The Transition to What you need to know for Pediatrics Newborn 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

Newborn affected by Maternal Condition Document specific maternal condition –Drug use –Alcohol use –Tobacco use –Infection (GBS positive) –Diabetes Pre existing or Gestational –Hypertension Pre existing or Gestational –Incomplete Cervix 8

Baby turned blue and began choking after feeding, ALTE not further specified Document apparent life- threatening event (ALTE) with obstructive apnea due to GERD 9

Cleft Lip Document: –Bilateral –Median –Lateral Document if present with cleft palate 10 Document: –Hard palate –Soft palate –Hard palate with soft palate –Uvula Document : –Bilateral –Median –Unilateral Document if present with cleft lip Cleft Palate

Meconium Aspiration Document any associated respiratory conditions: –Pneumonia –Respiratory Distress Syndrome 11

Neonatal Jaundice Document Etiology –Isoimmunization (Rh, ABO, other hemolytic diseases) –Preterm delivery –Physiologic 12

Post-operative Care after Congenital Heart Surgery Physician must document if cardiac condition is still present and under active treatment or if it was surgically corrected 13

Outcome of Delivery (Newborn Status) Document if : –Single birth –Twin birth –Multiple births Document for each baby if: –Live born –Stillborn 14 Omphalitis of Newborn Document with or without mild hemorrhage

Failure To Thrive Document if newborn is 28 days or less –Prematurity (Gestational age between completed weeks of gestation) –Extreme immaturity (Gestational age less than 28 completed weeks of gestation) Document failure to thrive, malnutrition –Poor feeding, decreased urine output, fussiness, failure to gain weight 15 A code for prematurity cannot be assigned based solely on the documentation of completed weeks. Physician must state that the infant is premature Prematurity

Feeding Problems of Newborn Instead of “feeding problems” or “feeding difficulty” be more specific, for example: –Regurgitation and rumination –Slow feeding –Underfeeding –Overfeeding –Difficulty with breast feeding –Vomiting –Other 16

Sepsis of Newborn Document if confirmed or suspected Document if ruled out Document organism known or suspected –Streptococcus –Staphylococcus –E. Coli –Anaerobes 17 If prophylactic antibiotics are given to a newborn pending cultures, physicians must document whether sepsis was ruled in or ruled out based on clinical results

Congenital Adrenal Hyperplasia Document if salt losing (codes to enzyme deficiency 18 Croup Document Type: –Bronchial –Diphtheritic –Stridulous

Spina Bifida Document Location: –Cervical –Thoracic –Lumbar –Sacral –Occulta Document with or without hydrocephalus 19

Intraventricular Hemorrhage (IVH) Specify –Grade 1 –Grade 2 –Grade 3 –Grade 4 20

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