The Transition to What you need to know for Neurology Date | Presenter Information

Tools Available Flat Screens in lounges AMGDoctors. com How can we reach our physicians? Intranet Blasts Physician Relations Team Website APP Newsletter Pocket Cards 2

Ongoing Support for ICD-10 Physician Advisors Clinical Informatics 3 -Public Reporting -Reimbursement -Physician Scorecards -Quality Improvement

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) 4

What should be documented? 5 Reimbursement Admit HPI: tell “the story” 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 Daily Rule out or confirm differential diagnosis based on test results, imaging results and response to empiric treatment. Discharge 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.

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. What Coders are Unable to Assume 6

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 8

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 9 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 10

Cerebrovascular Disease, Sequelae 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 11 Document affected side as dominant or non-dominant Document laterality When you don’t specify side affected as dominant or non- dominant: –Right side defaults to dominant –Left side defaults to non- dominant 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 12

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 13 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 14

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 15

Pain Management Acute /chronic pain due to: –Trauma –Cancer –post procedural –post thoracotomy –chronic with psychosocial dysfunction Document underlying cause Document site and laterality 16 Pain syndrome Document “central pain syndrome” or “chronic pain syndrome” Chronic pain syndrome is not equivalent to chronic pain

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 17

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 18

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 19

20