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39 days to ICD-10
The relationship of one condition to other conditions must be clear
Example: Asthma

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ICD-10 combines intrinsic and extrinsic asthma into one category, so there is no longer a need to clarify these conditions after October 1. The new codes are based on the severity of the asthma. Documentation will be needed to support:
mild
intermittent
mild persistent
moderate persistent
severe persistent
 
Today's Tip: Clearly document the relationship between asthma and chronic obstructive bronchitis or chronic obstructive pulmonary disease when applicable. Focus clinical documentation on the severity of asthma and relationship to other diseases when applicable.
  
How is your diabetes?
Etiology and blood sugar levels and relationship to other conditions

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In ICD-10, most diagnoses of diabetes are classified to one of five categories:
  • Diabetes mellitus due to underlying condition
  • Drug or chemical induced diabetes mellitus
  • Type 1 diabetes mellitus
  • Type 2 diabetes mellitus
  • Other specific diabetes mellitus.
Further document the Diabetes as controlled, out of control, or poorly controlled and if hypoglycemia or hyperglycemia is present.
 
Today's Tip: Focus documentation on the type or etiology of diabetes, body system affected, and any complications affecting that body system, and if hyperglycemia is present.
  
Pain filled moments
Residual conditions and chronic conditions
 

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Perhaps the most common sequela is pain. Many patients receive treatment long after an injury has healed as a result of pain.
 
Today's Tip: Document pain with Increased specificity
When documenting pain, include the following:
Acuity: e.g. Acute or chronic
Location: Be as specific as possible (E.g. right knee behind the patella or left upper quadrant)
 
When pain control or pain management is the reason for the encounter, the principal diagnosis recorded is for pain:
Central pain syndrome
Acute pain due to trauma
Acute post-thoracotomy pain
Other acute postprocedural pain
Chronic pain due to trauma
Chronic post-thoracotomy pain
Other chronic postprocedural pain
Other chronic pain
Neoplasm related pain (acute) (chronic)
Chronic pain syndrome
 
The underlying cause of the pain should be reported as an additional diagnosis, if known.
 
Example: A patient suffers a low back injury that heals on its own. The patient isn't seeking intervention for the initial injury, but for the pain that persists long after. The chronic pain is sequela of the injury. This is Chronic pain due to trauma; unspecified injury of muscle, fascia and tendon of lower back, sequela.
  • Fatigue fracture of vertebra, cervicothoracic region, sequela of fracture
  • Late effect of nontraumatic intracerebral hemorrhage
  • Sequela of pregnancy, childbirth, and the puerperium
  • Dysarthria following other cerebrovascular disease
Pregnancy documentation a bundle of joy
Weeks since LMP and tobacco use

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Obstetric conditions have three separate codes to identify the condition and identify the trimester of pregnancy in which the condition occurred. Because certain obstetric conditions or complications occur during certain trimesters, not all conditions include codes for all three trimesters. Documentation should capture the mother's use (or non-use) of tobacco, alcohol and substance abuse along with the associated risk to the child.
 
Today's Tip: Document the trimester in number of weeks, counted from the first day of the last menstrual period and the mother's use (or non-use) of tobacco.
How to be ready for October 1, 2015
To have a successful ICD-10 implementation, get your providers training and information about the type of information to include in documentation for ICD-10.

Save the Date: September 10, 2015, 6:30 pm - 8 pm
Documentation Excellence: ICD-10 from a Physician's Perspective
  
Clinical documentation is more important now than ever before. As Denny Flint said in his presentation to EPCMS on July 16, "You could be the best doctor in the world, but if your data doesn't demonstrate this no one will ever know but you and your patients."  And if your biller or coder doesn't see the documentation for it, they don't code it for its full level of complexity and specificity.