The Transition toWhat you need to know for Endocrinology

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

2

Ongoing Support for ICD-10Physician Advisors

Clinical Informatics

3

-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)

4

What should be documented?

5

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

6

Key Changes Needed to Support ICD-10 Coding

Diabetes• Document type as:

– Type 1– Type 2– Secondary

• Document associated complications, such as:– Diabetic peripheral angiopathy– Diabetic autonomic neuropathy– Diabetic foot ulcer

• If control is not maintained, document insulin control status as:– Inadequate controlled– Out of control– Poorly controlled

• Document if insulin pump is present and operating appropriately

8

Diabetic Complications

9

• Specify manifestations involved:– Diabetic retinopathy– Diabetic neuropathy– Diabetic nephropathy

Gout• Document acuity:

– Acute– Chronic

• Document type:– Idiopathic– Lead induced– Due to drugs– Due to thyroid

disorder– Due to pituitary

disorder

Malnutrition

• Document type such as:– Protein calorie– Protein energy

• Document severity:– Mild or 1st degree– Moderate or 2nd

degree– Sever or 3rd degree

• Document BMI

10

Acidosis-metabolic, respiratory, lactic

• Link abnormal lab value to clinical diagnosis

Obesity• Document etiology:

–Due to excess calories or nutritional –Due to drugs–Other, for example, due to thyroid or pituitary

disorder• Specify if morbid obesity• Document BMI• Document if:

–With alveolar hypoventilation/ hypoventilation syndrome

11

Pressure Ulcer/ Decubitus Ulcer• Document site and laterality:

–Lower leg–Foot –Heel

• Document if present on admission• Document stage if known

12

Non-pressure Ulcer (skin)• Document site and laterality:

– Lower leg – Foot– Heel

• Document type:– Non-healing– Chronic– Stasis– Diabetic– Atherosclerotic

• Document if with:– Infection– Gangrene

13

ECHO, EKG, CXR, and Laboratory

Results• Document diagnosis

based on clinical findings as well as diagnostic study results in progress notes or discharge summary indicating the clinical significance of the diagnosis

14

• Specify actual diagnosis

Dehydration

Atrial Fibrillation & Atrial Flutter• For atrial fibrillation, document type as:

–Paroxysmal–Persistent or–Chronic

• For atrial flutter, document type as: – Typical or Type I or– Atypical or Type 2

• For both, document if condition is a complication of surgery

15

Coronary Artery Disease (CAD)• Document Site as:

–Native artery and/or–Bypass graft

•Autologous vein•Autologous artery•Nonautologous

• Document if with:–Angina pectoris–Unstable angina pectoris–Angina pectoris and spasm

16

Congestive Heart Failure (CHF)• Document severity:

–Acute –Chronic–Acute on chronic

• Document type:–Systolic–Diastolic–Combined systolic & diastolic

• Document etiology, if known, such as due to:–Dilated cardiomyopathy

17

18