Clinical Documentation Improvement ICD-10 Transition from ICD-9

1. Clinical Documentation ImprovementICD-10 Transition from ICD-9 Karen Brown RHIT, CCS Clinical Documentation Specialist Date: October 3, 2014

2. ICD-10 Past • Team lead training • Coder education • Time study- 33 minutes per chart (average per chart 18 mins.) • Test claim submission- (Variance in payment)

3. ICD-10Present • 1. Coder retention • 2. Coder engagement • 3. Dual coding • 4. Internal review

4. Clinical DocumentationPast/Present • 1. ICD-10 training • 2. Physician education • 3. Query revision • 4. Surgery review

5. Clinical Documentation

6. Clinical DocumentationDiseases of the Respiratory Systems • Respiratory Failure • Acuity • Associated symptom/s(hypoxia, hypercapnia) • Acute respiratory failure with hypoxia – J9601 • Acute respiratory failure with hypercapnia – J9602

7. Diseases of the Respiratory System • Asthma • Severity (mild, mild intermittent, moderate, severe) • Relationship to other diseases (copd)

8. Clinical DocumentationDiseases of the Circulatory System • Congestive heart failure • Type • Acuity • Cause

9. Diseases of the Circulatory System • Myocardial Infarction • Type (nstemi, stemi, transmural) • Site • Encounter (initial, subsequent)

10. Injury and Poisoning • Fractures • Type (comminuted, transverse) • Cause (traumatic, non traumatic) • Laterality • Alignment (displaced, non displaced) • Encounter( initial, subsequent, sequela)

11. Injury and Poisoning • Wounds • Type (postoperative, ulcer, laceration) • Cause (diabetes, venous stasis ulcer)

12. Questions

13. References • Official Coding Guidelines for ICD-10 • Journal of Ahima, July 2014 • Justcoding.com