Clinical Documentation ICD-10
Importance of Clinical documentation for accurate ICD-10 coding
ICD-10 is not the coding but it’s improved Patient care which is documented
Descriptive documentation to support accurate coding is the base of reimbursement from the insurances
If physicians don't document their care, it can't be captured or coded
Proper documentation has the potential to improve:
Patient care,
Clinical data
Timely and appropriate claims payment
What needs to be documented? Basic concepts such as:
Laterality (Right, Left, Bilateral, Unilateral)
Anatomical locations
Trimester
Type of diabetes
Known complications or comorbid conditions
Description of severity, acute or chronic or other known parameters
Major Modifications
Revised diabetes mellitus codes (5th digits from ICD-9-CM will not be used)
Expanded codes (e.g., injury, diabetes)
Added trimesters to obstetrical codes (5th digits from ICD-9-CM will not be used)
Added code extensions for injuries and external causes of injuries
Laterality – Left Versus Right
Area specified in cases of Neoplasm
Examples
Malignant neoplasm, of central portion of breast
Malignant neoplasm of central portion of right female breast
Malignant neoplasm of central portion of left female breast
Most Commonly Encountered Disease/Problems – taken as example
DIABETES
HEART DISEASE (CAD, A-FIB, CHF etc.)
PAIN (BACK, LOWER BACK, LIMBS – UPPER OR LOWER)
OSTEOARTHRITIS
CHRONIC KIDNEY DISEASE
PULMONARY DISEASE
Examples on the following slides…………………………………
Must/Preferable – to dictate DIABETES
HEART DISEASE (CAD, A-FIB, CHF etc.)
Type I or Type II diabetes - Must dictate
Coronary Artery Disease (CAD):
Onset - Preferable if dictated
Native Artery involved – Preferable if dictated
When did it start? - Preferable if dictated
Status post bypass graft – Preferable if dictated
PAIN, OSTEOARTHRITIS, OSTEOPENIA, OSTEOPROSIS, ARTHRITIS, Anatomical location Which anatomical structure - Must dictate Proximal, distal, medial, lateral, central, peripheral, superior, inferior, anterior, posterior Preferable if dictated
Laterality
Right side or left side – Must dictate
Severity
Mild, moderate or severe – Preferable if dictated
CHRONIC KIDNEY DISEASE Stage 1 to 6 (end stage) – Must dictate Dependence on Dialysis – Must dictate
Example for -PULMONARY DISEASE Temporal Factors: Must dictate Acute / Chronic / Intermittent / Persistent
Severity: Must dictate Mild / Moderate / Severe
Asthma: Must dictate Acute / Chronic / Allergic / Exacerbation
COPD: Must dictate With exacerbation
Bronchitis specific: Must dictate Simple / Mucopurulent / Mixed simple and Mucopurulent / Tracheobronchitis
To be dictated by Provider Dictated currently – ICD-9
To be dictated now – ICD-10
Condition described : DIABETES
Condition described : DIABETES
HISTORY OF PRESENT ILLNESS: The patient is an 86 years old female with history of diabetes. At last visit, we had discussed about going up on her Lantus every three days, but it seems like the patient did not do that and she is still taking Lantus 17 to 20 units and she also continued to take NovoLog Mix 70/30 in the morning and with supper. She states that her blood sugar at suppertime is staying around 188 to 200 and fasting blood sugar is 127, but she did not bring those readings with her. Her last hemoglobin A1c was checked in January and it was high at that time. She is complaining of constipation. She has been taking over-the-counter medication, but it is not helping
HISTORY OF PRESENT ILLNESS: The patient is an 86 years old female with history of diabetes. At last visit, we had discussed about going up on her Lantus every three days, but it seems like the patient did not do that and she is still taking Lantus 17 to 20 units and she also continued to take NovoLog Mix 70/30 in the morning and with supper. She states that her blood sugar at suppertime is staying around 188 to 200 and fasting blood sugar is 127, but she did not bring those readings with her. Her last hemoglobin A1c was checked in January and it was high at that time. She is complaining of constipation. She has been taking over-the-counter medication, but it is not helping
ASSESSMENT: 1.Uncontrolled diabetes 2.Constipation.
ASSESSMENT: 1.Uncontrolled diabetes - Type I / Type II 2.Constipation.
DX
ICD-9
ICD-10
Uncontrolled Diabetes
250.02 (Uncontrolled Diabetes Type 2 /
E11.65 (Type 2 Diabetes with
Uncontrolled Diabetes Type 1 / insulin-dependent
250.03 (Uncontrolled Diabetes Type 1 /
E10.65 (Type 1 Diabetes with
insulin dependent)
hyperglycemia)
Diabetes
250.00 (Diabetes Type 2, not stated as
E11.9 (Type 2 Diabetes without
uncontrolled)
complications)
250.01 (Diabetes Type 1 (juvenile
E10.9 (Type 1 Diabetes without
type) / insulin-dependent, not stated as uncontrolled)
complications)
Diabetes - Type 1 / Insulindependent
non‑insulin dependent)
hyperglycemia)
To be dictated by Provider Dictated currently – ICD-9 Condition described : HEART DISEASE (CAD)
To be dictated now – ICD-10 Condition described : HEART DISEASE (CAD)
ASSESSMENT AND PLAN: The patient is an individual who has CAD, has dropped about 4 pounds since last time, status post multiple surgeries in the past, obesity, the patient has a history of anxiety, neuropathy, hypertension, intervertebral disk disease, hypertriglyceridemia, atrial fibrillation, GERD, and insulin-dependent diabetes mellitus.
ASSESSMENT AND PLAN: The patient is an individual who has CAD with/without - stable/unstable - other/unspecified etc angina, status post bypass graft, has dropped about 4 pounds since last time, status post multiple surgeries in the past, obesity, the patient has a history of anxiety, neuropathy, hypertension, intervertebral disk disease, hypertriglyceridemia, atrial fibrillation, GERD, and insulin-dependent diabetes mellitus.
DX
ICD-9
CAD-unspecified type of vessel, native, or graft
414.00
ICD-10 I25.10 125.110 (CAD-native artery with unstable angina) I25.111 (CAD-native artery with unstable angina with
CAD-native coronary artery
414.01
documented spasm)
I25.118 (CAD-native artery with other forms of angina pectoris) I25.119 (CAD-native artery with unspecified angina pectoris) I25.700 (Atherosclerosis of coronary artery bypass graft, unspecified, with unstable angina pectoris
CAD with bypass graft unspecified type
414.05
I25.701 (Atherosclerosis of coronary artery bypass graft, unspecified, with angina pectoris with documented spasm)
I25.708 (Atherosclerosis of coronary artery bypass graft, unspecified, with other forms of angina pectoris)
I25.709 (Atherosclerosis of coronary artery bypass graft, unspecified, with unspecified angina pectoris
To be dictated by Provider Dictated currently – ICD-9
To be dictated now – ICD-10
Condition described : PAIN
Condition described : PAIN
ASSESSMENT: The patient has UTI and history of kidney stones. The patient has chronic kidney disease. The patient has tobacco abuse. The patient has chronic pain of leg
ASSESSMENT: The patient has UTI and history of kidney stones. The patient has chronic kidney disease. The patient has tobacco abuse. The patient has chronic pain of right/left – upper/lower leg
Condition described : OSTEOARTHRITIS ASSESSMENT: This is an individual with chronic kidney disease, hypertension, insomnia, depression, chronic pain syndrome, knee pain, and gout. The patient is accompanied by her daughter. There is also underlying restless legs syndrome, COPD which is severe, degenerative joint disease, and osteoarthritis
Condition described : OSTEOARTHRITIS ASSESSMENT: This is an individual with chronic kidney disease, hypertension, insomnia, depression, chronic pain syndrome, knee pain, and gout. The patient is accompanied by her daughter. There is also underlying restless legs syndrome, COPD which is severe, degenerative joint disease, and osteoarthritis of knee right/left
DX
ICD-9
ICD-10
Pain of Leg
M79.606 (Pain in Unspecified Leg)
Pain of Right Leg
M79.604 (Pain in Right Leg)
Pain of Left Leg
M79.605 (Pain in Left Leg)
Pain of Thigh
M79.659 (Pain in Unspecified Thigh)
Pain of Right Thigh
729.5 (Pain in Limb)
M79.651 (Pain in Right Thigh)
Pain of Left Thigh
M79.652 (Pain in Left Thigh)
Pain of Lower Leg
M79.669 (Pain in Unspecified Lower Leg)
Pain of Right Lower Leg
M79.661 (Pain in Right Lower Leg)
Pain of Left Lower Leg
M79.662 (Pain in Left Lower Leg)
To be dictated by Provider Dictated currently – ICD-9
To be dictated now – ICD-10
Condition described : CHRONIC KIDNEY DISEASE
Condition described : CHRONIC KIDNEY DISEASE
ASSESSMENT: The patient is a 73-year-old who was recently in the hospital for volume overload, has chronic kidney disease as well as CHF, certainly does have multiple other issues including hyperlipidemia, CAD, hypertension, seasonal allergic rhinitis, is being followed by Dr. abcdef of renal. We will certainly get Dr. xyz to see him for his CHF
ASSESSMENT: The patient is a 73-year-old who was recently in the hospital for volume overload, has chronic kidney disease stage 3 , etc. / end-stage / on dialysis as well as CHF, certainly does have multiple other issues including hyperlipidemia, CAD, hypertension, seasonal allergic rhinitis, is being followed by Dr. abcdef of renal. We will certainly get Dr. XYZ to see him for his CHF
DX
ICD-9
ICD-10
Chronic Kidney Disease
585.9 (CKD, stage unspecified)
N18.9 (CKD, stage unspecified)
CKD-Stage 1
585.1 (CKD, stage 1)
N18.1 (CKD, stage 1)
CKD-Stage 2
585.2 (CKD, stage 2) (mild)
N18.2 (CKD, stage 2) (mild)
CKD-Stage 3
585.3 (CKD, stage 3) (moderate)
N18.3 (CKD, stage 3) moderate)
CKD-Stage 4
585.4 (CKD, stage 4) (severe)
N18.4 (CKD, stage 4) severe)
CKD-Stage 5
585.5 (CKD, stage 5)
N18.5 (CKD, stage 5)
CKD, end stage
585.6 (End Stage Renal Disease)
N18.6 (End Stage Renal disease)
Thank You
For free Medical Billing and ICD10 coding consultation, call us at 1 (866) 365 3909