the transition to what you need to know for pediatrics newborn date | presenter information
TRANSCRIPT
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The Transition toWhat you need to know for Pediatrics Newborn
Date | Presenter Information
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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
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Ongoing Support for ICD-10Physician Advisors
Clinical Informatics
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-Public Reporting-Reimbursement-Physician Scorecards-Quality Improvement
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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)
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What should be documented?
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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.
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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
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Key Changes Needed to Support ICD-10 Coding
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Newborn affected by Maternal Condition• Document specific maternal condition
– Drug use– Alcohol use– Tobacco use– Infection (GBS positive)– Diabetes Pre existing or Gestational– Hypertension Pre existing or
Gestational– Incomplete Cervix
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Baby turned blue and began choking after feeding, ALTE not further specified
• Document apparent life-threatening event (ALTE) with obstructive apnea due to GERD
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Cleft Lip• Document:
– Bilateral– Median– Lateral
• Document if present with cleft palate
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• Document:– Hard palate– Soft palate– Hard palate with soft
palate– Uvula
• Document :– Bilateral– Median– Unilateral
• Document if present with cleft lip
Cleft Palate
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Meconium Aspiration• Document any associated respiratory
conditions:– Pneumonia– Respiratory Distress Syndrome
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Neonatal Jaundice• Document Etiology
– Isoimmunization (Rh, ABO, other hemolytic diseases)
– Preterm delivery– Physiologic
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Post-operative Care after Congenital Heart Surgery
• Physician must document if cardiac condition is still present and under active treatment or if it was surgically corrected
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Outcome of Delivery (Newborn Status)
• Document if :– Single birth– Twin birth– Multiple births
• Document for each baby if: – Live born– Stillborn
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Omphalitis ofNewborn
• Document with or without mild hemorrhage
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Failure To Thrive• Document if newborn is 28 days
or less– Prematurity (Gestational age
between 28-36 completed weeks of gestation)
– Extreme immaturity (Gestational age less than 28 completed weeks of gestation)
• Document failure to thrive, malnutrition – Poor feeding, decreased
urine output, fussiness, failure to gain weight
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• A code for prematurity cannot be assigned based solely on the documentation of completed weeks.
• Physician must state that the infant is premature
Prematurity
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Feeding Problems of Newborn• Instead of “feeding problems” or “feeding
difficulty” be more specific, for example:– Regurgitation and rumination– Slow feeding– Underfeeding– Overfeeding– Difficulty with breast feeding– Vomiting– Other
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Sepsis of Newborn• Document if
confirmed or suspected
• Document if ruled out• Document organism
known or suspected– Streptococcus– Staphylococcus– E. Coli– Anaerobes
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• If prophylactic antibiotics are given to a newborn pending cultures, physicians must document whether sepsis was ruled in or ruled out based on clinical results
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Congenital Adrenal Hyperplasia
• Document if salt losing (codes to enzyme deficiency
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Croup
• Document Type:– Bronchial– Diphtheritic– Stridulous
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Spina Bifida• Document Location:
– Cervical– Thoracic– Lumbar– Sacral– Occulta
• Document with or without hydrocephalus
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Intraventricular Hemorrhage (IVH)
• Specify– Grade 1– Grade 2– Grade 3– Grade 4
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