Orthopedics INSTEAD OF PLEASE CONSIDER

Low or No Severity Diagnosis—NO High Severity Diagnosis---YES

ICD 10 Themes: Acuity/Severity/Type/Staging  Acute/Chronic/Acute on Chronic e.g. Acute on Chronic Systolic Heart Failure  Mild, Moderate, Severe  Systolic, Diastolic, Combined  Stage I, II, III, IV Anatomy/Site Specificity e.g. Malignant neoplasm of lower lobe right  Location of tumor bronchus  Bone/Joint/Muscle involved e.g. Decubitus Ulcer, Stage 3, Right Buttocks, Laterality Present on Admission  Right/Left/Bilateral/Overlapping (see Neoplasm re overlaps two or more contiguous (next to each other) sites) e.g. Hypertensive heart disease with chronic systolic Manifestations – LINK IT! heart failure  Associated or Related Conditions  ‘With’/‘Secondary’ to/’Due to’  ‘Evidence of’ and causative organism  Use ‘no organism isolated’, instead of ‘negative culture’ e.g. Likely Sepsis secondary to UTI; Etiology – ‘DUE TO’ WhAt? Evidence of Bacterial Pneumonia (‘Evidence of’ in  ‘LIKELY’ suspects….Who dun it? outpt setting can be captured as a diagnosis)  Possible, Probable, Suspected (Inpt Only)  Evidence of, As Evidenced by (Outpt Setting and Inpt Setting) e.g. Drug Poisoning/Adverse Effect Episode of Care/Incidence of Encounter (Trauma/Fractures/Medication.Chemical Event(Drug Poisoning))  Initial/Subsequent/Sequela Top Diagnosis Codes by Specialty: Osteoarthritis Type: Primary/Secondary/Post traumatic Anatomical Site: Hip/Knee/First Carpometacarpal joint/Shoulder/Elbow/Wrist/Hand/Ankle and Foot Laterality: Unilateral /Bilateral Right/Left

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Traumatic Fractures (Fracture Tib/Fib, Femur, Hip) Location: Specific Part of Body - Name of specific bone and specific site on bone Laterality Episode of Care:  Initial (receiving active treatment);  Subsequent (encounters AFTER the patient has received active treatment of the condition and is receiving routine care): o Routine Healing or Delayed Healing o Non-Union or Mal-union: . If non union: State if delayed

LEO C. FAUR Tx, (it’s Initial Encounter, otherwise it’s ‘Subsequent’) (acronym to remember elements of fracture documentation)  Sequela (Use for complications or Zupko and Associates conditions/residual effect that arise as a direct result of a condition (after the acute phase)…no time limit….i.e. Neuropathy of lower leg, ankle and foot due to previous crush injury)

Open or Closed Classifications: Open use Gustilo Classification: Type I, II, IIIA, IIIB, or IIIC (used for soft tissue classification); Salter; Physeal etc Fracture Pattern/Type/Orientation, i.e.:  Greenstick Comminuted Torus  Spiral Segmental  Transverse Avulsed  Oblique Torus Alignment: Displaced or Nondisplaced Underlying Bone Diseases: i.e. Fragility (Pathologic), Stress, Traumatic in healthy etc Results: Routine or Delayed Healing; Non union or Malunion

Pathological Fracture/Fragility Fracture Site and Laterality (fyi: any ground level fall of 50 yr old or greater is Etiology: usually a pathological fracture)  Age related  Osteoporosis or Osteopenia -When the fracture is out of proportion to the degree  Neoplastic of the trauma (weakening of the bone structure by  Some other disease pathologic processes i.e. Osteoporosis) 2 | P a g e R e v . 9 . 2 9 . 2 0 1 5

Episode of Care: Initial/Subsequent/Sequela For Subsequent: Routine or Delayed Healing; Non union or Malunion Current Fracture and/or personal history

Open Fractures Gustilo Classification: (used for soft tissue classification) Reference: Clin Orthop Relat Res. 201 November; Type 1 470(11): 3270 - 3274 Wound is less than 1cm with minimal soft tissue injury Wound bed is clean Bone Injury is simple with minimal comminution Type 2 Wound is greater than 1 cm with moderate soft tissue injury Wound bed is moderately contaminated Fracture contains moderate comminution Type 3 Wound is longer than 1 cm, with significant soft tissue disruption Mechanism often involves high-energy trauma, is unstable. Grade IIIA Adequate periosteal coverage of bone despite extensive soft-tissue laceration or damage Soft tissue coverage of bone is usually possible Grade IIIB Extensive soft-tissue loss and periosteal stripping and bone damage Usually associated with massive contamination Will often need further soft-tissue coverage procedure (i.e. free or rotational flap) Grade IIIC Fracture in which there is a major vascular injury requiring repair for limb salvage In some cases it will be necessary to consider amputation.

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Growth Plate (Physeal ) Fracture Use Salter Harris Classification: S (straight across) Type I – disrupt the physis Salter mneumonic refers to the fracture line and its A (above) Type II – involve a break from the growth relationship to the growth plate. plate up into the metaphysis, with the periosteum usually remaining intact. L (Lower or BeLow) Type III – intraarticular fractures through the epiphysis that extend across the physis T (Two or Through) Type IV – cross the epiphysis, physis, and metaphysis E R (ERasure of growth plate or cRush) Type V – compression injuries to the physis.

Sacral Fracture Vertical Fx: State if minimally vs. severely displaced

Zone 1: fracture involves the sacral ala lateral to the neural foramina Zone 2: fracture involves the neural foramina, but does not involve the spinal canal Zone 3: fracture is medial to the neural foramen, involving the spinal canal; these may be transverse or longitudinal, and can be sub-classified into 4 types:

Transverse Fx:

Type 1: only kyphotic angulation at the fracture site (no translation) Type 2: kyphotic angulation with anterior translation of the distal sacrum Type 3: kyphotic angulation with complete offset of the fracture fragments Type 4: comminuted S1 segment, usually due to axial compression

Complication/Infection of Internal Joint Prosthesis Laterality or Device Anatomical Site: Hip/Knee/Humerus/Radius/Ulna/Femur/Tibia/Fibula/ Spine/Other Complication: Infection/Inflammation/Embolism/Fibrosis/Hemorrha ge/Pain/Stenosis/Thrombosis/Other Episode of Care: Initial/Subsequent/Sequela

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Mechanical Complications with Internal Joint Laterality Prosthesis Anatomical Site: Hip/Knee/Other Type: Mechanical Loosening; Dislocation; Broken; Periprosthetic Fracture; Periprosthetic Osteolysis; Wear of articular bearing surface; Other Episode of Care: Initial/Subsequent/Sequela

Aseptic Necrosis Site and Laterality Idiopathic or Non-idiopathic Manifestations: With or Without Major Osseous Defect If with, What is the Site?

Excisional Debridement ‘Non-excisional’ Debridement - Minor removal of Excisional Debridement - Involves cutting outside or loose fragments with scissors or using a sharp beyond the wound margin. A scalpel is used to instrument to scrape away tissue (typically involves remove devitalized tissue. mechanical removal of tissue with brushing, scrubbing, washing etc). Debridement is usually only to level of subcutaneous tissue.

I & D, Debridement, Sharp Debridement ‘EXCISIONAL’ Debridement – Documentation to If it is actually an ‘excisional debridement’ include: designate the procedure as such, instead of stating I & D.  ‘Technique’ used (e.g., excisional, excised, cutting etc)  ‘Instrument’ used (e.g. scalpel, curette)

 Nature of ‘tissue’ removed (e.g. necrotic, devitalized tissue, nonviable tissue)  The ‘appearance’ and ‘size’ of the wound (e.g. down to flesh, bleeding tissue, 7cm x 10 cm etc)  ‘Depth’ of debridement (e.g. skin, subcutaneous, fascia, muscle, bone, etc.)

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Debridement---Low or No Severity Procedure “Excisional” Debridement - Best Practice Procedure Statement for Debridement Statement for Excisional Debridement

“I debrided the ulcer down to the pink tissue” “Using a #5 blade, I excisionally debrided the necrotic (Missing: technique, instrument used, nature of skin around the edges of the sacral ulcer. The wound tissue, size of wound, depth) measured 5 cm x 5 cm and was covered with damp gauze at the conclusion of the procedure.”

“I removed all the necrotic tissue down to the muscle resulting in a wound of 4 cm x 2 cm.” (Missing: technique, instrument used, appearance of the wound)

Secondary Conditions: Pneumonia Type: Healthcare Associated/Aspiration/Ventilator Associated/Radiation Induced CAUTION: CAP-Community Acquired PNA- defaults Causative Agent: Viral or Bacterial to a ‘simple pna’ with low severity; if documented, please also include if it is Viral or Bacterial (and other items listed from list on right, as applicable) to capture the true severity. Causative Organism (if known) Associated Illnesses: influenza/ lung abscess/Sepsis Common Secondary Conditions: Acute Respiratory Failure; Exacerbation of COPD, etc. Clinically significant diagnostic results from Lab and Radiology in the medical record. i.e. if elevated white count; infiltrate on CXR History of Tobacco Use, Present or Past

COPD Acute Exacerbation or Decompensated (Chronic RF is very common in pt with severe COPD) If with acute lower respiratory infection, as applicable CAUTION: ‘Respiratory Distress’ and ‘Respiratory (also include causative organism, if known) Insufficiency’ are vague and symptomatic of underlying condition – is the intended diagnosis Respiratory Failure OR what is other underlying condition? IF Oxygen Dependent Common Secondary Conditions: Acute, Chronic, Acute on Chronic Respiratory Failure; Pneumonia, etc. History of Tobacco Use, Present or Past

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Respiratory Failure Acuity: Acute/Chronic/Acute on Chronic (Chronic RF is very common in pt with severe COPD) Manifestation: With Hypoxia or With Hypercapnia, or CAUTION: ‘Respiratory Distress’ and ‘Respiratory both Insufficiency’ are vague and symptomatic of underlying condition – is the intended diagnosis Respiratory Failure OR what is other underlying condition? Etiology: if known (i.e. due to COPD Exacerbation; Pneumonia; Surgery, Trauma, etc)

Pleural Effusion Type: Malignant (Specify site and morphology of tumor if possible); Influenzal; Tuberculosis; In heart failure

Urinary Tract Infection Acuity: Acute or Chronic e.g. ‘Chronic Cystitis with hematuria’; ‘Acute Specific Site: Bladder (Cystitis)/Urethra Urethritis due to E.Coli’; ‘Acute on Chronic (Urethritis)/Kidney (Pyelonephritis) Pyelonephritis due to foley catheter with Candida’ Manifestations: Hematuria etc. Causative Organism i.e. E Coli or Candida IF related to a device i.e. foley catheter, state ‘due to’ or ‘secondary to’

Sepsis Type: Sepsis/Severe Sepsis/Septic Shock (fyi: negative or inconclusive blood cultures do not Causative Organism (if known) preclude a diagnosis of sepsis in patients with clinical evidence of the condition) (fyi: Bacteremia is a non specific diagnosis and Underlying Systemic Infection (the source of indicates the presence of bacteria in the blood, but infection) i.e. Sepsis due to UTI does not indicate the bacteria are pathological or has any resulting systemic illness needing treatment.)

(fyi: Urosepsis is non descriptive term and is NOT Any Associated Organ Dysfunction i.e. Acute Renal synonymous with sepsis and there is no default for Failure; Acute Respiratory Failure; Encephalopathy coders…please .use ‘Sepsis due to UTI’ instead) (fyi: Sepsis Syndrome is a non specific term..avoid using it)

SIRS Infectious or Non-infectious (If ‘non-infectious’ specify what ‘due to’, i.e. ‘SIRS due to Burn’) Always document the Etiology!! With severe Sepsis or Without Sepsis With or Without Organ Dysfunction (Does NOT code to Sepsis, unless stated ‘with Defaults to the underlying infectious process i.e. sepsis’) Pneumonia 7 | P a g e R e v . 9 . 2 9 . 2 0 1 5

Atrial Fibrillation Type: Paroxysmal/Persistent/Chronic

Atrial Flutter Type: Typical (Type 1) or Atypical (Type 2)

Diabetes Type: Type 1 or Type 2 ; Drug or Chemical Induced; or Gestational Terms i.e. ‘uncontrolled’ or ‘inadequately Control Status (Insulin): controlled’ code to ‘hyperglycemia’…even if recent  With: Hypoglycemia/Hyperglycemia ‘hypoglycemia’…..specifically use Hypoglycemia or Hyperglycemia instead. Or if used, stipulate if not hyperglycemic. Insulin Use Associated Diagnosis/Conditions: i.e. ulcers Manifestations or Secondary related problems (document LINK to Diabetes): i.e. neuropathy; nephropathy; retinopathy; ketoacidosis

Asthma Severity: Mild/Moderate/ Severe Type: Intermittent or Persistent With or Without Exacerbation With or Without Status Asthmaticus

Heart Failure Severity: Acute/Chronic/Acute on Chronic Type: Systolic/Diastolic/Combined Systolic and Diastolic/Congestive Etiology, if known, i.e. due to ischemic or primary cardiomyopathy Associated Conditions: i.e. Hypertension/Pericarditis

Alcohol Dependence with or without Alcohol Frequency of Usage: Use/Abuse/Dependence/In Withdrawal Remission Type of Dependence: Uncomplicated; In Remission, Current Intoxication Manifestations: Delirium, Delusions, Hallucinations, Anxiety, etc; Specify intoxication/withdrawal as: Uncomplicated or With Delirium

Cellulitis Anatomical Site: Trunk: Abdominal Wall/Back/Chest Wall/Groin; Toe/Foot Laterality: Left/Right/ Bilateral Manifestations: i.e. Febrile Neutrophilic Dermatosis/Lymphangitis etc

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Abscess Anatomical Site: Abdominal/Lung/Wound/Teeth/Extremity, etc Laterality: Right/Left/Bilateral Manifestations: i.e. Febrile Neutrophilic Dermatosis/Lymphangitis Causative Agent: Viral or Bacterial Causative Organism (if known) Episode of Care: Initial/Subsequent/Sequela (if ‘Wound’ related)

Non Pressure Ulcer Wound Acuity: Chronic Laterality Severity/Depth of Tissue Involved: Skin Breakdown; Fat Layer Exposed; Muscle Necrosis; Bone Necrosis; Unspecified Severity Etiology: Diabetes; Infection (specify); Other (specify) Present on Admission, if applicable

Pressure Ulcer Anatomical Site Laterality Stage: 1, 2, 3, 4 (Staging can be taken from wound care RN ) Associated Illnesses: i.e. Diabetes Gangrene, if applicable Present on Admission, if applicable

Osteomyelitis Acuity: Acute/Subacute/Chronic Anatomic Site: Body part (i.e. thigh); Specific bone (i.e. femur); Joint (i.e. shoulder) Laterality: Right/Left/Bilateral Causative Agent: Viral or Bacterial Causative Organism (if known) Etiology/’Due to’: i.e. Acute osteomyelitis, left humerus, ‘due to’ infect hip Complications: Abscess/Amputation/Avascular necrosis/Gangrene/Meningitis etc.

Pulmonary Embolism Severity: Acute/Chronic (still present) vs. Healed (Old) Type: Saddle/Septic Manifestations: With or Without Acute Cor Pulmonale

DVT Acuity: Acute or Chronic Laterality: Right/Left/Bilateral

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Dementia Etiology: Alzheimers/with Lewy Bodies/Epilepsy/Hypercalcemia/Parkinson’s Disease Manifestations: With behavioral disturbance or Without Behavioral disturbance

Alzheimers Type: Early Onset (presenile dementia); Late Onset (senile dementia) “Early onset Alzheimers with dementia. Pt wandered Manifestations: With ‘Behavioral’ Disturbances (i.e. into snow with bathing suit on and sustained a hand Aggressive; Combative; Violent, Wandering); With laceration of unknown mechanism”—link it. ‘Mind’ Disturbances (i.e. Dementia/Delirium) - Dementia with Wandering -With Associated Delirium

CVA/Cerebral Infarction Etiology: Thrombus or Embolism Artery Site: Precerebral – Vertebral, basilar, carotid, or other Cerebral – Middle, anterior, or posterior Cerebellar arteries Laterality, When Appropriate Dominant or Non-Dominant Side Affected Associated Conditions i.e. aphasia, hemiplegia, dysphasia

Obesity BMI 19 or less = Indicates Malnutrition BMI 25 – 29.9 = Overweight (BMI can be taken from Nursing Documentation; MD BMI 30.0 – 39.9 = Obesity needs to document the diagnosis and etiology/manifestation correlating to BMI) BMI ≥ 40 = Morbid Obesity (state Etiology: Excess Calories ; Other and Manifestation: Alveolar Hypoventilation, as applicable) Etiology: Excess Calories (for Morbid Obesity); Drug Induced; Endocrine; Familial; Constitutional; etc Manifestation: Alveolar Hypoventilation (for Morbid Obesity)

Malnutrition BMI 19 or less = Indicates Malnutrition Acuity: Acute (< 3 mo); Chronic (>3 mo) Severity: Mild/Moderate/Severe (BMI can be taken from Nursing Documentation; MD Type: Protein Calorie; Protein Energy needs to document the diagnosis and etiology/manifestation correlating to BMI) Etiology: Renal Disease; Pregnancy Related; Diabetes; Following Gastrointestinal Surgery, etc Utilize Dietician’s Assessment to assist you with Manifestations: Insufficient Energy Intake; 10 | P a g e R e v . 9 . 2 9 . 2 0 1 5 diagnosis. To review MNT Nutrition Evaluation in Unintentional Weight Loss; Significant Edema or CPSI, Go to

Kidney Failure Acuity: Acute/Chronic/Acute on Chronic If Chronic: Note: Re Chronic: ‘insufficiency’ and no ‘stage’ codes  Stage 1 (GFR ≥ 90) – Kidney Damage with to ‘unspecified’ code and does not reflect the severity normal or ↑ GFR of the patient  Stage 2 (mild) (GFR 60 – 90) + Kidney Damage  Stage 3 (moderate) (GFR 30-59)  Stage 4 (severe) (GFR 15-29)  Stage 5 (GFR ‹ 15)  End Stage Renal Disease Above per KDIGO 2012 Clinical Practice Guidelines Re Acute: ‘insufficiency’ and ‘kidney disease’ do not If Acute: due to traumatic injury or non trauma event report ‘failure, acute renal’ Manifestations: With-Acute Tubular Necrosis (ATN)/Acute Cortical Necrosis/Medullary Necrosis Etiology: Pre-renal AKI/ ATN/Post-Renal Obstructive AKI/Diabetic/Hypertensive

Hypotension Etiology: Postural; Orthostatic (chronic); Neurogenic (Orthostatic); Postoperative; Drug-induced; Cardiogenic; Idiopathic; etc

Atelectasis Etiology: i.e. Morbid Obesity/Pleural Effusion/Malignancy etc Associated Conditions: i.e. Apnea Present on Admission, if applicable

Diverticulitis Location: Small, Large or Both Intestines With or Without Bleeding With or Without Perforation/Abscess

Neoplasm Type: Malignant (Primary; Secondary/Metastatic); Benign; In-Situ; Uncertain Behavior (include cell type)

(Uncertain behavior is a specific pathologic diagnosis indicating behavior that cannot be predicted, as opposed to a diagnosis of unknown pathology) Morphology: Adenocarcinoma; Sarcoma; Lymphoma etc Note: A primary malignant neoplasm that overlaps Behavior: Primary or Secondary Site; Designate if two or more contiguous (next to each other) sites Overlapping

11 | P a g e R e v . 9 . 2 9 . 2 0 1 5 should be classified 'overlapping lesion', unless the combination is specifically indexed elsewhere. For For Secondary Site…document if primary site still exists multiple neoplasms of the same site that are not contiguous, such as tumors in different quadrants of the same breast, codes for each site should be assigned. Gender: Male or Female Laterality: Right; Left; Bilateral Anatomical Site: Breast: Upper-Outer; Upper-Inner; Lower Outer; Lower-Inner; Midline; Central; Nipple; Areola; Axillary tail etc Stage and Metastatic Sites (and indicate if primary site still exists) Caution: ‘History of’ – for coding purposes means Status – In remission, Not having achieved remission; when primary malignancy previously excised and no In Relapse; History of (preferably state more further treatment to that site, no evidence of any specifically i.e. ‘Previously excised or eradicated’; ‘No existing primary malignancy further treatment’; ‘No evidence of existing malignancy’)

Anemia Acuity: Acute/Chronic (Acute Blood Loss Anemia does not reflect a Etiology: Blood Loss; Iron Deficiency; Chemotherapy; complication of surgery, unless surgeon states it’s a Neoplastic; Aplastic, etc complication and there is a cause and effect relationship; May state ‘expected’/’inherent’; Documentation of ‘Post-op Anemia’ is not enough, instead ‘Post Operative Anemia due to Acute Blood Loss’)

Nutritional Anemia Type: i.e. if nutritional due to iron deficiency: Sideropenic iron deficiency anemia; Iron deficiency due to inadequate dietary iron intake Vitamin B12 type i.e. Due to intrinsic factor deficiency; Vitamin B12 malabsorption Folate Deficiency type: i.e. Due to diet; Drug induced Other Nutritional Types: i.e. Protein deficiency

Anemia in Chronic Disease Link to Chronic Disease i.e. -Anemia due to chronic kidney disease -Anemia due to colon cancer

Neutropenia Type: Agranulocytosis/Other Drug Induced/Congenital/Cyclic Etiology: Cancer Chemotherapy/Infection etc. If Drug-induced: - Specify Drug - Purpose of drug’s use (e.g. chemotherapy) 12 | P a g e R e v . 9 . 2 9 . 2 0 1 5

- Specify the malignancy (e.g. Cytoxan for primary malignancy upper-inner quadrant of left breast Associated Conditions (e.g. infection) Adverse Effect (e.g. fever or mucositis)

Thrombocytopenia Classification: -Idiopathic -Primary -Secondary -Congenital or Hereditary -Heparin Induced Secondary Thrombocytopenia: - Underlying Condition (e.g. alcohol induced) Specify Hemorrhagic Conditions (e.g. qualitative platelet defects)

Pancytopenia Definition - Anemia (e.g. Hct < 32%); and, - Thrombocytopenia (e.g. PPC < 150K); and, - Neutropenia (e.g. ANC < 1,500) – Physician must describe underlying cause and what individual component has been treated - e.g. Platelets for thrombocytopenia - PRBC transfusion for acute blood loss anemia Etiology - Malignancy (Specify Malignancy) - Drug induced (Specify specific drug) - ‘Pancytopenia due to antineoplastic chemotherapy’ or - ‘Pancytopenia secondary to Cisplatin and disease’ , Or - ‘Pancytopenia due to HIV disease.’

Pain Acuity: Acute/ Chronic Anatomic Site: Cervical/Lumbar/Thoracic/Ankle/Elbow/Buttock,etc Laterality: Right/Left ‘Chronic back pain due to spinal stenosis and Etiology: i.e. Device, implant, graft; Pyschogenic (list difficulty sleeping due to the pain.’ type) Manifestations: With: Myelopathy; Radiculopathy; Neuritis; Radiculitis; etc Episode of Care/Incidence of Encounter: Initial/Subsequent/Sequela

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Depression Acuity: Acute/Chronic/Recurrent/Single Episode Severity: Mild/Moderate/Severe Type: Anxious/Bipolar/Atypical/Post-Partum Etiology: Dementia; Head Injury; Multiple Sclerosis; Stroke; Pregnancy; Manifestations: Anxiety/Suicidal Ideation/Somatization Remission Status: Partial/Complete

Acute Myocardial Infarction (AMI) Acuity: Acute; Subsequent (Acute MI occurring within 28 days (4 weeks) of previous acute MI, regardless of Indicate exact date of initial MI, if unavailable, report site; Old (> 28 days of current encounter) in weeks, NOT months. Type: STEMI/NSTEMI Anatomical Site: For STEMI: Wall involved; also include artery involved; NSTEMI – no add’l documentation needed

Underdosing Intentional vs. Unintentional Reason for Underdosing i.e. financial hardship or Age related dementia Episode of Care: Initial/Subsequent/Sequela

Tobacco Use Use/Dependence/Contact with Second Hand Exposure (Acute or Chronic) Caution: ‘History of smoking’ can be an ambiguous Current/No longer Use Tobacco/Never statement. Type of Tobacco Product: Cigarette/Chewing Tobacco/Nicotine If Dependence: Uncomplicated/In remission/With withdrawal/With other Nicotine induced disorder

Incidental to Pregnant State vs. Impacting State “Does not affect or complicate the pregnancy” if Pregnancy incidental, otherwise will code as ‘impacting the pregnancy’ e.g. Pregnant patient with burn of hand, “Burn of hand

does not affect or complicate the pregnancy”

Complications of Surgery Affected Body System Specific Condition Timeframe: Intra operatively or Post operatively (Punctures or lacerations that are unavoidable or Link Complication to Diagnosis: ‘due to’/’secondary inherent to the procedure are not complications. to’ etc… When NOT a complication…include the medical decision making and characterize the event as There is no timeframe/deadline for a Postoperative 14 | P a g e R e v . 9 . 2 9 . 2 0 1 5

‘intentional’, ‘unavoidable’, or ‘inherent’ to the Complication (current condition due to previous procedure) surgery or procedure)

NOT Complications Document: Inherent, Expected, Intended Avoid ‘Accidental/Complication/Unavoidable/Slip/ Additional Terms that suggest non-accidental: to Iatrogenic/Unintended’ etc when it is not a facilitate; necessary; required; intentional; integral; complication. Avoid using ‘Post operative’ when not routinely expected a complication; if used, include that it was ‘intended, expected, inherent’ etc.

Procedure Coding System (PCS) – New with ICD 10

Pre-operative/Post Operative Diagnosis State difference b/w pre and post dx, as applicable Link ‘findings’ with post operative diagnosis Procedure Performed Be Explicit, including unplanned Post op drains/tubes – Specify type of drain/tube Be specific re ‘intent’ of surgery i.e. Excision/Biopsy etc Types of Anesthesia/Estimated Blood Loss -Site infused (Central/Peripheral) (EBL)/Transfusions - Type & Volume of Fluid (Fresh/Frozen/Autologous)

Procedure – -Intent of the Procedure - Excision (partial removal i.e. biopsy)/Resection (total removal)/Drain Coder needs ALL elements addressed in order to be fluid/Inspect i.e. endoscopy etc. able to assign a code…..physician can use their own language for coder to translate, yet all information -Approach—Specify technique used to reach the site needs to be available. i.e. open, percutaneous, use of scopes etc -Prose for steps and technique, not the name of Coders must have a clear understanding of the procedure ‘intent’ of the procedure..it will help the coder properly assign the appropriate code. -Laterality of incision/Relative Location

-Anatomical site – Be specific re site/Body Cavity (instead of quadrants)/How much of body part removed (all, partial, or measurements)

- Devices Used Intraoperatively – material or appliance that remains in the body after the procedure is completed. i.e. Biological or synthetic material (i.e. joint prosthesis, intrauterine device; Therapeutic material (i.e. radioactive implant); Mechanical or electronic appliances ( i.e. orthopedic pin, pacemaker) etc.

-Intraoperative Grafting – source and destination site

-Modality of Guidance

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-Specimens – specify if sent to pathology are intended to diagnose and help treatment decisions following the procedure.

-Medications applied at Surgical Site

-Closure – type/area

-Complications

ADDITIONAL DOCUMENTATION TIPS

Reason for Exam –Be Specific as to what looking for - Anatomical Site Specificity/Where specifically the problem is…i.e. ‘tender over T9’ instead of ‘back pain’ - Indication for X-ray, i.e. Lt Pleuritic Chest Pain; Orthopnea; SOB at rest Radiology Tests Ordered - Why doing exam/What are you looking for? i.e. re Cancer…’Looking for Metastasis ‘Better info given →Better outcome on Report’ - AVOID: R/O, Pre –Op, Vague terms i.e. cough, dizzy. Instead state, fever, shakes, chills so Radiologist can help you capture Pneumonia if present. - Example of Reason for Exam: ‘Pt fell of ladder, pain medial aspect Lt ankle x 3 days’ instead of ‘ankle pain’; OR, ‘Pt with fever, chills, productive cough green sputum x 2 days’ instead of, ‘cough’.

Chronic Conditions/Secondary Diagnosis Avoid stating ‘History of’ ……Instead document what you are doing for Chronic Conditions now! Capture the Severity!!! Examples of documentation showing link between the additional disease and this admission’s evaluation, treatment, or monitoring:

 Hypertensive Heart Disease and Chronic Kidney Disease (CKD), stage 3 (Strict I & O, Monitor BP)  Chronic Systolic Heart Failure (Echo, Lasix 40 mg)  Hypokalemia (K+ repleted)  Acute Blood Loss Anemia (2 U PRBC’s)

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Indicate “Present on Admission” (POA) status, as A diagnosis without documentation of being present applicable on admission could be inadvertently considered a hospital-acquired condition (HAC).

Example: Pneumonia not definitively diagnosed until hospital day two but suspected, probable, or likely on admission should be noted as such. This allows coders to most accurately report the condition as being POA as opposed to hospital-acquired.

AVOID Signs and Symptoms as Diagnosis Definitive diagnoses are preferred in the inpatient setting and support a higher evaluation and management (E/M) fee.

In the inpatient setting, coders can capture ‘probable’, ‘likely’, ‘suspected’, or presumed diagnoses when patients present with the signs and symptoms of the diagnoses being ruled out…. as long as those diagnoses are restated in the discharge summary and have not been ruled out during the stay.

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Discharge Summary Wrap it all up!! For all ‘Rule Out’ situations: Rule it in!/ Rule it Out!/or state ‘Resolved’ Avoid Conflicting with previous documentation INCLUDE: substantiated in the record……Caution: If primary Reason for hospitalization: Chief Complaint; including physician subsequent dictation conflicts with description of the initial diagnostic evaluation previous ‘consult’ note, the primary physician’s Significant Findings: diagnosis is taken. -Admitting Diagnosis - reason for hospitalization -Discharge Diagnosis - significant findings/diagnoses -As well as those conditions resolved during hospitalization -List all possible and probable diagnoses as well -Hospital Course (procedures performed and findings/surgical findings/test results/treatment rendered/consults) -Discharge Disposition – pt condition at discharge -Education -Follow up needed -Diet -Medications – discharge meds; changes; discontinued meds -Discharge Instructions (instructions to patient and family, including follow up)

References: 3M physician video; CMS Road to 10; Coding Guidelines; Check out www.tfhd.com/icd10 3M Doc tips; AHIMA ACDIS ICD 10 Webinar 12.2014; ACDIS ICD 10 CDI Bootcamp 2014; ICD 10 CM for Hospitals; Precyse Doc Talks; Exc Debridement: Docu prompter…CMS; Coding Clinic, Second Quarter 2004 Page 5; ACDIS Annual Conference 2015; TFHS P & P.

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