Transcript Clinical Documentation Improvement

Clinical Documentation
Improvement
(CDI)
Objectives.
!. What is CDI and why is it associated with ICD-10?
2. How to share information with physicians.
3.Longer time frame now. Delayed 10/1/2015
4. Will it be ICD-10 or ICD-11
Diabetes Mellitus
250.00 – 250.93
 Diabetes Mellitus Coding in ICD-10CM
The codes for diabetes mellitus have expanded in ICD-10CM into five categories of codes. The codes were made
into combination codes that bundle in the type, the body
system affected, and any complications of the body
system. The five categories are as follows:
 E08 Diabetes mellitus due to an underlying condition
E09 Drug or chemically induced diabetes mellitus
E10 Type 1 diabetes mellitus
E11 Type 2 diabetes mellitus
E13 Other specified diabetes mellitus
 Notice that there is no unspecified diabetes mellitus
code category. According to the guidelines (I.C.4.a.2),
if the type of diabetes mellitus is not documented in
the medical record the default is E11, Type 2 diabetes
mellitus.
 The differences from ICD-9-CM include the fact that
the codes do not include the fact that the codes do
not include "uncontrolled" and "not stated as
uncontrolled" in the descriptors any longer. Instead,
the codes are listed as with and without
complications. The second difference is the
combination of the complication into the code
 Definitions for the types of diabetes mellitus are
located in the "Includes notes" under each DM
category. Physicians and other providers should be
instructed to document the type of diabetes as type 1
or type 2, when appropriate, and not insulin and noninsulin dependent as these terms are no longer used
in the coding world.
 Our first CDI:
Code This one.
 Paulette, a type 1 diabetic, comes in today for a
recheck of her diabetic right heel ulcer. Upon
examination, it is healing well, with the breakdown
limited to the skin.
 E10.621 Type 1 diabetes mellitus with foot ulcer
L97.411 Non-pressure chronic ulcer of right heal and
midfoot limited to breakdown of skin
 Did you get it right???
 Notice that although combination codes exist, more
than one code is still necessary to indicate the site,
laterality, and severity of the ulcer.
All Conditions of DM
 If the documentation in a medical record does not
indicate the type of diabetes but does indicate that
the patient uses insulin, a code from category E11
should be assigned. Code Z79.4, Long-term (current)
use of insulin, should also be assigned to indicate that
the patient uses insulin.
DM
 Mary is a type 2 diabetic that presents to the clinic.
She is doing well with her diet and exercise routine.
She uses Lantus at bedtime and has her diabetes
under good control. She will remain on same
medication regimen and come for follow-up in three
months.
How did you do????
 ICD-10-CM Codes:
E11.9 Type 2 diabetes mellitus without complications
Z79.4 Long=term (current) use of insulin
 Rationale: Although the patient is using insulin, it cannot be
assumed that she is a type 1 diabetic. This example brings in two
guidelines. Guideline I.C.4.a.2 states if the type of diabetes
mellitus is not documented in the medical record the default is
E11, Type 2 diabetes mellitus. The second is regarding the use of
insulin. Guideline I.C.4.a.3 states if the documentation in a
medical record does not indicate the type of diabetes but does
indicate that the patient uses insulin, code Z79.4, Long-term
(current) use of insulin, should also be assigned to indicate that
the patient uses insulin.
Atrial Fibrillation
427.31
 Atrial fibrillation and flutter, separate codes for
flutter.
 I48.91 Unspecified atrial fibrillation
 Documentation needed for AF.: CDI
 1. Type: Paroxysmal I48.0
 2.
Persistent I48.1
 3.
Chronic
I48.2
Hyperlipidemia
272.4
 E78.4
 Other hyperlipidemia, Familial combined
hyperlipidemia.
 E78.5
 Hyperlipidemia, unspecified Try to Avoid!!!
LIPIDS
 More specific documentation is needed when coding
disorders of lipoprotein metabolism and other
lipidemia
 CDI
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E78.0 Pure Hypercholesterolemia
E78.1 Pure hyperglyceridemia
E78.2 Mixed hyperlipidemia
E78.3 Hyperchylomicronemia
Routine General Physicals.
V70.0/ V20.2
 Documentation needed for the ICD-10 codes:
 There are three general medical exams.
 1. General Medical Adult exam.
 A. Z00.00 without abnormal findings.
 B Z00.01 with abnormal findings.
Abnormal findings are identify as those found on the
exam for that day.
V20.2
2. Encounter for newborn, infant, & child exam.
A.Z00.110 Newborn, under 8 days.
B. Z00.111 Newborn 8 to 28 days.
3. Encounter for Routine Child Health Exam.
A. Z00.121 with abnormal findings.
B. Z00.129 without abnormal findings
Immunizations
Also when coding
immunizations you will
code
Z23 as the diagnosis
code.
Sports/DOT/ETC
V70.3
 In ICD-10, these codes are:
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Z02.0 Encounter for Administrative purposes.
Z02.1 Pre-employment
Z02.2 Residential institution
Z02.3 Recruitment to armed forces
Z02.4 Driving License
Z02.5 Sports
Z02.6 Insurance purpose
Unspecified Sinusitis.
473.9
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X reference to:
J32.9 Unspec. Chronic sinusitis
CDI:
Providers /Staff must Specify:
Acute/Chronic
Site of Sinusitis
Example, Maxillary, frontal, ethmoidal, etc.
Recurrent
Acute sinusitis
461.9
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J01.90 Acute sinusitis,
unspec.
CDI
Site of Sinusitis
Site of the sinusitis, Example: Maxillary, frontal,
ethmoidal, etc.
 Recurrent
Pharyngitis and Tonsillitis
462 and 463
 J03.00 – Acute Streptococcal tonsillitis
 J03.01 - Acute recurrent streptococcal tonsillitis
J03.80 – Acute tonsillitis due to other specify organisms
(additional code must be used to identify infectious agent)
 J03.81 – – Acute recurrent tonsillitis due to other specified
organism
 (additional code must be used to identify infectious agent)
 J03.90- Acute tonsillitis, unspec
 J03.91-Acute recurrent tonsillitis, unspec Avoid
Pharyngitis and Tonsillitis
462 and 463
 J02.0 –Acute Streptococcal pharyngitis
 J02.8 – Acute pharyngitis due to other specified
organism(additional code must be used to identify
infectious agent)
 J02.9 Acute pharyngitis, unspec. (Avoid)
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CDI
 1.
Specify acute vs. Chronic (Chronic will code a
different path i.e. tonsillitis, adenoid involvement, etc.)
 2.
What Organism. Streptococcal, mono, coxsacki,
herpes simplex, unknown, etc.
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 Admin staff: When scheduling appointment for sore
throat ask how long they have had symptoms
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 Nursing staff:
1-Make sure surgical history
accurately reflects if patient has had tonsils or adenoids
removed
Otitis Media, Acute
382.00
H66.009 Acute suppurative OM w/o spontaneous rupture of ear drum
.
CDI
 Specify where infection: internal vs. external ear (i.e. “media)
 Acute vs. Chronic or whether it is both (i.e. patient has had multiple
episodes visits for Otitis Media and now has a current infection)
 Which EAR – Right, Left, Bilateral (both)
 Is the ear draining? Suppurative vs serous
 Is the drum ruptured? Specify with or without rupture
 Other manifestation – ESPECIALLY exposure to tobacco smoke
Fatigue and Malaise 780.79
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G93.3
Postviral fatigue syndrome
R53.1
Weakness
R53.81
Other malaise
R53.83
Other fatigue
 CDI:
 You would code two codes for this one.
Hypertension
401.0 - 401.9
 Hypertension, controlled, uncontrolled, benign,
arterial, essential, malignant and high blood pressure
are all coded to :
I10
There are no hypertension table found in
ICD-10 CM.
Questions:????????