behaviors (check all appropriate):
[ ] Behavioral disturbances (aggressive, combative, violent)
[ ] Psychosis [ ] Delirium [ ] Delusions [ ] Hallucinations
[ ] Depression
[ ] Wandering
[ ] Other behaviors: ___________________
11 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 DocumentationDiabetes
ICD10 Documentation NeededIDENTIFY TYPE, ETIOLOGY, CONTROL and any MANIFESTATIONSTYPE: [ ] Type I [ ] Type II [ ] Insulin Use
Etiology: [ ] Drug / chemical induced [ ] Due to underlying condition (specify)________ [ ] Other specified type_____
Control: [ ] Inadequate [ ] Out of control [ ] Poor [ ] Hypoglycemia [ ] Hyperglycemia
Manifestation: [ ] Ketoacidosis [ ] Neurological complications (specify) __ [ ] Kidney complication (specify) ______________ [ ] Skin complication (specify) ____________________ [ ] Other (specify)________________________ [ ] Gastropathy/ Gastroparesis [ ] Osteomyelitis [ ] Cellulitis [ ] CKD
12 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 DocumentationEncephalopathy
ICD10 Documentation NeededIDENTIFY Acuity, Etiology and SeverityAcuity: [ ] Acute [ ] Subacute [ ] Chronic
Etiology:
[ ] Hypertensive [ ] Metabolic
[ ] Toxic [ ] Toxic Metabolic
[ ] Hepatic[ ] Hypoxic
[ ] Septic [ ] Alcohol
[ ] Drugs (specify)_______________
[ ] Post procedural (specify)______________
Severity: [ ] with coma [ ] without coma
13 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 DocumentationFunctional Quadriplegia[ ] Functional quadriplegia (complete
immobility)
[ ] Immobilization syndrome (impaired mobility)
ICD10 Documentation NeededSame as ICD 9
14 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Gout
ICD10 Documentation Needed
IDENTIFY Type, joint involved and acuity
Specify the type/cause of gout: [ ] Drug-induced [ ] Secondary
[ ] Idiopathic [ ] Syphilitic
[ ] Lead-induced [ ] Primary
[ ] With renal impairment (specify the specific renal disease/disorder, including acuity and/or state)____
Specify the specific joint involved _ [ ] Right [ ] Left
Specificity acuity of gout:[ ] Acute
[ ] Chronic – with or without tophus
[ ] Gout attack
[ ] Gout flare
15 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 DocumentationACUTE HEART FAILURE[ ] Acute Systolic Heart Failure
[ ] Acute Diastolic Heart Failure
[ ] Acute Systolic and Diastolic Heart Failure
ACUTE ON CHRONIC HEART FAILURE
[ ] Acute On Chronic Systolic Heart Failure
[ ] Acute On Chronic Diastolic Heart Failure
[ ] Acute On Chronic Systolic and Diastolic Heart Failure
ICD10 Documentation Needed
SAME as ICD 9 with the addition
OTHER ETIOLOGIES OF HEART FAILURE
[ ] Heart Failure Due To Valvular Disease
[ ] Right Heart Failure / Acute Cor Pulmonale
[ ] Right Heart Failure / Chronic Cor Pulmonale
[ ] Rheumatic Heart Disease
[ ] Endocarditis (valvular)
[ ] Myocarditis
[ ] Pericarditis
16 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 DocumentationCHRONIC HEART FAILURE[ ] Chronic Systolic Heart Failure
[ ] Chronic Diastolic Heart Failure
[ ] Chronic Systolic and Diastolic Heart Failure
ICD10 Documentation Needed
SAME as ICD 9 with the addition of etiology
Etiologies: [ ] Hypertension [ ] Valvular disease [ ] Rheumatic heart disease
17 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation HIV-AIDS[ ] HIV infection/disease symptomatic
related condition
[ ] AIDS
[ ] Non-HIV related condition
[ ] Asymptomatic HIV infection status
[ ] Non-specific serologic evidence of HIV
ICD10 Documentation Needed
Similar to ICD 9
18 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 DocumentationHypertension[ ] Malignant Hypertension
[ ] Accelerated Hypertension
[ ] Benign Hypertension
[ ] Unspecified Hypertension
ICD10 Documentation Needed
Same as ICD 9
19 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 DocumentationHyponatremia
ICD10 Documentation Needed
Identify specificity
[ ] Hyponatremia, unknown cause
[ ] Hyponatremia due to Sodium Deficiency
[ ] Hyponatremia due to SIADH (Syndrome of Inappropriate Secretion of Antidiuretic Hormone)
[ ] Insignificant lab value
20 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Lymphoma
ICD10 Documentation NeededIDENTIFY Anatomical Site, Type and
Cell TypeAnatomical Site: _______________________)
Type:
[ ] Hodgkins (Cell type: _________)
[ ] Follicular (Cell type: _________)
[ ] Non-Follicular (Cell type: _________)
[ ] Mature T/NK Cell (Cell type: _________)
[ ] Other Specified/ Unspecified Non-Hodgkin’s (Cell type: ___________________)
[ ] Other Specified T/NK Cell (Cell type: _____)
[ ] Unspecified
21 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 DocumentationAltered Mental Status
ICD10 Documentation NeededIDENTIFY SPECIFICITY
Altered Mental Status:[ ] Delirium
[ ] Mild Cognitive Impairment [ ] Drug-Induced Delirium [ ] Mental Disorder (Specify): __________ [ ] Other (Specify): ________
Altered Level of Consciousness: [ ] Coma [ ] Somnolence [ ] Persistent Vegetative State [ ] Stupor (Catatonic)[ ] Transient Alteration of Awareness
Encephalopathy:[ ] Alcoholic [ ] Due to Drugs [ ] Hepatic [ ] Hypertensive [ ] Anoxic / hypoxic[ ] Other (Specify): ___________ [ ] Metabolic / Septic [ ] Traumatic [ ] Hypoglycemic
22 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Acidosis/Alkalosis
ICD10 Documentation NeededIdentify Type of Acidosis or Alkalosis[ ] Acidosis:
[ ] Metabolic [ ] Respiratory
[ ] Lactic [ ] Renal
[ ] Alkalosis:
[ ] Metabolic [ ] Respiratory
23 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Mood Disorder
ICD10 Documentation NeededIDENTIFY Type, Status and SeverityType (check appropriate):
[ ] Manic
[ ] Bipolar [ ] Manic [ ] Depressive [ ] Mixed
[ ] Major Depressive Disorder
[ ] With Psychosis
[ ] Persistent Mood Disorder
[ ] Without Psychosis
Status:
[ ] Single past episode
[ ] Current episode
[ ] In remission [ ] Partial [ ] Full
[ ] With Psychosis
[ ] Without Psychosis
Severity:
[ ] Mild
[ ] Moderate
[ ] Severe
[ ] Unspecified
24 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation Neoplasm
ICD10 Documentation NeededIdentify Site, Laterality, Type, Malignancy
and associated conditionsSite: Identify:_______________
Laterality: [ ] Right [ ] Left [ ] Bilateral
Type: [ ] Primary [ ] Secondary
[ ] In situ [ ] Overlapping primary [ ] Secondary sites
[ ] Malignant [ ] Benign
[ ] Unspecified Behavior
[ ] Other__________
Malignancy:
[ ] Excised [ ] Eradicated
[ ] Treatment still provided for primary and/or metastatic site
[ ] Evidence of remaining malignancy at primary site
[ ] Conditions associated with neoplasm: (Specify) ____________________________
[ ] Any associated diagnoses / condition ____________________________________
25 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 DocumentationNon Pressure Ulcer
ICD10 Documentation NeededIdentify Location, laterality, depth, type
and gangrenousLocation
[ ] Back [ ] Buttock [ ] Lower limb
[ ] Ankle [ ] Calf [ ] Heel/ midfoot
[ ] Thigh [ ] Other__________
Laterality [ ] Left [ ] Right [ ] Bilateral [ ] Upper
[ ] Lower [ ] N/A
Depth [ ] Skin only [ ] Fat exposed [ ] Muscle Necrosis
[ ] Bone Necrosis
Type
[ ] Diabetic [ ] Vascular r/t PVD [ ] Varicose
[ ] Atherosclerosis of lower limb
[ ] Postphlebitic syndrome
[ ] Postthrombotic syndrome
[ ]Chronic venous hypertension [ ] Other (specify) ______
Gangrene [ ] Yes [ ] No
26 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 DocumentationMalnutrition[ ] Under-nutrition / Malnutrition:
[ ] Mild [ ] Moderate
[ ] Severe [ ] Unspecified
[ ] Protein Calorie Malnutrition:
[ ] Mild [ ] Moderate [ ] Severe
[ ] Unspecified
[ ] Marasmus
[ ] Nutritional Edema
[ ] Other Malnutrition (please specify) _______________________________
ICD10 Documentation NeededSame as ICD 9
27 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 DocumentationPain
ICD10 Documentation NeededIdentify acuity and cause [ ] Acute Pain
[ ] Trauma
[ ] Post- Thoracotomy
[ ] Post- operative / post-procedural
[ ] Other __________________
[ ] Chronic pain
[ ] Trauma
[ ] Post-Thoracotomy
[ ] Post-operative / post-procedural
[ ] Other __________________
[ ] Neoplasm pain
28 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 DocumentationAspiration Pneumonia
ICD10 Documentation NeededIDENTIFY SPECIFICITY and any
associated illnesses
[ ] Aspiration Bronchitis[ ] Pneumonia secondary to______ (specify organism / underlying disease)[ ] Community Acquired (simple) Pneumonia[ ] Healthcare / Hospital Acquired Pneumonia (outside facility / prior hospitalization) [ ] Ventilator associated[ ] Radiation induced
[ ] Associated illness: [ ] Respiratory failure [ ] Sepsis [ ] Underlying lung disease [ ] Other specify)_____
[ ] Pneumonia of unknown etiology[ ] Infiltrates without evidence of Pneumonia
29 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 DocumentationPneumonia- identify specificity[ ] Gram Negative Pneumonia [ ] Gram Positive Pneumonia
[ ] MRSA Pneumonia [ ] MSSA Pneumonia
[ ] Pneumonia due to ________ (specify organism / underlying disease)(e.g. E. Coli, Klebsiella, Pneumococcus, Pseudomonas, Other Staph)
[ ] Community acquired (simple) Pneumonia
[ ] Healthcare / Hospital Acquired Pneumonia (outside facility / prior hospitalization)
[ ] Aspiration pneumonia
[ ] Ventilator – associated pneumonia
[ ] Radiation induced pneumonia
[ ] Associated illness: [ ] Respiratory failure [ ] Sepsis [ ] Underlying lung disease [ ] Other _______________
[ ] Pneumonia of unknown etiology
[ ] Infiltrates without evidence of Pneumonia
ICD10 Documentation NeededSimilar to ICD 9
30 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 DocumentationPressure Ulcer
ICD10 Documentation NeededIdentify Location, stage, laterality, POA and gangrene presentDecubitus Ulcer: Location: __________
POA: [ ] Yes [ ] No [ ] Unable to determine
Stage (I to IV): _______
Laterality: Left_____ Right_____
Bilateral_____ N/A_____
[ ] Gangrene present [ ] Yes [ ] No
(Stage I: Erythema; Stage II: Partial thickness; Stage III: Full thickness; Stage IV: Necrosis to muscle/bone)
31 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 DocumentationProstatitis
ICD10 Documentation NeededIdentify acuity, bacterial vs viral and
organism if know [ ] Acute Prostatitis:
[ ] Bacterial (organism __________ if known)
[ ] Viral (organism ______________if known)
[ ] Chronic Prostatitis:
[ ] Bacterial (organism ________ if known)
[ ] Viral (organism ____________if known)
32 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 Documentation
Acute Renal Failure (ARF) / Acute Kidney Injury (AKI)
[ ] Prerenal Azotemia (dehydration, shock, CHF, renal obstruction, creatinine responds to IV fluid)
[ ] Acute Tubular Necrosis (ATN) (nephrotoxicity, extended decreased renal perfusion, increasing creatinine (0.5 / day) not responding to fluids, low urine output)
[ ] Acute Interstitial Nephritis (AIN) (nephritis in which the interstitial connective tissue is chiefly affected)
[ ] Acute cortical necrosis [ ] Acute medullary necrosis[ ] Acute kidney injury
[ ] traumatic injury [ ] Nontraumatic injury[ ] Other Etiology or underlying conditions related to the
diagnosis of ARF/ AKI:________________ [ ] Acute on Chronic Renal Failure please specify Type of ARF
(above) and Stage of CKD ________
ICD10 Documentation NeededSame as ICD 9
33 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 DocumentationChronic Renal Failure[ ] Chronic Renal Failure (CRF) / Chronic Kidney Disease (CKD)
Stage: _______ (I to V or ESRD—see below)
Dialysis dependent [ ] Yes [ ] No
CKD- National Kidney Foundation Guidelines for CKD StagingStage I Kidney damage with normal or increased GFR
GFR > 90
Stage II Kidney damage with mildly decreased GFRGFR 60-89
Stage III Kidney damage with moderately decreased GFRGFR 30-59
Stage IV Kidney damage with severely decreased GFRGFR 16-29
Stage V Kidney failure GFR<15
ESRD End Stage Renal Disease On dialysis
ICD10 Documentation NeededSame as ICD 9
34 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 DocumentationRespiratory Failure
ICD10 Documentation NeededIDENTIFY TYPE, ACUITY and ETIOLOGY
Acute Respiratory Failure: [ ] with Hypoxia [ ] with Hypercapnia
Acute On Chronic Respiratory Failure: [ ] with Hypoxia [ ] with Hypercapnia
Acute Respiratory Failure caused by: _____ (etiology)
[ ] Acute Respiratory Insufficiency following [ ] trauma [ ] other
35 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 DocumentationPost op Respiratory Issues
ICD10 Documentation NeededIdentify Acuity and surgery type[ ] Post-op Acute pulmonary insufficiency
[ ] Thoracic surgery [ ] Non-Thoracic surgery
[ ] Post-op Acute respiratory failure
[ ] Thoracic surgery [ ] Non-Thoracic surgery
[ ] Post-op Chronic pulmonary insufficiency
[ ] Post-op Chronic respiratory failure
[ ] Hypoxia
[ ] Respiratory failure not related to surgical procedure
[ ] Acute [ ] Chronic [ ] Acute on Chronic
36 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 DocumentationSepsis
ICD10 Documentation Needed Identify causative agent, due to, name
organ dysfunction- if applicable [ ] Sepsis (include causative agent if known)
_________Due to: [ ] Device [ ] Implant [ ] Graft [ ] Infusion [ ] Abortion
[ ] SIRS due to non-infectious process[ ] with organ dysfunction [ ] without organ dysfunction
[ ] Severe sepsis with acute organ dysfunction of: __________________________________________(Examples: respiratory failure, encephalopathy, acute kidney failure, other)
[ ] SIRS due to infection or infectious process[ ] with organ dysfunction [ ] without organ dysfunction
[ ] Septic shock[ ] Sepsis related to a device (i.e. port, IV line, pacer /
ICD leads, Foley, etc.) _______________________
37 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 DocumentationSHOCK[ ] Hypovolemic shock
[ ] Hemorrhagic shock
[ ] Cardiogenic shock
[ ] Septic shock (Circulatory failure associated with severe sepsis, represents organ failure)
ICD10 Documentation NeededSame as ICD 9
38 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 DocumentationSubstance Abuse
ICD10 Documentation Needed Identify substance, status, complication
and any induced disordersSubstance(s):
[ ] Alcohol [ ] Opioid [ ] Cannabis
[ ] Sedative, Hypnotic, Anxiolytic [ ] Cocaine
[ ] Other stimulant [ ] Hallucinogenic
[ ] Inhalant-related [ ] Other psychoactive drug: __________
[ ] Unspecified drug
Status: [ ] Use [ ] Abuse [ ] Dependence
Complications:
[ ] Intoxication [ ] Withdrawal [ ] In remission [ ] Uncomplicated
[ ] Other complication: ____________ [ ] Unspecified complication
Substance-Induced Disorders:
[ ] Psychosis: [ ] Delirium [ ] Delusions [ ] Hallucinations
[ ] Perceptual Disturbances: [ ] Anxiety Disorder [ ] Sexual Dysfunction
[ ] Sleep Disorder
[ ] Unspecified substance-induced disorder
[ ] Other substance-induced disorder: ________________________________
[ ] No substance-induced disorder
39 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 DocumentationTesticular Torsion
ICD10 Documentation NeededIdentify Extra or Intra vaginal and site[ ] Extravaginal:
[ ] Epididymis
[ ] Spermatic Cord
[ ] Testicle/Testis
[ ] Intravaginal:
[ ] Epididymis
[ ] Spermatic Cord
[ ] Testicle/Testis
40 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 DocumentationUROSEPSIS- codes to UTI, please state if [ ] Sepsis from a urinary source
Related to:
[ ] Urinary obstruction
[ ] Indwelling catheter
[ ] Self-catheterization
[ ] Suprapubic catheter
[ ] Localized urinary tract infection (without sepsis)
ICD10 Documentation NeededSame as ICD 9
41 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
ICD10 documentation specificity needed
ICD9 DocumentationUTI
ICD10 Documentation NeededIdentify acuity, site and due toAcuity:
[ ] Acute [ ] Chronic
[ ] Acute on Chronic
Site: [ ] Kidney [ ] Ureter
[ ] Bladder [ ] Urethra [ ] Other site __________
[ ] Unable to determine
[ ] UTI due to or related to:
[ ] Indwelling catheter
[ ] Self-catheterization
[ ] Neurogenic bladder
[ ] Suprapubic catheter
42 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
Questions—contact your Clinical Documentation Specialists at your hospital Jewish Hospital---502-587-2833 CDI office for all specialists Jewish Shelbyville -- 502-587-2833 CDI office Clinical Documentation Specialists --
Candy Rickard Peggy Barlar Charlotte Hopewell Susan Hinkle Dale Crosby Becki Fudge Sara Goff
Manager- Sandy Hodge- Bowman 502-409-2673 Supervisor- Kristen Boles 859-421-1542
43 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
Sts. Mary and Elizabeth Clinical Documentation Specialists
Mickey Decker– 502-361-6125 Cheryl Brooks-502-361-6549 Annette Majors- 502-361-6495
Manager- Sandy Hodge- Bowman 502-409-2673 Supervisor- Kristen Boles 859-421-1542
Questions—contact your Clinical Documentation Specialists at your hospital
44 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
University of Louisville Clinical Documentation Specialists
Katie Hernandez– 502-562-2895 Hilda Meehan—502-562-3801 Olga Soukhanova—502-562-3152 Cheryl Ward—502-562-3539 Peggy Fields—502-562-3730
Manager- Sandy Hodge- Bowman 502-409-2673 Supervisor- Kristen Boles 859-421-1542
Questions—contact your Clinical Documentation Specialists at your hospital
45 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
St Joe Main Clinical Documentation Specialists
Michelle Ahady—859-313-2178 Tina Baker—859-313-2254 Lynnette Tuttle—859-313-1925 Ann Spero—859-313-2254 Teressa Cozine—859-313-2178 Trudy Paynter—859-313-1927 Karen Browning—859-313-1925
Manager- Sandy Hodge- Bowman 502-409-2673 Supervisor- Kristen Boles 859-421-1542
Questions—contact your Clinical Documentation Specialists at your hospital
46 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
St. Joe East Clinical Documentation Specialists
Kimberly Gilbert-Morrison—502-316-5220 Kelly Geers—502-750-2329
Manager- Sandy Hodge- Bowman 502-409-2673 Supervisor- Kristen Boles 859-421-1542
Questions—contact your Clinical Documentation Specialists at your hospital
47 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
Flaget Clinical Documentation Specialist
Cheryl Mitchell—502-350-5247
Manager- Sandy Hodge- Bowman 502-409-2673 Supervisor- Kristen Boles 859-421-1542
Questions—contact your Clinical Documentation Specialists at your hospital
48 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
St Joe London Clinical Documentation Specialists
Katrina Henson—606-330-6759 Sherry Mills—606-330-6000
Manager- Sandy Hodge- Bowman 502-409-2673 Supervisor- Kristen Boles 859-421-1542
Questions—contact your Clinical Documentation Specialists at your hospital
49 ©2015 Conifer Health Solutions, LLC. All Rights Reserved.
St. Joe Mt. Sterling Clinical Documentation Specialists
Lori Barry—859-497-5458
Manager- Sandy Hodge- Bowman 502-409-2673 Supervisor- Kristen Boles 859-421-1542
Questions—contact your Clinical Documentation Specialists at your hospital