The Transition to What you need to know for Endocrinology 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

Diabetes Document type as: –Type 1 –Type 2 –Secondary Document associated complications, such as: –Diabetic peripheral angiopathy –Diabetic autonomic neuropathy –Diabetic foot ulcer If control is not maintained, document insulin control status as: –Inadequate controlled –Out of control –Poorly controlled Document if insulin pump is present and operating appropriately 8

Diabetic Complications 9 Specify manifestations involved: –Diabetic retinopathy –Diabetic neuropathy –Diabetic nephropathy Gout Document acuity: –Acute –Chronic Document type: –Idiopathic –Lead induced –Due to drugs –Due to thyroid disorder –Due to pituitary disorder

Malnutrition Document type such as: –Protein calorie –Protein energy Document severity: –Mild or 1 st degree –Moderate or 2 nd degree –Sever or 3 rd degree Document BMI 10 Acidosis-metabolic, respiratory, lactic Link abnormal lab value to clinical diagnosis

Obesity Document etiology: –Due to excess calories or nutritional –Due to drugs –Other, for example, due to thyroid or pituitary disorder Specify if morbid obesity Document BMI Document if: –With alveolar hypoventilation/ hypoventilation syndrome 11

Pressure Ulcer/ Decubitus Ulcer Document site and laterality: –Lower leg –Foot –Heel Document if present on admission Document stage if known 12

Non-pressure Ulcer (skin) Document site and laterality: –Lower leg –Foot –Heel Document type: –Non-healing –Chronic –Stasis –Diabetic –Atherosclerotic Document if with: –Infection –Gangrene 13

ECHO, EKG, CXR, and Laboratory Results Document diagnosis based on clinical findings as well as diagnostic study results in progress notes or discharge summary indicating the clinical significance of the diagnosis 14 Specify actual diagnosis Dehydration

Atrial Fibrillation & Atrial Flutter For atrial fibrillation, document type as: –Paroxysmal –Persistent or –Chronic For atrial flutter, document type as: –Typical or Type I or –Atypical or Type 2 For both, document if condition is a complication of surgery 15

Coronary Artery Disease (CAD) Document Site as: –Native artery and/or –Bypass graft Autologous vein Autologous artery Nonautologous Document if with: –Angina pectoris –Unstable angina pectoris –Angina pectoris and spasm 16

Congestive Heart Failure (CHF) Document severity: –Acute –Chronic –Acute on chronic Document type: –Systolic –Diastolic –Combined systolic & diastolic Document etiology, if known, such as due to: –Dilated cardiomyopathy 17

18