The Transition to What you need to know for Orthopedics 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

Fractures Pathological Specify whether etiology is: –Osteoporosis (senile vs. disuse) –Osteopenia –Neoplastic –Some other disease Document site and laterality If COMPRESSION fracture, clarify if traumatic or pathological 9 Fracture, Cancer Document site, laterality and etiology –Due to neoplasm (specify primary of secondary) –Due to trauma Document neoplasm linked to fracture

Fractures Traumatic Vertebral Document: –Level of vertebral column, for example L1 –Displaced versus nondisplaced –Part of vertebra fractured, for example, posterior arch Document type of fracture, for example: –Type II dens fracture of the 2 nd cervical vertebra –Type III spondylolisthesis of 2 nd cervical vertebra –Stable versus unstable burst fracture –Zone I-III or Type 1-4 sacral fracture 10 Document the healing process –Routine –Delayed –Nonunion –Malunion Indicate the encounter type –Initial –Subsequent –Sequela

Fractures Traumatic Document: –Open versus closed –Displaced versus nondisplaced –Name of specific bone and specific site on bone –Orientation of fractures, such as transverse, oblique, spiral and ‒ Laterality For open fractures of the forearm, femur, and lower leg, document type as –Type I, II, IIIA, IIIB, or IIIC according to Gustilo classification For physeal fractures, document –Type I, II, III, IV according to Salter Harris classification 11 For sacral fractures, document: –Zone I, II, III and ‒ Minimally versus severely displaced or ‒ Type 1, 2, 3, 4 Document the healing process –Routine –Delayed –Nonunion –Malunion Indicate the encounter type ‒ Initial ‒ Subsequent ‒ Sequela

Intervertebral Disc Disorders Document site as: –Cervical –Thoracic –Lumbar –Sacral –Other Document any associated: –Disc Displacement –Disc Degeneration –Myelopathy –Radiculopathy –Sciatica 12

Osteoarthritis Document type, for example: –Primary –Posttraumatic –Other Secondary Document site, for example: –Hip –Knee –Shoulder Document laterality –Right –Left –Bilateral 13

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 14

Spondylosis Document by type –Anterior spinal artery compression syndrome –Vertebral artery compression syndrome –Other spondylosis Document site as –Occipito-atlanto-axial –Cervical or Cervical-thoracic –Thoracic or Thoracolumbar –Lumbar or Lumbosacral –Sacral or Sacrococcygeal Document if with –Myelopathy –Radiculopathy 15

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