ICD-10-CM/PCS Documentation Tips - NC
Clinical Documentation Improvement
ICD-10-CM/PCS Documentation Tips
MX10028
Clinical Documentation Improvement
CDI Tips by Chapter
Introduction ICD-10-CM
Chapter 1 Systemic Infection/
Inflammation Meningitis Hepatitis MRSA/MSSA Herpes Simplex
Chapter 2 Neoplasms
Chapter 3 Anemia Hemolytic Anemia Nutritional Anemia Aplastic Anemia Pancytopenia Coagulopathy Purpura
Chapter 4 Diabetes Obesity Malnutrition
Chapter 5 Alcohol, Tobacco and
Substance Use Major Depressive Disorder
Chapter 6 Altered Mental Status Cerebral Palsy
Chapter 7 Glaucoma
Chapter 8 Otitis Media Hearing Loss
Chapter 9 Heart Failure CVA Myocardial Infarction Cardiac Arrest
Chapter 10 Respiratory Failure Pneumonia Asthma
Chapter 11 Crohn's Disease/
Regional Enteritis Appendicitis Hepatic Encephalopathy
Chapter 12 Pressure Ulcers Non-Pressure Ulcers Cellulitis
Chapter 13 Pathologic Fractures Gout Scoliosis
Chapter 14 Chronic Kidney Disease Acute Renal Failure
Chapter 15 OB/Pregnancy
Chapter 16 Newborn
Chapter 17 Congenital Foot Deformities Cleft Palate
Chapter 18 Coma
Chapter 19 Gustilo Classification Fractures Burns Underdosing
Chapter 20 External Cause
Chapter 21 Encounter For History (Personal and Family) Genetic Carrier Retained Foreign Body Contact With and Exposure To Reproduction Services Socioeconomic and
Psychosocial Circumstances Body Mass Index
Other ICD-10-CM
Mechanical Device Complications
Surgical Complications
ICD-10-PCS
Lymph Node Chains Omentectomy Lysis of Adhesions Cleft Palate Repair CABG Spinal Fusion Amputations Debridement
ICD-10-CM/PCS Documentation Tips
MX10028
Clinical Documentation Improvement
Introduction
The AHIMA CDI Workgroup has responded to the needs of ICD-10 implementation by creating a large library of CDI ICD-10 documentation tips that are now available for the healthcare industry. These tips focus on the language and/or wording that will garnish greater details and specificity of the coded data for a given diagnosis, condition, disease and/or surgical procedure.
Participants of the AHIMA CDI Workgroup
? Danita Arrowood, RHIT, CCS ? Dee Banet, RN, BSN, CCDS, CDIP ? Suzonne Bourque, RHIA, CCS, CCDS ? Gloryanne Bryant, RHIA, CDIP, CCS, CCDS ? Patty Buttner, RHIA, CDIP, CCS ? Alexandra Chaudry RHIT, LPN, CDIP ? Angie Comfort, RHIA, CDIP, CCS ? Chris Davenport, RHIA, CCS-P ? Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA ? William Haik, MD, FCCP, CDIP ? Kathy Hallock, RHIA, CDIP ? Heidi Hillstrom, MS/HSA, MBA, RN, PHN, CCDS, CCS ? Amy Hyman CCS, CDIP, CIRCC, CPMA ? Robin Johnson, RHIA, CCS ? Carole Liebner, RHIT, CCS ? Kendra Massa, RHIA, CCS ? Pamela O'Neal, BS, RHIT, LPN, CDIP, CCS ? Sandy Plummer, RHIT, CCDS ? Maria Ward, Med, RHIT, CCS-P ? Sherry Wilkerson, RHIA, CCS, CCS-P, CCDS
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ICD-10-CM/PCS Documentation Tips
MX10028
Clinical Documentation Improvement
Systemic Infection/Inflammation
? Bacteremia (positive blood cultures only) ? Urosepsis--MUST specify sepsis with UTI, versus UTI only ? Sepsis--specify causative organism if known ? Sepsis due to:
--Device --Implant --Graft --Infusion --Abortion ? Severe sepsis--sepsis with organ dysfunction --Specify organ dysfunction
??Respiratory failure ??Encephalopathy ??Acute kidney failure ??Other (specify) ? SIRS (Systemic Inflammatory Response Syndrome --With or without organ dysfunction ? Document septic shock if present ? Document any associated diagnoses/conditions
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ICD-10-CM/PCS Documentation Tips
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Clinical Documentation Improvement
Meningitis
Viral Meningitis
? Documentation of "Viral Meningitis" should include the specific viral organism if known (i.e., adenovirus, enterovirus, chickenpox, measles, etc.).
? Document any associated diagnoses/conditions
Bacterial Meningitis
? Documentation of "Bacterial meningitis" should include the specific bacterial organism (i.e., Escherichia coli, bacillus, gram-negative, Klebsiella, staph, strep, etc.) if known.
? Document if the meningitis is due to "other causes," which can include "nonpyogenic meningitis," "chronic meningitis," "Benign recurrent meningitis."
? Document any associated diagnoses/conditions
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ICD-10-CM/PCS Documentation Tips
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Clinical Documentation Improvement
Hepatitis
? Document acuity: --Acute --Chronic
? Document etiology: --Alcoholic --Drug (specify) --Viral (Type A, B, C, or E)
? Document also: --With hepatic coma --Without hepatic coma --With delta agent --Without delta agent
? Document any associated diagnoses/conditions
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ICD-10-CM/PCS Documentation Tips
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Clinical Documentation Improvement
MRSA/MSSA
Methicillin-resistant Staphylococcus aureus
? Include documentation of "MRSA infection" when the patient has that condition.
? Document if sepsis and/or septic shock is present. ? Document any associated diagnoses/conditions.
Methicillin susceptible Staphylococcus aureus
? Include documentation of "MSSA infection" when the patient has that condition.
? Document if sepsis, and/or septic shock is present. ? Document any associated diagnoses/conditions.
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ICD-10-CM/PCS Documentation Tips
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Clinical Documentation Improvement
Herpes Simplex
? Specify if "Eczema herpeticum" is present. ? Document if "Herpesviral vesicular dermatitis" is present
--Herpes simplex facialis --Herpes simplex labialis --Vesicular dermatitis of ear or lip ? Document if "Herpesviral gingivostomatitis and pharyngotonsillitis" are present ? Document if "Herpesviral meningitis" is present ? Specify if "Herpesviral encephalitis" is present ? Simian B disease ? Document if "Herpesviral ocular disease" is present --Herpesviral iridocyclitis --Herpesviral keratitis --Herpesviral conjunctivitis ? Specify if "Disseminated herpesviral disease" is present ? Document if "Other forms of herpesviral infections" are present --Herpesviral hepatitis --Herpes simplex myelitis --Other herpesviral infection
??Herpesviral whitlow ? Document any associated diagnoses/conditions
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ICD-10-CM/PCS Documentation Tips
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