General Surgery INSTEAD of PLEASE CONSIDER

General Surgery 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

Intestinal or Peritoneal Adhesions With Obstruction/Without Obstruction

Intestinal Obstruction Type/Etiology: Paralytic ileus, Intussusceptions, Volvulus, Gallstone ileus impaction, Adhesions (other).

Cholecystitis with or without Cholelithiasis Acuity: Acute/Chronic/Acute on Chronic Anatomical Site: Gallbladder/Bile Duct/Gallbladder & Bile Duct With Obstruction/Without Obstruction

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Diverticulitis Anatomical Site: Small, Large or Both Intestines, e.g. sigmoid colon With or Without Bleeding With or Without Hemorrhage With or Without Perforation/Abscess

Appendicitis Acuity: Acute/Chronic/Acute on Chronic/Recurrent With or Without Rupture If rupture: With Localized or Generalized Peritonitis With or Without Perforation With or Without (Peritoneal) Abscess

Traumatic Pneumothorax/Hemothorax Type: Traumatic, Traumatic Hemothorax, Traumatic Hemopneumothorax, Other (Specify) With or Without Open wound into Thorax; Open; Closed Encounter: Initial/Subsequent/Sequela

Neoplasm of Breast 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 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

Neoplasm of Colon Type: Malignant; Benign; In-Situ; Metastatic; Distant Metastatic Staging; With invasion or adherence to (other organs/submucosa/muscularis propria/muscularis propria into pericolorectal tissues); Uncertain Behavior (include cell type)

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Note: A primary malignant neoplasm that overlaps Behavior: Primary or Secondary Site; Designate if two or more contiguous (next to each other) sites Overlapping 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. Laterality: Right; Left; Bilateral Anatomical Site: Ascending; Descending; Sigmoid, Transverse; Cecum; Hepatic Flexure; Splenic Flexure; With Rectum; Regional Lymph Node involvement; etc

Spleen Laceration Anatomical Site: Extending into Parenchyma Cavity With or Without Open Wound into Cavity Severity: Major (greater than 3 cm); Moderate (1 to 3 cm); Superficial (less than 1 cm) Encounter: Initial/Subsequent/Sequela

Hemorrhage/Infection Complicating Procedure Anatomical Site: i.e. seroma Encounter: Initial/Subsequent/Sequela

Volvulus Anatomical Site: Intestinal; Ileal; Jejunal; Ascending Colon; Descending Colon etc With or Without Perforation

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)

Ileus Type: Paralytic; Gallstone; Mechanical; Spastic; Obstructive; Post-operative

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Traumatic Fractures (Fracture Clavicle; Tib/Fib, Location: Specific Part of Body - Name of specific bone Femur, Hip) and specific site on bone Laterality Episode of Care/Encounter:  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 Tx,

LEO C. FAUR (it’s Initial Encounter, otherwise it’s ‘Subsequent’) (acronym to remember elements of fracture documentation)  Sequela (Use for complications or conditions Zupko and Associates that arise as a direct result of a condition…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

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 to’ inherent to the procedure are not complications. etc… When NOT a complication…include the medical decision making and characterize the event as There is no timeframe/deadline for a Postoperative ‘intentional’, ‘unavoidable’, or ‘inherent’ to the Complication (current condition due to previous

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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 fluid/Inspect i.e. Coder needs ALL elements addressed in order to be 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 i.e. needs to be available. 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 Procedure Documentation:

Lymph Node Removal Differentiate between removal of: -One or more (portion) lymph nodes Versus -Removal of an entire chain of lymph nodes Anatomical Site: Head; Right/Left Neck; Right/Left Axillary; Mesenteric; Right/Left inguinal etc

Lysis of Adhesions Anatomical Site of each organ or body part RELEASED/FREED, i.e. (The body part value coded, is the body part being -Greater Omentum freed, not the tissue being manipulated or cut to free -Lesser Omentum the body part.) -Mesentery Etiology: i.e. previous surgery; chronic infection/inflammation; preventing access to surgical site (Adhesions that exist without being organized or Amount: Extensive; Numerous etc without causing any symptoms or without increasing the difficulty of performing the operative procedure will not be coded separately.) Timeframe: i.e. Extensive lysis; Tedious lysis; long time to lyse

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 remove instrument to scrape away tissue (typically involves 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,

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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.)

Secondary Conditions:

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”

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

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- Purpose of drug’s use (e.g. chemotherapy) - 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.’

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’

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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 infection) indicates the presence of bacteria in the blood, but 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

Dehydration Manifestations: With Hyponatremia or Hypernatremia Etiology: Decreased Intake i.e. stomatitis; Increased output i.e. diarrhea; Increased Insensible losses i.e. fever

Atrial Fibrillation Type: Paroxysmal/Persistent/Chronic

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

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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

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)

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

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

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

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

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(document LINK to Diabetes): i.e. neuropathy; nephropathy; retinopathy; ketoacidosis

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

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

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; diagnosis. To review MNT Nutrition Evaluation in Unintentional Weight Loss; Significant Edema or Ascites; CPSI, Go to

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Nutrition Evaluation, page 1 and 2.

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 normal to ‘unspecified’ code and does not reflect the severity 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

Gastrointestinal Bleed Acuity: Acute or Chronic Manifestations: Hemorrhage; Perforation; Obstruction Etiology: ETOH; Ulcer, Drug i.e. NSAIDS, Esophageal Varices, etc Anatomical Site: Esophagus; Intestinal; Gastric, etc

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

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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.

Depression Acuity: Acute/Chronic/Recurrent/Single Episode Severity: Mild/Moderate/Severe Type: Anxious/Bipolar/Atypical/Post-Partum CAUTION: ‘Unspecified Depression’ codes to MAJOR Etiology: Dementia; Head Injury; Multiple Sclerosis; Depressive Disorder….is it actually a LESS severe Stroke; Pregnancy; disorder i.e. Adjustment Disorder; Anxiety Depression..please be specific Manifestations: Anxiety/Suicidal Ideation/Somatization Remission Status: Partial/Complete

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) Current/No longer Use Tobacco/Never Type of Tobacco Product: Cigarette/Chewing Tobacco/Nicotine If Dependence: Uncomplicated/In remission/With withdrawal/With other Nicotine induced disorder

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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 Xray, 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)

Indicate “Present on Admission” (POA) status, as A diagnosis without documentation of being present on applicable 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.

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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.

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; 3M Doc Check out www.tfhd.com/icd10 tips; AHIMA ACDIS ICD 10 Webinar 12.2014; ACDIS ICD 10 CDI Bootcamp 2014; ACDIS Annual Conference 2015; TFHS P & P.

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