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SJPE ICD10 Preparation Series
Asthma & AnemiaJuly 15, 2015
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77 Days Left to
prepare for ICD10’s arrival!
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Agenda
• Optum Fast Finder Tools• .ICD10 smart text • Problem List Calculator• Anemia and Asthma Documentation Tips• Top 20 Medical PC Diagnoses • Top 25 Diagnosis Report Handout to Providers
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Clinical Documentation Challenges
• Over 1/3 of the expansion of ICD-10 codes is due to the addition of laterality (left, right, bilateral). Physicians and other clinicians likely already note the side when evaluating the clinically pertinent anatomical site(s).
• Ensuring sufficient documentation to support code assignment while allowing providers to document in clinical, (not coding) terms
• Need good clinical documentation-o NOT a greater volume of documentation
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Documentation Focus Areas for ICD-10
Disease type
Disease acuity
Disease stage
Site specificity
Laterality
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Terminology Changes
ICD9 TermAmputation
Anastomosis
Arthrodesis
Arthroscopy, Cystoscopy
Aspiration
Bunionectomy
Cesarean Section
Tonsillectomy
Debridement
ICD10 TermDetachment
Bypass
Fusion
Inspection, Endoscopic Approach
Drainage
Resection of Metatarsal
Extraction of products of Conception
Resection of Tonsils
Excision, Extraction, Irrigation, Extirpation
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Provider Tools
• CMS - Road To 10 site http://www.roadto10.org/• Hyperlink to ICD10 Fast Finder Documents via EPIC• Problem List Calculator (aka Diagnosis Calculator)• .ICD10 Smart Text Phrases• Precyse University – Online Courses o (email Celeste Helinski - [email protected] to
obtain access via Healthstream)
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Optum Fast Finder tools
SJPE has purchased a number of Optum ICD10 Fast Finder tools, by specialty to share with providers/staff.
These tools will be provided to Practice Managers in addition to Coding Staff.
*Key tool for Family Practice is the Primary Care Fast Finder tool. (This will be sent following the webex.)
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Sample of Fast Finder tool
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Problem List Calculator
IT has been building a
Problem List Calculator
for high volume diagnoses
(aka Diagnosis Calculator)
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Anemia via Diagnosis Calculator (preferred method for Ambulatory visits)
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Anemia via Diagnosis Calculator (2)
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.ICD10 smart texts
IT has also been building .ICD10 smart texts
to assist in documentation building.
Ie. ICD10 a will bring up a list of diagnoses
built that begin with the letter “a”
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Anemia .ICD10 Smart Text(preferred method for IP related
visits)
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Documentation Concepts
Anemia & Asthma
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Anemia
• Be Specific! Anemia is a nonspecific term. o Is the patient anemic due to blood loss? o Where are they bleeding?
Your documentation should be specific, for example:
“acute blood loss anemia 2◦ to GI hemorrhage from bleeding duodenal ulcer”.
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Anemia documentation Elements
• Include in documentation if Anemia is due to:• Nutrition or mineral deficits resulting in a nutritional
anemia• A neoplasm (primary and/or secondary)• Related to or due to “chemo or radiotherapy treatments• Any “cause-and effect” relationship between the
intervention and the blood or immune disorder• The specific drug if anemia is drug-induced
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Anemia documentation elements cont.
• Documentation of Anemia should include the type of anemia:• Nutritional• Hemolytic• Aplastic• Due to blood loss• Other (please specify)
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Anemia ICD10 Codes
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Anemia documentation guidance from CMS
Road to 10 Anemia reference link:
http://www.roadto10.org/action-plan/phase-2-train/clinical-scenarios-family-practice/
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Asthma
Documentation Requirements:
Must include the relationship between Asthma and other chronic/acute conditions such as COPD, Bronchitis, acute lower respiratory infections and/or exposure to or use of Tobacco (if present) in addition to the severity, and form or type.
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Asthma documentation elements
Severity• Mild intermittent• Mild persistent• Moderate persistent• Severe persistent
With• Acute lower
respiratory infection• COPD• Chronic obstructive
bronchitis• Exacerbation• Status asthmatics
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Asthma documentation
elements cont.
As well as the Form or Type• Cough variant• Childhood• Exercise induced bronchospasm• Extrinsic allergic• Idiosyncratic• Intrinsic non allergic• Late-onset• Mixed• Other (specify)
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Asthma ICD10 Codes
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Next Week’s Topic:
Diabetes Coding in ICD10
7/22/15