The Transition to
What you need to know for Neurology
Date | Presenter Information
Tools Available
Intranet
Pocket Cards
Physician
Relations
Team
APP
Newsletter
Email Blasts
How can we
reach our
physicians?
Website
Twitter
@AdvocateICD10
Flat Screens
in lounges
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AMGDoctors.
com
Ongoing Support for ICD-10
Physician Advisors
-Public
Reporting
-Reimbursement
-Physician
Scorecards
-Quality
Improvement
Clinical Informatics
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What’s in it for me?
• Better reflection of the quality of the care you
provided to your patient
• A more accurate assessment of the Severity of Illness
(SOI) i.e. how sick your patient was during the
hospitalization
• Improves your publicly reported quality measure
scores
• Supports the improvement of your patient’s clinical
outcomes and safety
• Enables a better capture of SOI (severity of illness)
and ROM (risk of mortality)
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What should be documented?
Admit
•
•
Daily
HPI: tell “the story”
Reimbursement
PMH: all chronic conditions
in as much detail as
available (e.g., Chronic
Systolic CHF)
PSH: all surgeries (e.g., left
hip arthroplasty)
Assessment and Plan:
Differential diagnosis
Working diagnoses
Other conditions being
treated
•
•
•
•
•
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Discharge
•
•
•
Rule out or confirm
differential diagnosis based
on test results, imaging
results and response to
empiric treatment.
All treated/resolved
diagnoses should be
documented.
For diagnoses that are
documented as suspected,
possible, probable at the
time of discharge should be
listed in the discharge
summary.
What Coders are Unable to Assume
No Matter How Obvious it is to the Clinician
•
It is not appropriate for the coder to report a diagnosis based on abnormal findings:
– Laboratory
– Pathology
– Imaging
• A query must be sent to document a definitive diagnosis
•
Only a physician can establish a cause and effect relationship between a diagnosis such
as gastroparesis and diabetes
•
Possible, probable and suspected conditions can be reported, but ONLY if documented at
the time of discharge (for inpatient records)
•
Outpatient Surgical and Observation Records: Enter as much information as known at the
time.
Patient with shortness of breath and lung nodule. Coded to shortness of breath and lung
nodule.
Patient with shortness of breath and lung nodule, suspected lung cancer with pathology
pending. Coded to shortness of breath and lung nodule.
We would not code a possible condition as an established diagnosis on outpatient
records.
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Key Changes Needed to
Support ICD-10 Coding
Alzheimer's disease
• Document onset as
– Early or late
• If with dementia, document as
– With behavioral disturbance, for example
combative and or aggressive behavior
– Without behavioral disturbance
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Brain Compression
• Link diagnostic study
to clinical diagnosis
and clinical
significance
• CT findings are not
equivalent to a
diagnostic term that
must be documented
by a hands on PR
actioner
• Midline shift is not
equivalent to brain
compression
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Cerebral Edema
•
•
Link diagnostic
study to clinical
diagnosis
CT findings are not
equivalent to a
diagnosis
Cerebral Infraction/Stroke
• Document etiology:
– Due to embolus
– Due to thrombus
• Document specific artery affected and right or left when appropriate:
– Vertebral
– Middle
– Basilar
– Anterior
– Carotid
– Posterior
– Other
• Document residuals from current stroke:
– Hemiplegia/Hemiparesis
– Dysphasia
– Cognitive Defects
• Document if TPA was given at another facility within last 24 hours
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Cerebrovascular Disease, Sequelae
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Document cause and effect relationship
– Dysphagia due to CVA
– Hemiplegia due to traumatic brain
injury
Document underlying type of
Cerebrovascular Disease
– Cerebral infraction/stroke
– Cerebral hemorrhage
– Traumatic Brain injury
– Other
Document specific sequelae being treated
– Cognitive defects
– Speech:
• Aphasia
• Dysphasia
• Dysarthria
– Fluency disorder
– Monoplegia
– Hemiplegia
– Hemiparesis
•
•
•
•
Document affected side as dominant
or non-dominant
Document laterality
When you don’t specify side
affected as dominant or nondominant:
– Right side defaults to dominant
– Left side defaults to nondominant
Use term paresis vs. weakness
Epilepsy
• Document type and status
– Intractable versus not intractable and
– With or without status epilepticus
• Specify type:
– Localization –related idiopathic or symptomatic
– Simple partial or complex partial seizures
– Generalized idiopathic
• Document if due to
– Alcohol
– Drugs
– Sleep deprivation
– Stress
– Other cause
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Hemorrhage
Brain
• Document site
– Left or right cerebrum
– Cerebellum
– Brainstem
– Epidural
– Subdural
– Subarachnoid
– Other
• Document non-traumatic vs.
traumatic
• Document if with loss of
consciousness and for how
long in minutes
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Hemorrhage
Subdural
• Document type:
– Acute
– Subacute
– Chronic
• Document non traumatic
vs traumatic
• Document if with loss of
consciousness and for
how long in minutes
Hemorrhage Intracerebral or
Subarachnoid
• For intracerebral hemorrhage, document site
as
– Hemisphere, subcortical, etc.
• For subarachnoid hemorrhage, document site
and laterality when appropriate
• Document non-traumatic vs traumatic
• Document if with loss of consciousness and
for how long in minutes and if Coma GCS
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Migraines
• Document type and status
– Intractable versus not intractable and
– With or without status migrainosus
• Document severity
– With or without aura
– Persistent
– Refractory
– Specify if complications: seizures hemilplegia,
cerebral infarction, vomiting, opthalmoplegic,
other
– other
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Pain Management Pain syndrome
• Acute /chronic pain due to: • Document “central pain
syndrome” or “chronic
– Trauma
pain syndrome”
– Cancer
– post procedural
• Chronic pain syndrome is
– post thoracotomy
not equivalent to chronic
– chronic with psychosocial
pain
dysfunction
• Document underlying
cause
• Document site and laterality
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Spinal Cord Injury
• Document site of injury
– Specific segment injured e.g. C4
• Document type of injury, for example:
– Compression and edema
– Complete lesion
– Incomplete lesion with central or anterior cord
syndrome
– Brown-Sequard paralysis syndrome
• Document associated plegia and/or paresis
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Spinal Column Injury or Disease
• For conditions of the spinal column,
document site affected as
– Occipito-atlanto-axial
– Cervical or cervical-thoracic
– Thoracic or thoracolumbar
– Lumbar or lumbosacral
– Sacral or sacrococcygeal
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Transient Ischemic Attack (TIA)
• TIA may result in an Unspecified code
• Be clear on your intended diagnosis. If known or
suspected, document
– Vertebro-basilar artery syndrome
– Carotid artery syndrome
– Precerebral artery syndrome
– Amaurosis fugax
– Transient global amnesia
– Other cerebral ischemia attacks and
syndromes
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