Clinical Documentation Improvement

1. Clinical Documentation Improvement (CDI)

2. 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

3. Diabetes Mellitus250.00 – 250.93 Diabetes Mellitus Coding in ICD-10CMThe codes for diabetes mellitus have expanded in ICD-10-CM 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 conditionE09   Drug or chemically induced diabetes mellitusE10   Type 1 diabetes mellitusE11   Type 2 diabetes mellitusE13   Other specified diabetes mellitus

4. 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.

5. 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

6. 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 non-insulin dependent as these terms are no longer used in the coding world. Our first CDI:

7. 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.

8. E10.621   Type 1 diabetes mellitus with foot ulcerL97.411   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.

9. 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.

10. 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.

11. How did you do???? ICD-10-CM Codes:E11.9   Type 2 diabetes mellitus without complicationsZ79.4   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.

12. Atrial Fibrillation427.31 • 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

13. Hyperlipidemia272.4 E78.4 Other hyperlipidemia, Familial combined hyperlipidemia. E78.5 Hyperlipidemia, unspecified Try to Avoid!!!

14. LIPIDS More specific documentation is needed when coding disorders of lipoprotein metabolism and other lipidemia CDI E78.0 Pure Hypercholesterolemia E78.1 Pure hyperglyceridemia E78.2 Mixed hyperlipidemia E78.3 Hyperchylomicronemia

15. 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.

16. 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

17. Immunizations Also when coding immunizations you will code Z23 as the diagnosis code.

18. Sports/DOT/ETCV70.3 • In ICD-10, these codes are: • 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

19. Unspecified Sinusitis.473.9 X reference to: J32.9 Unspec. Chronic sinusitis CDI: Providers /Staff must Specify: Acute/Chronic Site of Sinusitis Example, Maxillary, frontal, ethmoidal, etc. Recurrent

20. Acute sinusitis461.9 J01.90 Acute sinusitis, unspec. CDI Site of Sinusitis Site of the sinusitis, Example: Maxillary, frontal, ethmoidal, etc. Recurrent

21. Pharyngitis and Tonsillitis462 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, unspecAvoid

22. Pharyngitis and Tonsillitis462 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)

23. 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. Admin staff: When scheduling appointment for sore throat ask how long they have had symptoms Nursing staff: 1-Make sure surgical history accurately reflects if patient has had tonsils or adenoids removed

24. Otitis Media, Acute382.00 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

25. Fatigue and Malaise 780.79 G93.3 Postviral fatigue syndrome R53.1 Weakness R53.81 Other malaise R53.83 Other fatigue

26. CDI: You would code two codes for this one.

27. Hypertension401.0 - 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.

28. Questions:????????