Why Words Matter

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Why Words Matter

Through an OB/GYN Lens

1. Develop understanding of the role documentation plays in determining patient severity of illness (SOI), risk of mortality (ROM) and physician quality scores

2. Understand definition and key terminology changes in ICD-10-CM and ICD- 10-PCS

3. Understand the concepts of linking conditions and manifestations for more accurate depiction of patient‟s clinical status

1 Importance of Documentation and Basics of ICD-10-CM/PCS

2 Concepts Drive Documentation Requirements

3 Examples of OB/GYN Diagnoses & Procedures in ICD-10-CM/PCS

©2015 The Advisory Board Company 3 advisory.com The Evolution of Clinical Documentation What was once a tool for communication between providers and clinicians is now the primary data source to determine quality of patient care. Market forces are leading to Increase in documentation scrutiny. Who is the audience for your notes?

Insurance Companies Self State Government Care Team

Other Patients Federal Doctors Government

MyCigna.com

HealthGrades- all material and images are sourced from www.healthgrades.com (accessed on 6/18/2012) Leapfrog- all material and images are sourced from www.leapfroggroup.org (accessed on 6/18/2012)

©2015 The Advisory Board Company 5 advisory.com Transition from ICD-9-CM to ICD-10-CM/PCS Per Bill H.R. 4302, “The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD–10-CM/PCS code sets”.

Benefits and Goals of ICD-10-CM/PCS • Provides better detail, a more accurate depiction, and improved communication of patients clinical status • Allows for more accurate payment for new procedures • Improves capture of morbidity and mortality data • Reduces the number of miscoded, rejected and improper claims for reimbursement

2011, The Clinical documentation Improvement Specialist's Guide to ICD-10 p.9 Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPR, C-CDI, CCDS and Sylvia Hoffman, RN, C-CDI, CCDS.

72,000 69,000

Why so many new codes?

The main difference between ICD-9-CM and ICD-10-CM/PCS codes, outside of structural changes, is the SPECIFICITY of the code.

ICD-10-CM/PCS codes specify several 14,000 components not found ICD-9-CM, such as causal agent, type, laterality, approach, 4,000 episode of care, root operation, etc.

ICD-9 ICD-10 Diagnosis Codes Procedure Codes

Source: Nichols, J.C. (2011). ICD-10 – Physician impacts. Advisory Board Applications and Technologies Collaborative; CMS (2013). 1) Code Volume Expansion in ICD-10-CM/PCS ICD-10 Implementation guide for small hospitals

α # α/# α/# α/# α/# α/#

Category Sub-categories Extension (Etiology, Anatomic Site, Severity, Laterality, (3-16 options Complication) depending on category)

Key ICD-10-CM Documentation Concepts

Degree (mild, moderate, severe, or Specific anatomical location unspecified; total/complete vs. partial/incomplete) Episode of Care (Initial, Subsequent, Type (primary, secondary, unspecified) Sequelae) Acuity (acute, subacute, chronic, acute on Laterality (Right, Left, bilateral, or unspecified) chronic, or unspecified )

Trimester (1,2,3,unspecified) Number of fetus (1-5, other)

Section Body Root Body Approach Device Qualifier System Operation Part

1. Section –16 options identifying the general type of procedure. Example: Physician documentation Medical/Surgical Section represents the vast majority of procedures required: reported in an inpatient setting

2. Body System - e.g. circulatory system, respiratory system • Type and intent of procedure (root operation) 3. Root Operation - 31 options, based on the objective of the procedure • Specific anatomic sites treated 4. Body Part - e.g. pericardium, coronary artery, heart, atrium, mitral valve • Approach

5. Approach - 7 options, e.g. open, percutaneous, percutaneous endoscopic • Specific type of device used • Validate surgical 6. Device - 4 basic groups: Grafts/prostheses, implants, simple or mechanical complications appliances, and electronic appliance • Diagnoses that support inpatient medical necessity 7. Qualifier - e.g. identify destination site in a Bypass, Diagnostic, Full thickness burn

Source: AHIMA; The Advisory Board Company research

1 Importance of Documentation and Basics of ICD-10-CM/PCS

2 Key Concepts To Capture in Your Documentation

3 Examples of OB/GYN Diagnoses & Procedures in ICD-10-CM/PCS

©2015 The Advisory Board Company 10 advisory.com Remember: Signs, Symptoms & Test Results Must Be Linked to Related Diagnoses While important pieces of the medical record, signs, symptoms and test results are not sufficient for coders to assign a diagnosis.

• Linking signs and symptoms to diagnoses may increase SOI and ROM in the inpatient setting. (The terms „probable‟, „likely‟, or „suspected‟ are all acceptable on the inpatient record)

• In the ambulatory setting, documentation regarding patient condition should be to the highest level known, treated or evaluated

• Abnormal findings (laboratory, x-ray, pathology and other diagnostic test results) cannot be coded and reported unless the clinical significance is identified by the treating provider ICD-10-CM Official Coding Guidelines III.B

Reminder:

The attending physician is responsible for: • Documenting all conditions in the progress notes and discharge summary • Resolving conflicts in the documentation

©2015 The Advisory Board Company 11 advisory.com Linking Conditions Critical to Capturing Patient Severity There is a significant increase in the number of “combination codes” available in the ICD-10-CM/PCS code set. These codes can help capture the highest level of complexity and acuity in the public eye.

Linking clinically relevant conditions, where appropriate, is the key takeaway for physicians. Coders cannot assume clinical relationships.

Examples: Linking Diseases

• Ectopic Pregnancy d/t Pelvic Inflammatory Disease • Gestational HTN with Proteinuria • Dehydration with Hyponatremia d/t Hyperemesis

Use terms like “due to” , “secondary” or “with” Note: Lists, commas, and the word “and” do not link conditions

©2015 The Advisory Board Company 12 advisory.com Severity of Illness (SOI) and Risk of Mortality (ROM) Documentation drives SOI and ROM level assignment. These levels are used to measure patient acuity, and therefore drive expected patient LOS and mortality rate.

Breakdown of SOI/ROM and their Implication on Quality Measures

Four mutually exclusive SOI/ROM categories exist (1-4), and are determined based on a number of factors including primary and secondary diagnoses, comorbidities, demographics, patient history, treatment/procedure delivered, etc.

Level Assigned SOI/ROM Category

Minor 1

Moderate 2

Major 3

Extreme 4

1 Importance of Documentation and Basics of ICD-10-CM/PCS

2 Key Concepts To Capture in Your Documentation

Examples of OB/GYN Diagnoses & Procedures in ICD-10- 3 CM/PCS

1 Intent of Encounter

2 Root Operation

3 Body Part

4 Approach

5 Malnutrition

6 Pain

7 Best Practice Documentation

8 Complication Documentation

Intent of Encounter Examples:

• Initial/repeat prescription of contraceptive pills, emergency contraception, injectable contraception, instruction in a natural family Documentation Tip: planning • Sterilization reversal Encounters without delivery • IUD (e.g. insertion, routine checking, removal, • Document the principal condition that removal and reinsertion) necessitated the encounter • Fallopian tube patency testing • Document all conditions treated or • Testing of male partner of patient with recurrent monitored pregnancy loss • Pregnancy Test (state if its positive or negative) • Normal first pregnancy, trimester • Antenatal screening of mother • Care of mother immediately after delivery outside a healthcare facility • Routine postpartum follow-up

Documentation Should Include

• What was removed: portion or all of an organ/body part ‒Clarify if it is solid matter ‒Identify the mechanism used (e.g. stripping, cutting, or destruction) • Intended and performed procedure ‒If they differ identify/document why ‒If the intended procedure is modified or discontinued, the root operation is determined by the procedure actually performed

Key Takeaways: There are 31 separate root operations in ICD-10-PCS. Physicians do not need to memorize or document the specific root operation term. Instead provide specific and clear documentation so coders can assign the appropriate root operation.

Documentation Should Include

• Specific anatomic site of the body system on which the procedure is performed ‒Identify the specific nerves, arteries or veins, portion of the spinal cord, etc. • Tubular body parts are hollow body parts that provide a route of passage for solids, liquids or gases

Documentation of Surgical Approach Should Include:

• Skin or mucous membranes Access Location • External orifice • Open • Percutaneous • Percutaneous endoscopic Method of • Via Natural or Artificial Opening Approach • Via Natural or Artificial Opening Endoscopic • Via Natural or Artificial Opening with Percutaneous Endoscopic • External

Type of • Puncture Instrumentation • Incision

©2015 The Advisory Board Company advisory.com 19 Malnutrition Criteria American Academy of Nutrition and Dietetics & American Society for Parental and Enteral Nutrition (ASPEN) Malnutrition Criteria: Need at least two or more of the following six characteristics help to identify a malnutrition diagnosis:

Malnutrition Criteria

Insufficient energy intake

Weight loss

Loss of muscle mass

Loss of subcutaneous fat Localized or generalized fluid accumulation that may sometime mask weight loss Diminished functional status as measure by hand grip strength

Multiple Key Components to Weight-Related Diagnoses • Will impact SOI/ROM • For protein-calorie malnutrition, indicate mild, moderate or BMI<19 severe • Use “starvation” in abuse cases Documentation Tip: • Abnormal weight loss + acuity of weight loss • Link to other illnesses • Weight loss, failure to • Will impact SOI/ROM thrive, cachectic • Severe or morbid obesity appearing, and ‒ Link to cause malnourished BMI>40 ‒ May find in medical history documentation does not • If drug induced, give the name of the drug impact SOI/ROM ‒ Bariatric procedures performed ‒ Identify any associated conditions such as obesity hypoventilation syndrome

• History of • Exam ‒ Skin care/assessment Additional • Diagnostic tests documentation • Diagnoses and linkage needs: • Treatments in place to treat malnutrition

‒ Possible infusion (e.g. TPN) ‒ Administration of vitamins/supplements (e.g. Ensure/Boost) ‒ Dietician physical therapy notes

Documentation Concepts

Clarify if the pain is “Acute” or “Chronic” Clarify: Is this an admission for inpatient treatment of pain or is an underlying condition causing the pain?

Example: Admitted for treatment of pain due to bone metastases of breast cancer Link pain type to the condition.

Example: • Chronic pain due to… • Phantom limb pain from R BKA

If pain is from a polyneuropathy, what is the cause? • Inflammatory or due to diabetes

Is a spinal neurostimulator or intrathecal infusion pump being used to treat the patient? If so, specify this in documentation.

G 8 9 1 1

Other disorders of the nervous system Acute Type of Pain

Post- thoracotomy

Acute

Other disorders of the Trauma nervous system

Chronic Post-procedural

Procedure Codes Capture 0 U L 7 3 C Z

Body Root Body Section Approach Device Qualifier System Operation Part

Medical & Female Fallopian Tubes, Extraluminal Occlusion Percutaneous No qualifier Surgical Reproductive Bilateral Device

Definitions Options Options Options Completely • Fallopian Tube, • Open • Intraluminal closing an Right • Percutaneous Device orifice or lumen • Fallopian tube, • Percutaneous • Extraluminal of a tubular Left Endoscopic Device body part • Fallopian tube, • Via Natural or • No Device Bilateral Artificial Opening • Cul-de-sac • Via Natural or • Vagina Artificial Opening Endoscopic

Source: http://www.cms.gov/Medicare/Coding/ICD10/Downloads/pcs_2013_g uidelines.pdf

Procedure Codes Capture 0 U N 1 4 Z Z

Body Root Body Section Approach Device No Qualifier System Operation Part

Medical & Female Percutaneous Release Ovary, Left No Device No Qualifier Surgical Reproductive Endoscopic

Definition: Options: Options: Freeing a body • Ovary, (right, left • Open part from an or bilateral) • Percutaneous abnormal • Uterine • Percutaneous physical supporting Endoscopic constraint by structure • Via Natural or cutting or by the • Fallopian tube Artificial Opening use of force (right, left, or • Via Natural or bilateral) Artificial Opening • Uterus Endoscopic • Cervix • Cul-de-sac • Vagina • Hymen • Clitoris • Vestibular Gland • Vulva ©2015 The Advisory Board Company 25 advisory.com D&C - Miscarriage Extraction of products of conception, retained, via natural or artificial opening endoscopic

Procedure Codes Capture 1 0 D 1 8 Z Z

Body Root Body Section Approach Device Qualifier System Operation Part Products of Via Natural or Conception, Artificial Obstetrics Pregnancy Extraction No Device No Qualifier retained Opening Endoscopic

Definitions: Options: Options: Pulling or • Products of • Via Natural or stripping out or Conception Artificial Opening off all or a Retained • Via Natural or portion of a • Products of Artificial Opening body part by Conception, Endoscopic the use of force Ectopic (A qualifier of diagnostic is used for biopsies

Source: http://www.cms.gov/Medicare/Coding/ICD10/Downloads/pcs_2013_g uidelines.pdf

Best Practice ICD-10-PCS Concepts To Include

Date/Time Procedure Intended Procedure Performed (document reason for difference) Heart Failure Combination Additional procedures performed Codes Examples: Procedure checklist: • Body system • Device Identified • Root operation • What made the procedure difficult/longer • Body part • Unusual findings • Approach • Complication • Devices • Qualifier • Accidental or complication? • Common complications • Due to: • Disease/condition • Patient characteristics • Surgery • Drugs

Two Key Components to Remember:

ICD-10-CM has replaced the term post-operative with “post-procedural” or “post-surgical”

Conditions occurring in the post-operative period should be clarified as: • An expected post-procedural or post-surgical condition • An unexpected post-procedural or post-surgical condition related to surgical care (a complication of care) • An unexpected post-procedural or post-surgical condition, unrelated to surgical procedure • An unexpected post-procedural or post-surgical condition, related to the patient‟s underlying medical comorbidities

Documentation Concepts

• Intraoperative Timing • Postprocedure • Late effect Reminder

• Aspiration, puncture, other • Often times the terms “post-surgical, • Endoscopic exam post-procedural or post-operative” are Procedure • Infusion, transfusion, injection a time stamp and not a complication of • Removal of a catheter or packing care. • Medical procedure – Name It • When documentation within the record • Accidental puncture/laceration is unclear, it is advised that the • Same or different system physician be queried. • Blood products • Central venous catheters Associated • Drugs: with: ‒ What adverse effect ‒ Drug name ‒ Correctly prescribed ‒ Properly administered • Initial Encounter • Subsequent • Sequelae

Key Considerations When Documenting Procedures in the Outpatient or Ambulatory Setting

1. ICD-10-PCS is only used on inpatient procedures 2. If you do an outpatient procedure on a patient who is admitted within 3 days, then that procedure is rolled into the inpatient admission if the admission is for a related diagnosis 3. Physician should document outpatient procedures to satisfy ICD-10-PCS, HCPCS and CPT in case the patient is admitted as an inpatient

ICD-10-PCS and CPT Billing

If this information is not accurate and not coded correctly, the provider may not receive payment due to new Part A/Part B cross claim audits (pre-payment audits). As a result, your surgical fees can be denied because the new ICD-10-PCS codes are not in sync

1 Normal Pregnancy & Delivery

2 Trimester Documentation

3 Fetus Identification

4 Pre-Existing Conditions Hypertension /Diabetes

5 Renal Problems

6 Maternal Infection/HIV/Sepsis

7 Tobacco Exposure

8 Substance Abuse/Abuse

Key Changes in OB Definitions in ICD-10-CM/PCS

• Abortion: up to 20 weeks of gestation Abortion vs. fetal death • Fetal death: after 20 weeks of gestation

Early vs. late vomiting Timeframe changes from 20 to 22 weeks

Post-term pregnancy Pregnancy over 40 to 42 completed weeks of gestation

Prolonged pregnancy Pregnancy that has advanced beyond 42 completed weeks of gestation

• 1st : <14 weeks zero days Trimester counted from 1st • 2nd: 14 weeks zero days to < 28 weeks zero days day of last menstrual • 3rd : 28 weeks zero days until delivery period: Note: The coder cannot use the LMP to determine trimester, but can utilize weeks to determine trimester

Young primigravida Younger than 16 years old at expected date of delivery

Elderly patients 35 years or older at the expected date of delivery

Incomplete abortion Abortion with retained products of conception

Key Changes in OB Definitions in ICD-10-CM/PCS

Preterm Time period before 37 completed weeks of gestation

Postpartum Time period from delivery to 6 weeks after delivery

Peripartum Last month of pregnancy to 5 months postpartum

Premature rupture of Onset of labor more than 24 hours after the rupture of membranes membranes

Preterm labor Spontaneous onset of labor before 37 completed weeks of gestation

• Afibrinogenemia Coagulation defects • Disseminated intravascular coagulation include: • Hyperfibrinolysis • Hypofibrinogenemia The reason for observation, hospitalization, other obstetric care, or Maternal care Cesarean section delivery before onset of care

1. Clearly document the reason for each encounter: why did you see and treat the patient?

2. Encounters with no delivery: • Document the principal condition that necessitated the encounter • Document all condition(s) treated or monitored

For Your Reference: Examples of Reasons for Encounters with ICD-10-CM Codes

• Initial/repeat prescription of: contraceptive pills, emergency contraception, injectable contraception, instruction in a natural family planning • IUD (e.g. insertion, routine checking, removal, removal and reinsertion) • Post-vasectomy sperm count • Fallopian tube patency testing • Female/male testing for genetic disease carrier status • Testing of male partner of patient with recurrent pregnancy loss • Genetic counseling • Rh incompatibility status • Pregnancy Test (state if its positive or negative) • Elective termination of pregnancy • Normal first pregnancy, trimester • Antenatal screening of mother • Routine postpartum follow-up

Z 3 4 0 1

Encounter for supervision of normal First Trimester pregnancy pregnancy, Other or Unspecified

Unspecified First Encounter for supervision of normal pregnancy First

Other

Second

Unspecified Third

When Documenting a Normal Pregnancy, Please Specify:

• First pregnancy or other pregnancy

• Include the trimester the encounter is occurring (documenting the exact number of weeks will be sufficient)

A full-term uncomplicated delivery is one requiring minimal or no assistance. It is a spontaneous, cephalic, vaginal delivery of a full term, single, live born infant. Documentation should include the following as appropriate:

• With or without an episiotomy • ICD-10-PCS examples: • Division, perineum, female, external approach • Repair, perineum, female, external approach

• If any fetal manipulation is performed, this is no longer an uncomplicated delivery. Fetal manipulation includes rotation, version or instrumentation such as forceps • ICD-10-PCS example: Extraction of products of conception, classical, via natural opening

ICD-10-CM Guidelines for Documenting Trimester

Key Takeaway: In ICD-10-CM, the provider‟s documentation of the number of weeks is used to assign the appropriate code to identify the trimester.

• If the provider does not document the number of weeks/trimester, a query will likely be issued

• Coders may not calculate the number of weeks or trimester from the date of Last Menstrual Period

Admissions

• For a “pre-existing condition”, document the trimester at the time of the encounter of the admission

• If the condition is concurrent and spans more than one trimester, use the trimester at admission, not discharge trimester Trimester documentation is not needed when:

• The condition always occurs in a specific trimester

• The concept of trimester is not applicable

If delivery occurs during any encounter, the time frame and documentation is “in childbirth”

Documentation for the Maternal Record (not the Newborn):

• Multiple gestations: • Which fetus • Number of • Placentas Documentation Tip: • Fetuses • Amniotic sacs • ICD-10-CM coding uses numbers to identify fetuses – • Identify complications for each fetus by number not letters! • Papyraceous fetus • Continuing pregnancy after: • Spontaneous abortion • Intrauterine death • Elective fetal reduction

• Document Trimester

• If documentation identifying a fetus is insufficient, a clarification is required

3 Key Concepts to Documenting Pre-Existing Conditions

1. Clarify maternal medical • “Pre-existing” or conditions as: • “A direct result of pregnancy”

• Hypertensive heart disease • Heart failure (include type: acute, chronic, acute 2. If preexisting hypertension on chronic, systolic, diastolic) during pregnancy, document • Hypertensive chronic kidney disease (CKD) whether there is also: • Stage • Transplant and dialysis status

• Any condition that is a direct result of the 3. Clear documentation is pregnancy needed on the inpatient H&P • Current conditions requiring ongoing care for the following conditions: • Conditions that have been resolved prior to the inpatient care

“Pre-existing” Hypertension Documentation “Gestational” Hypertension Documentation

• Hypertension • Findings without hypertension • Hypertension with proteinuria • Edema • Hypertensive • Edema with proteinuria • Heart disease • Proteinuria • CKD + stage • Hypertension • Heart and CKD (+ stage) • With significant proteinuria • Secondary hypertension • Without significant proteinuria • If possible, document the underlying • Pre-eclampsia cause • Mild to moderate • Hypertension with pre-eclampsia • Severe • HELLP syndrome • Eclampsia

Documentation Tips:

• Always document trimester, childbirth, puerperium

Key Documentation Concepts

• Gestational DM • Preexisting type 1 • Juvenile onset • Ketosis-prone diabetes • Preexisting type 2 • Diabetes due to an underlying condition (e.g. Cushing's Identify DM Type: syndrome, malnutrition) • Drug/chemically induced diabetes (adverse effect) • Name of the drug/chemical • Whether the drug was correctly prescribed and properly administered • Encounter (initial, subsequent) • Document whether it is “postprocedural” diabetes • “Preexisting”: Onset was prior to this current pregnancy Indicate if: • Abnormal glucose tolerance test and not diabetes Clarify if the pregnancy was • Preexisting type 1 diabetes with pregnancy related to incidental to the encounter for insulin dosing diabetic conditions? • CKD Stage 4 due to type 2 DM, unrelated to the pregnancy • Diet Is the diabetes controlled by: • Insulin Link diabetes to any associated complications and manifestations

Two Ways to Capture Documentation: The term “with”: • Diabetes with: • Hypoglycemia • Hyperglycemia • Hyperosmolarity • Ketoacidosis • Coma/nonketotic hyperglycemic-hyperosmolar coma

The term “Diabetic”: • Diabetic nephropathy • Diabetic chronic kidney disease stage 4 • Diabetic gastroparesis • Diabetic neuropathy (mono/poly/autonomic)

Example: “Type 2 DM with hypoglycemia without coma with diabetic gastroparesis”

Key Terminology Changes:

• The term “uncontrolled” or “controlled” does not exist in ICD-10-CM. • When diabetes is documented as “inadequately controlled, poorly controlled, or out of control” it will be coded to diabetes by type with the complication of hyperglycemia.

Documentation of Renal Problems

Key Documentation Concepts UTI • Site of UTI (e.g. bladder, kidney, ureter, urethra, unspecified) • Organism or suspected organism • Sepsis • Severe sepsis and organ failure • Identify organ • Septic shock Chronic kidney disease • Stage • Origin (hypertension, diabetes) Other renal disease • Acuity: acute or chronic • Type: • Nephritic syndrome • Nephrotic syndrome • Proteinuria • Recurrent or persistent hematuria

Key Documentation Concepts Documentation • It is complicating the pregnancy needed if: • It is aggravated by the pregnancy • It is the reason for obstetric care • It is known or suspected that it can affect the fetus Drug resistance Specify drug name Location Specify location: • Examples: bladder, cervix, endometritis, kidney, oophoritis, parametritis, pelvis peritonitis, salpingo-oophoritis, urethra Carrier state Specify state of carrier: • Strephtococcus B carrier state • Other infection carrier state Organism Specify the organism • Examples: e. coli, herpes gestationis, obstetrical tetanus, TB, syphilis, gonorrhea, viral hepatitis

Key Documentation Concepts • Asymptomatic HIV infection Document or distinguish if: • AIDS • Symptoms If AIDS, document: • Link symptoms to the HIV (“due to” / “with”) If patient is admitted due to an HIV- • Name the HIV-related condition and link it to related illness rather than pregnancy: HIV

The obstetric code (HIV disease complicating pregnancy) always takes sequencing priority whether the OB patient has symptomatic HIV (AIDS) or is simply HIV positive

Patients with any known prior diagnosis of an HIV-related illness should be coded as HIV infection on every subsequent admission or encounter. They should never be assigned to asymptomatic HIV infection status

Document type of infection and link to:

• During labor • Sepsis • Pyrexia

• Puerperal infections Documentation Tips • Puerperal sepsis

• Fever of unknown origin Always document: • Genital tract infection (cervix, endometrium,

vagina) • Trimester • Urinary tract infection (kidney, bladder, urethra) • Childbirth • Infected surgical wound (cesarean, perineal repair) • Puerperium • Obstetric pyemic or septic embolism • Abortion • Puerperal septic thrombophlebitis • Organism

• Severe sepsis • Following abortion • Organ dysfunction • Spontaneous, attempted, or elective? • Septic shock • Complete, incomplete or failed? • Drug resistance

• Example: “Severe sepsis following failed spontaneous abortion with acute renal failure due to group B strep”

Key Documentation Concepts

• Alcohol: • Any use during pregnancy or postpartum • Blood alcohol level • Toxic effect of alcohol Specify substance • Cannabis • Cocaine • Opioids • Sedative, hypnotic, anxiolytic • Tobacco (e.g. cigarettes, chewing tobacco, other tobacco)

Type of use • (e.g. abuse, dependence, use, second-hand)

Current status • (e.g. in remission, with intoxication, with withdrawal)

• With anxiety disorder • With delirium Behavioral disorder • With intoxication delirium • With mood disorder • With psychotic disorder (delusions or hallucinations) • Trimester Always document • Childbirth • Puerperium

• Document type of abuse: • Detail current injuries • Physical • Encounter: Initial or subsequent • Rape • Identify perpetrator of abuse: • Sexual abuse • Spouse/partner; male/female • Psychological abuse • Parent: biological/adoptive/foster; • During encounter, document if: mother/father, • Abuse suspected, • Sibling; male/female • Abuse confirmed, or • Specific step-family member • Abuse ruled out • Other family member: aunt/uncle/cousin; male/female • If confirmed: • Specific healthcare worker/caregiver • Document the abuse, neglect, or mistreated • Teacher

• Assault and type • Mental health problems or injury

Key Documentation Concepts

• Conflicting, incomplete, or ambiguous documentation will lead to a query • Many key definitions including changes for OB • Trimester is determined from weeks documented: • 1st : <14 weeks zero days • 2nd: 14 weeks zero days to < 28 weeks zero days • 3rd: 28 weeks zero days until delivery • Identify complications for each NUMBERED fetus • Document “preexisting” or “gestational hypertension” and link to underlying conditions • Identify the type, associated conditions and manifestations related to DM • Clarify if maternal infections were: – Complicating the pregnancy – Aggravated by the pregnancy – The reason for obstetric care • Link associated conditions to the pregnancy, or make it clear if a secondary condition is not related to the pregnancy • Multiple gestations: document number of placentas, fetuses and amniotic sacs • Carry all documentation over from diagnostic test results into the progress notes & discharge summary to ensure it will be captured in the coded record

Key Documentation Concepts • Conflicting, incomplete, or ambiguous documentation will lead to a query • Carry all documentation from diagnostic test into progress notes to ensure it will be captured • Documentation of tobacco exposure is crucial • Sign, symptoms and test results do not contribute to SOI unless their significance is documented or they are linked to a named disease • Document intent of the encounter • Clarify what was removed during the procedure: either a portion or all of an organ or body part • Remember to document specific anatomical site of the body system on which the procedure is performed (include laterality) • Remember to capture documentation of any procedural complications

Term Definition Abortion Artificially terminating a pregnancy

Bypass Altering the route of passage of the contents of a tubular body part

Change Taking out or off a device from a body part and putting back an identical or similar device in or on the same body part without cutting or puncturing the skin or a mucous membrane Delivery Delivery of Products of Conception, External Approach

Destruction Physical eradication of all or a portion of a body part by the direct use of energy, force, or a destructive agent

Dilation Expanding an orifice or the lumen of a tubular body part Division Cutting into a body part without draining fluids and/or gases from the body part in order to separate or transect a body part Drainage Taking or letting out fluids/or gases from a body part

Excision Cutting out or off, without replacement, a portion of a body part

Extirpation Taking or cutting out solid matter from a body part (the solid matter may be an abnormal byproduct, imbedded or may be or may not have been broken into pieces) Extraction Pulling or stripping out or off all or a portion of a body part by the use of force (A qualifier of diagnostic is used for biopsies) Fragmentation Breaking solid matter in a body part into pieces

Insertion Putting in a nonbiological appliance that monitors, assists, performs or prevents a physiological function but does not physically take the place of a body part

Term Definition

Inspection Visually and/or manually exploring a body part

Occlusion Completely closing an orifice or lumen of a tubular body part

Reattachment Putting back in or on all or a portion of a separated body part to its normal location or other suitable location Release Freeing a body part from an abnormal physical constraint by cutting or by use of force

Removal Taking out or off a device from a body part

Repair Restoring, to the extent possible, a body part to its normal anatomic structure and function

Reposition Moving to its normal location or other suitable location all or a portion of a body part

Resection Cutting out or off, without replacement, all of a body part

Revision Correcting, to the extent possible, a malfunctioning or displaced device

Transplantation Putting in or on all or a portion of a living body part taken from another individual or animal to physician take the place and/or function of all or a portion of a similar body part

Samantha Hauger Dr. Sylvia Morris Rob Byrd Partner Senior Medical Director Director [email protected] [email protected] [email protected] 202-266-6679 202-266-6132

Jill Lindsey Matt Ruiz Associate Director Senior Associate [email protected] [email protected] 202-568-7141 202-266-5884

Please do not hesitate to contact your team with any questions or comments.

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