SJPE
ICD10 Preparation Series
Asthma & Anemia
July 15, 2015
77 Days
Left to
prepare for
ICD10’s
arrival!
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Optum Fast Finder Tools
.ICD10 smart text
Problem List Calculator
Anemia and Asthma Documentation Tips
Top 20 Medical PC Diagnoses
Top 25 Diagnosis Report Handout to Providers
Agenda
Clinical Documentation Challenges
• Over 1/3 of the expansion of ICD-10 codes is due to the
addition of laterality (left, right, bilateral). Physicians and
other clinicians likely already note the side when evaluating
the clinically pertinent anatomical site(s).
• Ensuring sufficient documentation to support code
assignment while allowing providers to document in clinical,
(not coding) terms
• Need good clinical documentationo NOT a greater volume of documentation
Documentation Focus Areas for ICD-10
Disease type
Disease acuity
Disease stage
Site specificity
Laterality
ICD9 Term
ICD10 Term
Amputation
Anastomosis
Arthrodesis
Arthroscopy, Cystoscopy
Aspiration
Bunionectomy
Cesarean Section
Tonsillectomy
Debridement
Detachment
Bypass
Fusion
Inspection, Endoscopic Approach
Drainage
Resection of Metatarsal
Extraction of products of Conception
Resection of Tonsils
Excision, Extraction, Irrigation, Extirpation
Terminology Changes
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CMS - Road To 10 site http://www.roadto10.org/
Hyperlink to ICD10 Fast Finder Documents via EPIC
Problem List Calculator (aka Diagnosis Calculator)
.ICD10 Smart Text Phrases
Precyse University – Online Courses
o (email Celeste Helinski - Celeste.Helinski@sjhsyr.org to
obtain access via Healthstream)
Provider Tools
SJPE has purchased a number of Optum ICD10 Fast Finder
tools, by specialty to share with providers/staff.
These tools will be provided to Practice Managers in
addition to Coding Staff.
*Key tool for Family Practice is the Primary Care Fast
Finder tool. (This will be sent following the webex.)
Optum Fast Finder tools
Sample of Fast Finder tool
IT has been building a
Problem List Calculator
for high volume diagnoses
(aka Diagnosis Calculator)
Problem List Calculator
Anemia via Diagnosis Calculator
(preferred method for Ambulatory visits)
Anemia via Diagnosis Calculator (2)
IT has also been building .ICD10 smart texts
to assist in documentation building.
Ie. ICD10 a will bring up a list of diagnoses
built that begin with the letter “a”
.ICD10 smart texts
Anemia .ICD10 Smart Text
(preferred method for IP related visits)
Anemia & Asthma
Documentation Concepts
Anemia
• Be Specific! Anemia is a nonspecific term.
o Is the patient anemic due to blood loss?
o Where are they bleeding?
Your documentation should be specific, for example:
“acute blood loss anemia 2◦ to GI hemorrhage from
bleeding duodenal ulcer”.
Anemia documentation Elements
• Include in documentation if Anemia is due to:
• Nutrition or mineral deficits resulting in a nutritional
anemia
• A neoplasm (primary and/or secondary)
• Related to or due to “chemo or radiotherapy treatments
• Any “cause-and effect” relationship between the
intervention and the blood or immune disorder
• The specific drug if anemia is drug-induced
• Documentation of Anemia should include the type of
anemia:
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Nutritional
Hemolytic
Aplastic
Due to blood loss
Other (please specify)
Anemia documentation elements cont.
Anemia ICD10 Codes
Road to 10 Anemia reference link:
http://www.roadto10.org/action-plan/phase-2-train/clinicalscenarios-family-practice/
Anemia documentation guidance from CMS
Asthma
Documentation Requirements:
Must include the relationship between Asthma and other
chronic/acute conditions such as COPD, Bronchitis, acute lower
respiratory infections and/or exposure to or use of Tobacco (if
present) in addition to the severity, and form or type.
Severity
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Mild intermittent
Mild persistent
Moderate persistent
Severe persistent
With
• Acute lower
respiratory infection
• COPD
• Chronic obstructive
bronchitis
• Exacerbation
• Status asthmatics
Asthma
documentation elements
As well as the Form or Type
• Cough variant
• Childhood
• Exercise induced bronchospasm
• Extrinsic allergic
• Idiosyncratic
• Intrinsic non allergic
• Late-onset
• Mixed
• Other (specify)
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Asthma documentation elements cont
Asthma ICD10 Codes
Next Week’s Topic:
Diabetes Coding in ICD10
7/22/15