More Detailed Coding Requires - abeo

More Detailed Coding Requires More Specific Documentation

Audit Results of Documentation Challenges for ICD-10

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Diagnosis Description

I-9

I-10

Problem

Information Needed

Abdominal Pain Abscess anal rectal region Acquired absence of breast

Alcohol dependence

789.00 566

V45.71

303.90

R10.-K61.0Z90.1-

Missing information to code Missing information to code Missing information to code

F10.20 Additional information needed

Right or left? Upper or lower, periumbilic, epigastric, or generalized? Anal, rectal, anorectal, ischiorectal, and intrashincteric? Laterality? Use, abuse, or dependence of alcohol? Blood alcohol level if applicable? With other related disorders (withdrawal, intoxication, in remission, mood disorder, etc.)?

Amputation Stump Complication 997.69 T87.5- or T8781 Missing information to code

Anemia

285.9

D64.9 Unspecified Code

Appendicitis

540.90

K35.-- Missing information to code

Laterality? Necrosis or dehiscence? Due to? Aplastic? Acute or Chronic? Type: Hemorrhagic, Idiopathic, Iron Deficiency, Nutritional, Blood Loss, etc.

Acute, chronic or recurrent? With or without generalized or localized peritonitis?

x

Arthritis

Aseptic necrosis of femur Atrial fibrillation Atrial flutter Barrett's esophagus

Bipolar 1 disorder

716.90

733.42 427.31 427.32 530.85

297.7

M19.90 Unspecified Code

M87.05-

I48.91 I48.92 K22.719

Missing information to code

Additional information needed Additional information needed Additional information needed

F31.9

Additional information needed

Type-infectious, juvenile, meaning osteoarthritis, rheumatoid, etc.? If meaning osteoarthritis, need if generalized, primary, secondary, or post-traumatic? Specific location?

Directed to Idiopathic, osteonecrosis, due to drugs, previous trauma, secondary? Specific location of pelvis or femur? Laterality?

Paroxysmal, persistent, or chronic? ICD-10 specific to persistent, typical, atypical or unspecified Presence or absence of dysplasia?

Specific to recent episode, in remission, partial remission, or full remission.

Bladder Cancer

x

Breast Cancer

Breech presentation

CAD

188.9 174.9

652.21 414.00

C67.9 Additional information needed C50.91 Missing information to code

O641XX0 Additional information needed I25.10 Additional information needed

Specify site, trigone, dome, lateral wall, anterior or posterior wall, bladder neck, ureteric, overlapping site? Laterality? Specific location, quadrant, or overlapping site. Estrogen receptor status if known.

The codes for breech presentation has additional classification on the basis of no. of gestation (fetus) Due to calcified lesion or lipid rich plaque? Use or exposure to smoking? With or without angina pectoris?

Calculus of ureter Carotid Stenosis (Occlusion and stenosis)

592.1 433.10

N20.1 I65.2-

Additional information needed Kidney with ureter?

Missing information to code

Laterality?

Carpal tunnel syndrome

354.0

G56.0- Missing information to code

Laterality?

Audit Results of Documentation Challenges for ICD-10

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Diagnosis Description

x

Cataract

x

Cesarean Delivery

Cesarean, Repeat

CVA Chalazion

Cholecystitis Cholelithiasis Chondromalacia

Chronic tonsillitis Colon cancer

x

Colon polyps

I-9

366.9

669.91 654.21

434.91 373.2

575.10 574.20 733.92 474.00 153.9

211.3

Complication of AV fistula Complication of internal orthopedic device, implant, and graft, mechanical

996.74 996.--

Complication of vascular device

COPD

Crohn's Disease, large intestine

996.74 496

555.1

CVA Cystitis, interstitial, chronic

434.91 595.1

I-10

H26.9

082 O34.21

I63.5-H00.016

K81.9 K80.20 M94.2-J35.01 C18.9

D12.2

T82.9--

Problem

Additional information needed

Additional information needed Additional information needed

Additional information needed Additional information needed

Additional information needed Additional information needed Additional information needed Additional information needed Additional information needed

Additional information needed

Specifics needed

Information Needed

Type (infantile/juvenile, drug induced, senile, anterior, diabetic, presenile, nuclear, traumatic, etc.)? Laterality? Indicate if any complications. Requires outcome of delivery (single liveborn, twins, stillborn, etc.) Requires weeks of gestation and outcome of delivery Codes are depended upon the artery involved in the infarction and laterality.

Upper or lower eyelid? Acute, chronic or acute on chronic? With calculus, if so where?

With or without obstruction Laterality? Specific anatomical location?

Use or exposure to smoking? Use, abuse, or dependence of alcohol? Site specific: cecum, ascending, transverse, descending sigmoid, etc. Embolism, Fibrosis, Hemorrhage, Pain, Stenosis, Thrombosis? Cardiac or Vascular device, implant, or graft? Episode of care: Initial or subsequent? Or Sequela?

T84.----

T82.8-8J44.9 K50.10 I63.5-N30.10

Additional information needed

Missing information to code Additional information needed Additional information needed Missing information to code Additional information needed

What kind of device, implant, or graft? Breakdown, displacement, osteolysis, wear of articular bearing surface, Type of cardiovascular device, implant, or graft? Type of complication (breakdown, displacement, infection, embolism, etc.)? Episode of care: Initial or subsequent? Or Sequela? With respiratory infection, exacerbation? Does patient additionally have asthma? Use or exposure to tobacco? Specific to: with bleeding, with obstruction, with fistula, with abscess, with other complication, with or without unspecified complications Codes are dependent on the artery involved in the infarction: Anterior cerebral artery, posterior or cerebellar artery. Also laterality?

With or without hematuria?

Top

Diagnosis Description

Delivery (Spontaneous)

x

(Normal) (Vaginal)

Derangement of medial

x

meniscus

Diabetes

Dislocation of prosthetic

joint

Diverticulosis

DVT Dysfunction of Eustachian tube

Ectopic pregnancy Emphysema

Esophagitis

Audit Results of Documentation Challenges for ICD-10

I-9

650

717.3 250.00 996.42 562.10 453.4 381.81

633.90

I-10

O80

M23.204 E11.9

T84.02-K57.-I82.409 H69.8-

O00.9

Problem

Additional information needed

Missing information to code Additional information needed Missing information to code Missing information to code Unspecified Code Missing information to code

Additional information needed

Information Needed Needs additional descriptors for "full term", "uncomplicated", if applicable. Also, needs outcome of delivery (single liveborn, stillborn, twins, etc.) Acute /Chronic is not specified, based on the statement: "having failed conservative management" chronic ICD9/ICD-10 was selected. Episode of care is not documented Type? Additional manifestations? Insulin usage? Requires right or left, and episode of care: Initial or subsequent? Or Sequela?

Small or large intestine? Where-Upper or Lower Extremity? Distal or Proximal? Acute or Chronic? Right, Left, or Bilateral? Which vein? Complication of PE tubes? Laterality? Use or exposure to tobacco? Weeks of gestation? Abdominal, with viable fetus? Tubal? Ovarian? Complicated by (infection, renal failure, sepsis, hemorrhage, etc.)?

492.8 530.1

J43.9 K20.9

Additional information needed Unspecified Code

Specify type? Eosinophilic? Use additional code to identify alcohol abuse and dependence

x

ESRD

585.6

N18.6 Additional information needed Need additional information to identify dialysis status?

Failed back syndrome (Post-

laminectomy syndrome)

722.83

M96.1

Somewhat difficult to find

Failed induction of labor

659.11

Failed spinal cord stimulator 996.2

Femur Fracture

821.00

O61.9 Additional information needed T85.192A Additional information needed

S72.92XA Missing information to code

Trimester?

Specific to breakdown, displacement, or other complication. Requires episode of care: Initial or subsequent encounter? Or Sequela?

Codes for femur fracture are classified on the basis of following: Episode of care: Initial (treatment phase)/ subsequent (Routine healing/ Delayed healing , Non-union/ Malunion) Type of fracture: open or closed (Type I, II, IIIA, IIIB, IIIC for open fracture) Displaced or non-displaced

Audit Results of Documentation Challenges for ICD-10

Diagnosis Top Description

Foreign body

x

Fractures

Ganglion

Gangrene

Gastritis

x

GERD

Glaucoma

Goiter Hardware complication

Headaches Herniated Nucleus Pulpous Hip Dislocation

Humeral Supracondylar fracture

I-9

816 727.43 785.4 535.5 530.81 365.9 240.9 996.78 784.0 722.10

835

812.41

I-10

Problem

Information Needed

With laceration or puncture wound? Causing acute reaction? Location? Missing information to code Complication of? Retained foreign body? Episode of care:

S62.602A Episode of care not specified

Codes for fractures are classified on the basis of following: Traumatic or Pathologic (+ underlying condition)? Specific anatomical information (which finger, which bone, proximal-shaftdistal, head, neck, etc.)? Type of fracture: open or closed (Type I, II, IIIA, IIIB, IIIC for open fracture) Displaced or non-displaced? Right, Left, or Bilateral? Episode of care: Initial (treatment phase)/ subsequent (Routine healing/ Delayed healing , Non-union/ Malunion) Initial or subsequent encounter? Or sequela (detail original injury)?

M67.4I96

K29.70

Missing information to code Need specific anatomical site and laterality

Laterality? Specific anatomic information? Due to diabetes, drug induced,

Additional information needed atherosclerosis of native arteries or by-pass grafts (type of graft)?

Acute or Chronic? If Chronic - superficial or atrophic? Alcoholic? With or

Unspecified Code

without bleeding?

K21.9 H40.9

Additional information needed With or without esophagitis?

Type? Suspect, open angle (risk), ocular hypertension, pigmentary,

Unspecified Code

capsular, acute, chronic, intermittent, residual, secondary to, etc.?

E04.9 Additional information needed Iodine deficiency? What kind of complication-hemorrhage, pain, stenosis, embolism, etc.?

T84.9XX- Missing information to code Episode of care: Initial or subsequent encounter? Or Sequela? Type? If Migraine: Type, with or without aura, intractable, persistent, with

R51 Additional information needed or without status migrainosus? Occipito-atlanto-axial, cervical, cervicothoracic, thoracic, thoracolumbar,

M51.2- Missing information to code lumbar, lumbosacral, sacral and sacrococcygeal, or multiple sites?

S73.004A Episode of care not specified Initial or subsequent encounter? Or Sequela? Laterality: LT/ RT. Episode or Care: Initial/ Subsequent/ Sequela. Nature of the fracture: Displaced/ Non-displaced Anatomical Location: There are separate codes for medial condyle/ lateral

S42.412A Missing information to code condyle of the humerus.

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