The Transition to What you need to know for Gynecology 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

Anemia, Blood Loss Document, when appropriate: –Anemia due to acute blood loss –Anemia due to chronic blood loss –Postoperative anemia due to acute blood loss 8 Document site and type: –Cervix: mild, moderate, or severe –Vaginal: mild, moderate, or severe –Vulva: mild, moderate, or severe Dysplasia

Complications of Surgery Physician documentation must include the cause and effect relationship between the procedure and the condition that may be considered a complication Physician documentation must indicate that condition is a complication The physician may be asked for clarification if the complication is not clearly documented 9

Endometriosis Document site: –Ovarian –Fallopian tube –Parametrium –Uterus –Vagina –Specify other site 10 Female Genital Prolapse Document type: –Cephocystoc: midline or lateral –Uterine prolapse: 1 st, 2 nd degree –Rectocele –Vaginal intercelic

Menstruation Excessive and Frequent Document: –With regular cycle versus –With irregular cycle Document if occurring during: –Puberty –Perimenopausal period –Postmenopausal period Document if appropriate additional dx of acute/chronic blood loss anemia 11

Neoplasms Document site and laterality such as: –Ectocervix –Left ovary Differentiate between primary and secondary (metastatic) site –Document primary site and if it is still present, treated in remission etc. For secondary sites: –Document suspected final pathology results Document final pathology results –EVEN IF RECEIVED AFTER THE PATIENT IS DISCHARGED WITH A LATE ENTRY DATED AS NEEDED Document if neoplasm is benign or malignant 12

Urinary Tract Infection (UTI)/CAUTI If UTI is related to a device, such as Foley catheter or cystostomy tube, clearly indicate this by using words such as “due to” or “secondary to”. Document if Present on Admission Identify the specific site of the UTI, if known, such as: –Bladder –Urethra –Kidney Document causative organism, when known or suspected, such as E. coli or Candida 13

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