orthopedics

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Orthopedics

INSTEAD OF PLEASE CONSIDER

Low or No Severity Diagnosis—NO

High Severity Diagnosis---YES

ICD 10 Themes: e.g. Acute on Chronic Systolic Heart Failure

Acuity/Severity/Type/Staging

Acute/Chronic/Acute on Chronic

Mild, Moderate, Severe

Systolic, Diastolic, Combined

Stage I, II, III, IV

e.g. Malignant neoplasm of lower lobe right bronchus

Anatomy/Site Specificity

Location of tumor

Bone/Joint/Muscle involved

e.g. Decubitus Ulcer, Stage 3, Right Buttocks, Present on Admission

Laterality

Right/Left/Bilateral/Overlapping (see Neoplasm re overlaps two or more contiguous (next to each other) sites)

e.g. Hypertensive heart disease with chronic systolic heart failure

Manifestations – LINK IT!

Associated or Related Conditions

‘With’/‘Secondary’ to/’Due to’

‘Evidence of’ and causative organism

Use ‘no organism isolated’, instead of ‘negative culture’

e.g. Likely Sepsis secondary to UTI; Evidence of Bacterial Pneumonia (‘Evidence of’ in outpt setting can be captured as a diagnosis)

Etiology – ‘DUE TO’ WhAt?

‘LIKELY’ suspects….Who dun it?

Possible, Probable, Suspected (Inpt Only)

Evidence of, As Evidenced by (Outpt Setting and Inpt Setting)

e.g. Drug Poisoning/Adverse Effect Episode of Care/Incidence of Encounter (Trauma/Fractures/Medication.Chemical Event(Drug Poisoning))

Initial/Subsequent/Sequela

Top Diagnosis Codes by Specialty:

Osteoarthritis Type: Primary/Secondary/Post traumatic

Anatomical Site: Hip/Knee/First Carpometacarpal joint/Shoulder/Elbow/Wrist/Hand/Ankle and Foot

Laterality: Unilateral /Bilateral Right/Left

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Traumatic Fractures (Fracture Tib/Fib, Femur, Hip) Location: Specific Part of Body - Name of specific bone and specific site on bone

Laterality

LEO C. FAUR

(acronym to remember elements of fracture documentation)

Zupko and Associates

Episode of Care:

Initial (receiving active treatment);

Subsequent (encounters AFTER the patient

has received active treatment of the condition

and is receiving routine care):

o Routine Healing or Delayed Healing

o Non-Union or Mal-union:

If non union: State if delayed

Tx, (it’s Initial Encounter,

otherwise it’s ‘Subsequent’)

Sequela (Use for complications or

conditions/residual effect that arise as a

direct result of a condition (after the acute

phase)…no time limit….i.e. Neuropathy of

lower leg, ankle and foot due to previous crush

injury)

Open or Closed

Classifications: Open use Gustilo Classification: Type I, II, IIIA, IIIB, or IIIC (used for soft tissue classification); Salter; Physeal etc

Fracture Pattern/Type/Orientation, i.e.:

Greenstick Comminuted Torus

Spiral Segmental

Transverse Avulsed

Oblique Torus

Alignment: Displaced or Nondisplaced

Underlying Bone Diseases: i.e. Fragility (Pathologic), Stress, Traumatic in healthy etc

Results: Routine or Delayed Healing; Non union or Malunion

Pathological Fracture/Fragility Fracture (fyi: any ground level fall of 50 yr old or greater is usually a pathological fracture) -When the fracture is out of proportion to the degree of the trauma (weakening of the bone structure by pathologic processes i.e. Osteoporosis)

Site and Laterality Etiology:

Age related

Osteoporosis or Osteopenia

Neoplastic

Some other disease

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Episode of Care: Initial/Subsequent/Sequela For Subsequent: Routine or Delayed Healing; Non union or Malunion Current Fracture and/or personal history

Open Fractures Reference: Clin Orthop Relat Res. 201 November; 470(11): 3270 - 3274

Gustilo Classification: (used for soft tissue classification) Type 1

Wound is less than 1cm with minimal soft tissue injury Wound bed is clean Bone Injury is simple with minimal comminution

Type 2 Wound is greater than 1 cm with moderate soft tissue injury Wound bed is moderately contaminated Fracture contains moderate comminution

Type 3 Wound is longer than 1 cm, with significant soft tissue disruption Mechanism often involves high-energy trauma, is unstable.

Grade IIIA Adequate periosteal coverage of bone despite extensive soft-tissue laceration or damage Soft tissue coverage of bone is usually possible

Grade IIIB Extensive soft-tissue loss and periosteal stripping and bone damage

Usually associated with massive contamination Will often need further soft-tissue coverage procedure (i.e. free or rotational flap)

Grade IIIC Fracture in which there is a major vascular injury requiring repair for limb salvage In some cases it will be necessary to consider amputation.

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Growth Plate (Physeal ) Fracture Salter mneumonic refers to the fracture line and its relationship to the growth plate.

Use Salter Harris Classification: S (straight across) Type I – disrupt the physis A (above) Type II – involve a break from the growth plate up into the metaphysis, with the periosteum usually remaining intact. L (Lower or BeLow) Type III – intraarticular fractures through the epiphysis that extend across the physis T (Two or Through) Type IV – cross the epiphysis, physis, and metaphysis E R (ERasure of growth plate or cRush) Type V – compression injuries to the physis.

Sacral Fracture

Vertical Fx: State if minimally vs. severely displaced Zone 1: fracture involves the sacral ala lateral to the neural foramina Zone 2: fracture involves the neural foramina, but does not involve the spinal canal

Zone 3: fracture is medial to the neural foramen, involving the spinal canal; these may be transverse or longitudinal, and can be sub-classified into 4 types: Transverse Fx: Type 1: only kyphotic angulation at the fracture site (no translation) Type 2: kyphotic angulation with anterior translation of the distal sacrum Type 3: kyphotic angulation with complete offset of the fracture fragments Type 4: comminuted S1 segment, usually due to axial compression

Complication/Infection of Internal Joint Prosthesis or Device

Laterality

Anatomical Site: Hip/Knee/Humerus/Radius/Ulna/Femur/Tibia/Fibula/ Spine/Other

Complication: Infection/Inflammation/Embolism/Fibrosis/Hemorrhage/Pain/Stenosis/Thrombosis/Other

Episode of Care: Initial/Subsequent/Sequela

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Mechanical Complications with Internal Joint Prosthesis

Laterality

Anatomical Site: Hip/Knee/Other

Type: Mechanical Loosening; Dislocation; Broken; Periprosthetic Fracture; Periprosthetic Osteolysis; Wear of articular bearing surface; Other

Episode of Care: Initial/Subsequent/Sequela

Aseptic Necrosis Site and Laterality

Idiopathic or Non-idiopathic

Manifestations: With or Without Major Osseous Defect

If with, What is the Site?

Excisional Debridement

‘Non-excisional’ Debridement - Minor removal of loose fragments with scissors or using a sharp instrument to scrape away tissue (typically involves mechanical removal of tissue with brushing, scrubbing, washing etc). Debridement is usually only to level of subcutaneous tissue.

Excisional Debridement - Involves cutting outside or beyond the wound margin. A scalpel is used to remove devitalized tissue.

I & D, Debridement, Sharp Debridement If it is actually an ‘excisional debridement’ designate the procedure as such, instead of stating I & D.

‘EXCISIONAL’ Debridement – Documentation to include:

‘Technique’ used (e.g., excisional, excised, cutting etc)

‘Instrument’ used (e.g. scalpel, curette)

Nature of ‘tissue’ removed (e.g. necrotic, devitalized tissue, nonviable tissue)

The ‘appearance’ and ‘size’ of the wound (e.g. down to flesh, bleeding tissue, 7cm x 10 cm etc)

‘Depth’ of debridement (e.g. skin, subcutaneous, fascia, muscle, bone, etc.)

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Debridement---Low or No Severity Procedure Statement for Debridement

“Excisional” Debridement - Best Practice Procedure Statement for Excisional Debridement

“I debrided the ulcer down to the pink tissue” (Missing: technique, instrument used, nature of tissue, size of wound, depth)

“Using a #5 blade, I excisionally debrided the necrotic skin around the edges of the sacral ulcer. The wound measured 5 cm x 5 cm and was covered with damp gauze at the conclusion of the procedure.”

“I removed all the necrotic tissue down to the muscle resulting in a wound of 4 cm x 2 cm.” (Missing: technique, instrument used, appearance of the wound)

Secondary Conditions:

Pneumonia Type: Healthcare Associated/Aspiration/Ventilator Associated/Radiation Induced

CAUTION: CAP-Community Acquired PNA- defaults to a ‘simple pna’ with low severity; if documented, please also include if it is Viral or Bacterial (and other items listed from list on right, as applicable) to capture the true severity.

Causative Agent: Viral or Bacterial

Causative Organism (if known)

Associated Illnesses: influenza/ lung abscess/Sepsis

Common Secondary Conditions: Acute Respiratory Failure; Exacerbation of COPD, etc.

Clinically significant diagnostic results from Lab and Radiology in the medical record. i.e. if elevated white count; infiltrate on CXR

History of Tobacco Use, Present or Past

COPD Acute Exacerbation or Decompensated

(Chronic RF is very common in pt with severe COPD) CAUTION: ‘Respiratory Distress’ and ‘Respiratory Insufficiency’ are vague and symptomatic of underlying condition – is the intended diagnosis Respiratory Failure OR what is other underlying condition?

If with acute lower respiratory infection, as applicable (also include causative organism, if known)

IF Oxygen Dependent

Common Secondary Conditions: Acute, Chronic, Acute on Chronic Respiratory Failure; Pneumonia, etc.

History of Tobacco Use, Present or Past

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Respiratory Failure Acuity: Acute/Chronic/Acute on Chronic

(Chronic RF is very common in pt with severe COPD) CAUTION: ‘Respiratory Distress’ and ‘Respiratory Insufficiency’ are vague and symptomatic of underlying condition – is the intended diagnosis Respiratory Failure OR what is other underlying condition?

Manifestation: With Hypoxia or With Hypercapnia, or both

Etiology: if known (i.e. due to COPD Exacerbation; Pneumonia; Surgery, Trauma, etc)

Pleural Effusion Type: Malignant (Specify site and morphology of tumor if possible); Influenzal; Tuberculosis; In heart failure

Urinary Tract Infection Acuity: Acute or Chronic

e.g. ‘Chronic Cystitis with hematuria’; ‘Acute Urethritis due to E.Coli’; ‘Acute on Chronic Pyelonephritis due to foley catheter with Candida’

Specific Site: Bladder (Cystitis)/Urethra (Urethritis)/Kidney (Pyelonephritis)

Manifestations: Hematuria etc.

Causative Organism i.e. E Coli or Candida

IF related to a device i.e. foley catheter, state ‘due to’ or ‘secondary to’

Sepsis Type: Sepsis/Severe Sepsis/Septic Shock

(fyi: negative or inconclusive blood cultures do not preclude a diagnosis of sepsis in patients with clinical evidence of the condition)

Causative Organism (if known)

(fyi: Bacteremia is a non specific diagnosis and indicates the presence of bacteria in the blood, but does not indicate the bacteria are pathological or has any resulting systemic illness needing treatment.)

Underlying Systemic Infection (the source of infection) i.e. Sepsis due to UTI

(fyi: Urosepsis is non descriptive term and is NOT synonymous with sepsis and there is no default for coders…please .use ‘Sepsis due to UTI’ instead) (fyi: Sepsis Syndrome is a non specific term..avoid using it)

Any Associated Organ Dysfunction i.e. Acute Renal Failure; Acute Respiratory Failure; Encephalopathy

SIRS Infectious or Non-infectious (If ‘non-infectious’ specify what ‘due to’, i.e. ‘SIRS due to Burn’)

Always document the Etiology!! With severe Sepsis or Without Sepsis

With or Without Organ Dysfunction

(Does NOT code to Sepsis, unless stated ‘with sepsis’)

Defaults to the underlying infectious process i.e. Pneumonia

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Atrial Fibrillation Type: Paroxysmal/Persistent/Chronic

Atrial Flutter Type: Typical (Type 1) or Atypical (Type 2)

Diabetes Type: Type 1 or Type 2 ; Drug or Chemical Induced; or Gestational

Terms i.e. ‘uncontrolled’ or ‘inadequately controlled’ code to ‘hyperglycemia’…even if recent ‘hypoglycemia’…..specifically use Hypoglycemia or Hyperglycemia instead. Or if used, stipulate if not hyperglycemic.

Control Status (Insulin):

With: Hypoglycemia/Hyperglycemia

Insulin Use

Associated Diagnosis/Conditions: i.e. ulcers

Manifestations or Secondary related problems (document LINK to Diabetes): i.e. neuropathy; nephropathy; retinopathy; ketoacidosis

Asthma Severity: Mild/Moderate/ Severe

Type: Intermittent or Persistent

With or Without Exacerbation

With or Without Status Asthmaticus

Heart Failure Severity: Acute/Chronic/Acute on Chronic

Type: Systolic/Diastolic/Combined Systolic and Diastolic/Congestive

Etiology, if known, i.e. due to ischemic or primary cardiomyopathy

Associated Conditions: i.e. Hypertension/Pericarditis

Alcohol Dependence with or without Alcohol Withdrawal

Frequency of Usage: Use/Abuse/Dependence/In Remission

Type of Dependence: Uncomplicated; In Remission, Current Intoxication

Manifestations: Delirium, Delusions, Hallucinations, Anxiety, etc;

Specify intoxication/withdrawal as: Uncomplicated or With Delirium

Cellulitis Anatomical Site: Trunk: Abdominal Wall/Back/Chest Wall/Groin; Toe/Foot

Laterality: Left/Right/ Bilateral

Manifestations: i.e. Febrile Neutrophilic Dermatosis/Lymphangitis etc

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Abscess Anatomical Site: Abdominal/Lung/Wound/Teeth/Extremity, etc

Laterality: Right/Left/Bilateral

Manifestations: i.e. Febrile Neutrophilic Dermatosis/Lymphangitis

Causative Agent: Viral or Bacterial

Causative Organism (if known)

Episode of Care: Initial/Subsequent/Sequela (if ‘Wound’ related)

Non Pressure Ulcer Wound Acuity: Chronic

Laterality

Severity/Depth of Tissue Involved: Skin Breakdown; Fat Layer Exposed; Muscle Necrosis; Bone Necrosis; Unspecified Severity

Etiology: Diabetes; Infection (specify); Other (specify)

Present on Admission, if applicable

Pressure Ulcer Anatomical Site

Laterality

Stage: 1, 2, 3, 4 (Staging can be taken from wound care RN )

Associated Illnesses: i.e. Diabetes

Gangrene, if applicable

Present on Admission, if applicable

Osteomyelitis Acuity: Acute/Subacute/Chronic

Anatomic Site: Body part (i.e. thigh); Specific bone (i.e. femur); Joint (i.e. shoulder)

Laterality: Right/Left/Bilateral

Causative Agent: Viral or Bacterial

Causative Organism (if known)

Etiology/’Due to’: i.e. Acute osteomyelitis, left humerus, ‘due to’ infect hip

Complications: Abscess/Amputation/Avascular necrosis/Gangrene/Meningitis etc.

Pulmonary Embolism Severity: Acute/Chronic (still present) vs. Healed (Old)

Type: Saddle/Septic

Manifestations: With or Without Acute Cor Pulmonale

DVT Acuity: Acute or Chronic

Laterality: Right/Left/Bilateral

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Dementia Etiology: Alzheimers/with Lewy Bodies/Epilepsy/Hypercalcemia/Parkinson’s Disease

Manifestations: With behavioral disturbance or Without Behavioral disturbance

Alzheimers Type: Early Onset (presenile dementia); Late Onset (senile dementia)

“Early onset Alzheimers with dementia. Pt wandered into snow with bathing suit on and sustained a hand laceration of unknown mechanism”—link it.

Manifestations: With ‘Behavioral’ Disturbances (i.e. Aggressive; Combative; Violent, Wandering); With ‘Mind’ Disturbances (i.e. Dementia/Delirium)

- Dementia with Wandering

-With Associated Delirium

CVA/Cerebral Infarction Etiology: Thrombus or Embolism

Artery Site: Precerebral – Vertebral, basilar, carotid, or other Cerebral – Middle, anterior, or posterior Cerebellar arteries

Laterality, When Appropriate

Dominant or Non-Dominant Side Affected

Associated Conditions i.e. aphasia, hemiplegia, dysphasia

Obesity BMI 19 or less = Indicates Malnutrition

BMI 25 – 29.9 = Overweight

(BMI can be taken from Nursing Documentation; MD needs to document the diagnosis and etiology/manifestation correlating to BMI)

BMI 30.0 – 39.9 = Obesity

BMI ≥ 40 = Morbid Obesity (state Etiology: Excess Calories ; Other and Manifestation: Alveolar Hypoventilation, as applicable)

Etiology: Excess Calories (for Morbid Obesity); Drug Induced; Endocrine; Familial; Constitutional; etc

Manifestation: Alveolar Hypoventilation (for Morbid Obesity)

Malnutrition BMI 19 or less = Indicates Malnutrition

Acuity: Acute (< 3 mo); Chronic (>3 mo)

Severity: Mild/Moderate/Severe

(BMI can be taken from Nursing Documentation; MD needs to document the diagnosis and etiology/manifestation correlating to BMI)

Type: Protein Calorie; Protein Energy

Etiology: Renal Disease; Pregnancy Related; Diabetes; Following Gastrointestinal Surgery, etc

Utilize Dietician’s Assessment to assist you with Manifestations: Insufficient Energy Intake;

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diagnosis. To review MNT Nutrition Evaluation in CPSI, Go to <chartlink> <C/H Section tab> <MNT Nutrition Evaluation, page 1 and 2.

Unintentional Weight Loss; Significant Edema or Ascites; Diminished Functional Capacity; Cachexia; Dehydration;

Kidney Failure Note: Re Chronic: ‘insufficiency’ and no ‘stage’ codes to ‘unspecified’ code and does not reflect the severity of the patient

Acuity: Acute/Chronic/Acute on Chronic If Chronic:

Stage 1 (GFR ≥ 90) – Kidney Damage with normal or ↑ GFR

Stage 2 (mild) (GFR 60 – 90) + Kidney Damage

Stage 3 (moderate) (GFR 30-59)

Stage 4 (severe) (GFR 15-29)

Stage 5 (GFR ‹ 15)

End Stage Renal Disease Above per KDIGO 2012 Clinical Practice Guidelines

Re Acute: ‘insufficiency’ and ‘kidney disease’ do not report ‘failure, acute renal’

If Acute: due to traumatic injury or non trauma event

Manifestations: With-Acute Tubular Necrosis (ATN)/Acute Cortical Necrosis/Medullary Necrosis

Etiology: Pre-renal AKI/ ATN/Post-Renal Obstructive AKI/Diabetic/Hypertensive

Hypotension Etiology: Postural; Orthostatic (chronic); Neurogenic (Orthostatic); Postoperative; Drug-induced; Cardiogenic; Idiopathic; etc

Atelectasis Etiology: i.e. Morbid Obesity/Pleural Effusion/Malignancy etc

Associated Conditions: i.e. Apnea

Present on Admission, if applicable

Diverticulitis Location: Small, Large or Both Intestines

With or Without Bleeding

With or Without Perforation/Abscess

Neoplasm Type: Malignant (Primary; Secondary/Metastatic); Benign; In-Situ; Uncertain Behavior (include cell type) (Uncertain behavior is a specific pathologic diagnosis indicating behavior that cannot be predicted, as opposed to a diagnosis of unknown pathology)

Morphology: Adenocarcinoma; Sarcoma; Lymphoma etc

Note: A primary malignant neoplasm that overlaps two or more contiguous (next to each other) sites

Behavior: Primary or Secondary Site; Designate if Overlapping

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should be classified 'overlapping lesion', unless the combination is specifically indexed elsewhere. For multiple neoplasms of the same site that are not contiguous, such as tumors in different quadrants of the same breast, codes for each site should be assigned.

For Secondary Site…document if primary site still exists

Gender: Male or Female

Laterality: Right; Left; Bilateral

Anatomical Site: Breast: Upper-Outer; Upper-Inner; Lower Outer; Lower-Inner; Midline; Central; Nipple; Areola; Axillary tail etc

Stage and Metastatic Sites (and indicate if primary site still exists)

Caution: ‘History of’ – for coding purposes means when primary malignancy previously excised and no further treatment to that site, no evidence of any existing primary malignancy

Status – In remission, Not having achieved remission; In Relapse; History of (preferably state more specifically i.e. ‘Previously excised or eradicated’; ‘No further treatment’; ‘No evidence of existing malignancy’)

Anemia Acuity: Acute/Chronic

(Acute Blood Loss Anemia does not reflect a complication of surgery, unless surgeon states it’s a complication and there is a cause and effect relationship; May state ‘expected’/’inherent’; Documentation of ‘Post-op Anemia’ is not enough, instead ‘Post Operative Anemia due to Acute Blood Loss’)

Etiology: Blood Loss; Iron Deficiency; Chemotherapy; Neoplastic; Aplastic, etc

Nutritional Anemia Type: i.e. if nutritional due to iron deficiency: Sideropenic iron deficiency anemia; Iron deficiency due to inadequate dietary iron intake

Vitamin B12 type i.e. Due to intrinsic factor deficiency; Vitamin B12 malabsorption

Folate Deficiency type: i.e. Due to diet; Drug induced

Other Nutritional Types: i.e. Protein deficiency

Anemia in Chronic Disease Link to Chronic Disease i.e. -Anemia due to chronic kidney disease -Anemia due to colon cancer

Neutropenia Type: Agranulocytosis/Other Drug Induced/Congenital/Cyclic

Etiology: Cancer Chemotherapy/Infection etc.

If Drug-induced: - Specify Drug - Purpose of drug’s use (e.g. chemotherapy)

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- Specify the malignancy (e.g. Cytoxan for primary malignancy upper-inner quadrant of left breast

Associated Conditions (e.g. infection)

Adverse Effect (e.g. fever or mucositis)

Thrombocytopenia Classification: -Idiopathic -Primary -Secondary -Congenital or Hereditary -Heparin Induced

Secondary Thrombocytopenia: - Underlying Condition (e.g. alcohol induced)

Specify Hemorrhagic Conditions (e.g. qualitative platelet defects)

Pancytopenia Definition - Anemia (e.g. Hct < 32%); and, - Thrombocytopenia (e.g. PPC < 150K); and, - Neutropenia (e.g. ANC < 1,500)

–

Physician must describe underlying cause and what individual component has been treated

- e.g. Platelets for thrombocytopenia - PRBC transfusion for acute blood loss anemia

Etiology - Malignancy (Specify Malignancy) - Drug induced (Specify specific drug) - ‘Pancytopenia due to antineoplastic

chemotherapy’ or - ‘Pancytopenia secondary to Cisplatin and

disease’ , Or - ‘Pancytopenia due to HIV disease.’

Pain Acuity: Acute/ Chronic

Anatomic Site: Cervical/Lumbar/Thoracic/Ankle/Elbow/Buttock,etc

Laterality: Right/Left

‘Chronic back pain due to spinal stenosis and difficulty sleeping due to the pain.’

Etiology: i.e. Device, implant, graft; Pyschogenic (list type)

Manifestations: With: Myelopathy; Radiculopathy; Neuritis; Radiculitis; etc

Episode of Care/Incidence of Encounter: Initial/Subsequent/Sequela

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Depression Acuity: Acute/Chronic/Recurrent/Single Episode

Severity: Mild/Moderate/Severe

Type: Anxious/Bipolar/Atypical/Post-Partum

Etiology: Dementia; Head Injury; Multiple Sclerosis; Stroke; Pregnancy;

Manifestations: Anxiety/Suicidal Ideation/Somatization

Remission Status: Partial/Complete

Acute Myocardial Infarction (AMI) Indicate exact date of initial MI, if unavailable, report in weeks, NOT months.

Acuity: Acute; Subsequent (Acute MI occurring within 28 days (4 weeks) of previous acute MI, regardless of site; Old (> 28 days of current encounter)

Type: STEMI/NSTEMI

Anatomical Site: For STEMI: Wall involved; also include artery involved; NSTEMI – no add’l documentation needed

Underdosing Intentional vs. Unintentional

Reason for Underdosing i.e. financial hardship or Age related dementia

Episode of Care: Initial/Subsequent/Sequela

Tobacco Use Use/Dependence/Contact with Second Hand Exposure (Acute or Chronic)

Caution: ‘History of smoking’ can be an ambiguous statement.

Current/No longer Use Tobacco/Never

Type of Tobacco Product: Cigarette/Chewing Tobacco/Nicotine

If Dependence: Uncomplicated/In remission/With withdrawal/With other Nicotine induced disorder

Incidental to Pregnant State vs. Impacting Pregnancy

State “Does not affect or complicate the pregnancy” if incidental, otherwise will code as ‘impacting the pregnancy’

e.g. Pregnant patient with burn of hand, “Burn of hand does not affect or complicate the pregnancy”

Complications of Surgery Affected Body System

Specific Condition

Timeframe: Intra operatively or Post operatively

(Punctures or lacerations that are unavoidable or inherent to the procedure are not complications. When NOT a complication…include the medical decision making and characterize the event as

Link Complication to Diagnosis: ‘due to’/’secondary to’ etc… There is no timeframe/deadline for a Postoperative

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‘intentional’, ‘unavoidable’, or ‘inherent’ to the procedure)

Complication (current condition due to previous surgery or procedure)

NOT Complications Document: Inherent, Expected, Intended

Avoid ‘Accidental/Complication/Unavoidable/Slip/ Iatrogenic/Unintended’ etc when it is not a complication. Avoid using ‘Post operative’ when not a complication; if used, include that it was ‘intended, expected, inherent’ etc.

Additional Terms that suggest non-accidental: to facilitate; necessary; required; intentional; integral; routinely expected

Procedure Coding System (PCS) – New with ICD 10

Pre-operative/Post Operative Diagnosis State difference b/w pre and post dx, as applicable

Link ‘findings’ with post operative diagnosis

Procedure Performed Be Explicit, including unplanned

Post op drains/tubes – Specify type of drain/tube

Be specific re ‘intent’ of surgery i.e. Excision/Biopsy etc

Types of Anesthesia/Estimated Blood Loss (EBL)/Transfusions

-Site infused (Central/Peripheral) - Type & Volume of Fluid (Fresh/Frozen/Autologous)

Procedure – Coder needs ALL elements addressed in order to be able to assign a code…..physician can use their own language for coder to translate, yet all information needs to be available. Coders must have a clear understanding of the ‘intent’ of the procedure..it will help the coder properly assign the appropriate code.

-Intent of the Procedure - Excision (partial removal i.e. biopsy)/Resection (total removal)/Drain fluid/Inspect i.e. endoscopy etc. -Approach—Specify technique used to reach the site i.e. open, percutaneous, use of scopes etc -Prose for steps and technique, not the name of procedure -Laterality of incision/Relative Location -Anatomical site – Be specific re site/Body Cavity (instead of quadrants)/How much of body part removed (all, partial, or measurements) - Devices Used Intraoperatively – material or appliance that remains in the body after the procedure is completed. i.e. Biological or synthetic material (i.e. joint prosthesis, intrauterine device; Therapeutic material (i.e. radioactive implant); Mechanical or electronic appliances ( i.e. orthopedic pin, pacemaker) etc. -Intraoperative Grafting – source and destination site -Modality of Guidance

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-Specimens – specify if sent to pathology are intended to diagnose and help treatment decisions following the procedure. -Medications applied at Surgical Site -Closure – type/area -Complications

ADDITIONAL DOCUMENTATION TIPS

Radiology Tests Ordered

‘Better info given →Better outcome on Report’

Reason for Exam –Be Specific as to what looking for - Anatomical Site Specificity/Where specifically the

problem is…i.e. ‘tender over T9’ instead of ‘back pain’

- Indication for X-ray, i.e. Lt Pleuritic Chest Pain; Orthopnea; SOB at rest

- Why doing exam/What are you looking for? i.e. re Cancer…’Looking for Metastasis

- AVOID: R/O, Pre –Op, Vague terms i.e. cough, dizzy. Instead state, fever, shakes, chills so Radiologist can help you capture Pneumonia if present.

- Example of Reason for Exam: ‘Pt fell of ladder, pain medial aspect Lt ankle x 3 days’ instead of ‘ankle pain’; OR, ‘Pt with fever, chills, productive cough green sputum x 2 days’ instead of, ‘cough’.

Chronic Conditions/Secondary Diagnosis Capture the Severity!!!

Avoid stating ‘History of’ ……Instead document what you are doing for Chronic Conditions now! Examples of documentation showing link between the additional disease and this admission’s evaluation, treatment, or monitoring:

Hypertensive Heart Disease and Chronic Kidney Disease (CKD), stage 3 (Strict I & O, Monitor BP)

Chronic Systolic Heart Failure (Echo, Lasix 40 mg)

Hypokalemia (K+ repleted)

Acute Blood Loss Anemia (2 U PRBC’s)

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Indicate “Present on Admission” (POA) status, as applicable

A diagnosis without documentation of being present on admission could be inadvertently considered a hospital-acquired condition (HAC). Example: Pneumonia not definitively diagnosed until hospital day two but suspected, probable, or likely on admission should be noted as such. This allows coders to most accurately report the condition as being POA as opposed to hospital-acquired.

AVOID Signs and Symptoms as Diagnosis Definitive diagnoses are preferred in the inpatient setting and support a higher evaluation and management (E/M) fee. In the inpatient setting, coders can capture ‘probable’, ‘likely’, ‘suspected’, or presumed diagnoses when patients present with the signs and symptoms of the diagnoses being ruled out…. as long as those diagnoses are restated in the discharge summary and have not been ruled out during the stay.

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Discharge Summary Wrap it all up!!

For all ‘Rule Out’ situations: Rule it in!/ Rule it Out!/or state ‘Resolved’

Avoid Conflicting with previous documentation substantiated in the record……Caution: If primary physician subsequent dictation conflicts with previous ‘consult’ note, the primary physician’s diagnosis is taken.

INCLUDE: Reason for hospitalization: Chief Complaint; including description of the initial diagnostic evaluation Significant Findings: -Admitting Diagnosis - reason for hospitalization -Discharge Diagnosis - significant findings/diagnoses -As well as those conditions resolved during hospitalization -List all possible and probable diagnoses as well -Hospital Course (procedures performed and findings/surgical findings/test results/treatment rendered/consults) -Discharge Disposition – pt condition at discharge -Education -Follow up needed -Diet -Medications – discharge meds; changes; discontinued meds -Discharge Instructions (instructions to patient and family, including follow up)

References: 3M physician video; CMS Road to 10; Coding Guidelines; 3M Doc tips; AHIMA ACDIS ICD 10 Webinar 12.2014; ACDIS ICD 10 CDI Bootcamp 2014; ICD 10 CM for Hospitals; Precyse Doc Talks; Exc Debridement: Docu prompter…CMS; Coding Clinic, Second Quarter 2004 Page 5; ACDIS Annual Conference 2015; TFHS P & P.

Check out www.tfhd.com/icd10