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SJPE ICD10 Preparation Series Asthma & Anemia July 15, 2015.

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Presentation on theme: "SJPE ICD10 Preparation Series Asthma & Anemia July 15, 2015."— Presentation transcript:

1 SJPE ICD10 Preparation Series Asthma & Anemia July 15, 2015

2 77 Days Left to prepare for ICD10’s arrival!

3 Agenda Optum Fast Finder Tools.ICD10 smart text Problem List Calculator Anemia and Asthma Documentation Tips Top 20 Medical PC Diagnoses Top 25 Diagnosis Report Handout to Providers

4 Clinical Documentation Challenges Over 1/3 of the expansion of ICD-10 codes is due to the addition of laterality (left, right, bilateral). Physicians and other clinicians likely already note the side when evaluating the clinically pertinent anatomical site(s). Ensuring sufficient documentation to support code assignment while allowing providers to document in clinical, (not coding) terms Need good clinical documentation- o NOT a greater volume of documentation

5 Documentation Focus Areas for ICD-10 Disease type Disease acuity Disease stage Site specificity Laterality

6 Terminology Changes ICD9 Term Amputation Anastomosis Arthrodesis Arthroscopy, Cystoscopy Aspiration Bunionectomy Cesarean Section Tonsillectomy Debridement ICD10 Term Detachment Bypass Fusion Inspection, Endoscopic Approach Drainage Resection of Metatarsal Extraction of products of Conception Resection of Tonsils Excision, Extraction, Irrigation, Extirpation

7 Provider Tools CMS - Road To 10 site http://www.roadto10.org/http://www.roadto10.org/ Hyperlink to ICD10 Fast Finder Documents via EPIC Problem List Calculator (aka Diagnosis Calculator).ICD10 Smart Text Phrases Precyse University – Online Courses o (email Celeste Helinski - Celeste.Helinski@sjhsyr.org to obtain access via Healthstream)Celeste.Helinski@sjhsyr.org

8 Optum Fast Finder tools SJPE has purchased a number of Optum ICD10 Fast Finder tools, by specialty to share with providers/staff. These tools will be provided to Practice Managers in addition to Coding Staff. *Key tool for Family Practice is the Primary Care Fast Finder tool. (This will be sent following the webex.)

9 Sample of Fast Finder tool

10 Problem List Calculator IT has been building a Problem List Calculator for high volume diagnoses (aka Diagnosis Calculator)

11 Anemia via Diagnosis Calculator (preferred method for Ambulatory visits)

12 Anemia via Diagnosis Calculator (2)

13 .ICD10 smart texts IT has also been building.ICD10 smart texts to assist in documentation building. Ie. ICD10 a will bring up a list of diagnoses built that begin with the letter “a”

14 Anemia.ICD10 Smart Text (preferred method for IP related visits)

15 Documentation Concepts Anemia & Asthma

16 Anemia Be Specific! Anemia is a nonspecific term. o Is the patient anemic due to blood loss? o Where are they bleeding? Your documentation should be specific, for example: “acute blood loss anemia 2◦ to GI hemorrhage from bleeding duodenal ulcer”.

17 Anemia documentation Elements Include in documentation if Anemia is due to: Nutrition or mineral deficits resulting in a nutritional anemia A neoplasm (primary and/or secondary) Related to or due to “chemo or radiotherapy treatments Any “cause-and effect” relationship between the intervention and the blood or immune disorder The specific drug if anemia is drug-induced

18 Anemia documentation elements cont. Documentation of Anemia should include the type of anemia: Nutritional Hemolytic Aplastic Due to blood loss Other (please specify)

19 Anemia ICD10 Codes

20 Anemia documentation guidance from CMS Road to 10 Anemia reference link: http://www.roadto10.org/action-plan/phase-2-train/clinical- scenarios-family-practice/

21 Asthma Documentation Requirements: Must include the relationship between Asthma and other chronic/acute conditions such as COPD, Bronchitis, acute lower respiratory infections and/or exposure to or use of Tobacco (if present) in addition to the severity, and form or type.

22 Asthma documentation elements Severity Mild intermittent Mild persistent Moderate persistent Severe persistent With Acute lower respiratory infection COPD Chronic obstructive bronchitis Exacerbation Status asthmatics

23 Asthma documentation elements cont. As well as the Form or Type Cough variant Childhood Exercise induced bronchospasm Extrinsic allergic Idiosyncratic Intrinsic non allergic Late-onset Mixed Other (specify)

24 Asthma ICD10 Codes

25 Next Week’s Topic: Diabetes Coding in ICD10 7/22/15

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