7th Annual
Association for Clinical Documentation
Improvement Specialists
Conference
ICD-10-CM/PCS Documentation
Requirements for Children's Hospitals
Rebecca A. “Ali” Williams, RN, MSN, CCDS
Manager Clinical Documentation
Improvement Consulting
United Audit Systems, Inc.
Cincinnati, Ohio
Natalie Sartori, MEd, RHIA, AHIMAApproved ICD-10-CM/PCS Trainer
Senior Consultant
United Audit Systems, Inc.
Cincinnati, Ohio
2
Learning Objectives
• At the completion of this educational activity, the
learner will be able to:
– Explain the difference in terminology & specificity
between ICD-9 and ICD-10-CM/PCS codes for
common conditions/procedures in children’s hospitals
– Recognize clinical documentation required to fully
leverage the specificity available in ICD-10-CM/PCS
codes in children’s hospitals
– Determine how to modify current documentation
improvement efforts to begin to incorporate the
additional specificity that will be needed to ensure
appropriate reflection of severity of illness and risk of
mortality using ICD-10-CM/PCS codes
3
Outline
• Brief review of ICD-10 compared to ICD-9
• Conditions/procedure & relative information
– Asthma
– Respiratory failure
– Cerebral palsy
– Traumatic fracture repair
• Summary for documentation for ICD-10 in
children’s hospitals
4
Brief Review of ICD-10 Compared
to ICD-9
Difference in terminology and specificity
Key impacts in children’s hospitals
5
Diagnosis Code Structure
•
•
•
•
•
ICD-9-CM
3–5 characters
First is numeric or alpha
(E, V)
2–5 are numeric
Always at least 3
characters
Use of decimal after first
3 characters
•
•
•
•
•
ICD-10-CM
3–7 characters
First is always alpha
2–7 are alpha or numeric
Always at least 3
characters
Use of decimal after first
3 characters
6
More New Features
• Inclusion of trimester in obstetrics codes (and
elimination of 5th digits for episode of care)
• Updated clinical terminology (e.g., diabetes
mellitus, malignant/benign hypertension)
• Changes in time frames specified in certain
codes
• Added standard definitions for two types of
excludes notes
• More combination codes
7
Some Common Pediatric Diagnoses
Impacted
•
•
•
•
•
•
•
•
•
Acute otitis media
Asthma
Cerebral palsy
Chromosomal abnormalities
Coma
Epilepsy
Injuries (fractures, brain, internal)
Respiratory failure
Diabetes mellitus
8
Documentation Requirements:
Asthma
Specificity available in ICD-9 codes
Specificity available in ICD-10 codes
Documentation required for ICD-10 codes
Relevant clinical indicators (if applicable)
9
Asthma
ICD-9-CM classification (493)
ICD-10-CM classification (J45)
• Classified as either intrinsic,
extrinsic, other, or
unspecified asthma
• Finally asthma is classified
as uncomplicated, with
acute exacerbation or with
status asthmaticus
• Both intrinsic and extrinsic
asthma included in this
category
• Asthma classified as mild,
moderate, severe, or
unspecified
• Mild asthma is further
classified as intermittent or
persistent
• Finally asthma is classified
as uncomplicated, with
acute exacerbation or with
status asthmaticus
10
Asthma
ICD-9-CM asthma codes
ICD-10-CM asthma codes
 Total of 10 valid codes
 Total of 18 valid codes
The following fifth-digit
subclassification is for use with
category 493.0–493.2, 493.9:
0 unspecified
1 with status asthmaticus
2 with (acute) exacerbation
493.0 Extrinsic asthma
493.1 Intrinsic asthma
493.2 Chronic obstructive asthma
493.9 Asthma, unspecified
The following subcategories
(J45.2–J45.5 & J45.90) are further
specified with the following fourth or
fifth digits:
0 unspecified
1 acute exacerbation
2 status asthmaticus
J45.2 Mild intermittent asthma
J45.3 Mild persistent asthma
J45.4 Moderate persistent asthma
J45.5 Severe persistent asthma
11
Asthma
ICD-9-CM asthma codes
493.8 Other forms of asthma
493.81 Exercise induced
bronchospasm
493.82 Cough variant asthma
ICD-10-CM asthma codes
J45.90 Unspecified asthma
J45.901 Unspecified asthma w/
(acute) exacerbation
J45.902 Unspecified asthma w/
status asthmaticus
**J45.909 Unspecified asthma,
uncomplicated
J45.99 Other asthma
J45.990 Exercise induced
bronchospasm
J45.991 Cough variant asthma
J45.998 Other asthma
12
Asthma ICD-10-CM CC Codes
J45.21 Mild intermittent
asthma with acute
exacerbation
J45.22 Mild intermittent
asthma with status
asthmaticus
J45.31 Mild persistent asthma
with (acute) exacerbation
J45.32 Mild persistent asthma
with status asthmaticus
J45.41 Moderate persistent
asthma with (acute)
exacerbation
J45.42 Moderate persistent
asthma with status
asthmaticus
J45.51 Severe persistent
asthma with (acute)
exacerbation
J45.52 Severe persistent
asthma with status
asthmaticus
J45.901 Unspecified asthma
with (acute) exacerbation
J45.902 Unspecified asthma
with status asthmaticus
13
Asthma
Other ICD-10-CM documentation considerations
New instructional notes to use additional codes to identify (if
specified; it is NOT mandatory):
•
•
•
•
Exposure to environmental tobacco smoke (Z77.22)
Exposure to tobacco smoke in the perinatal period (P96.81)
History of tobacco use (Z87.891)
Occupational exposure to environmental tobacco smoke
(Z57.31)
• Tobacco dependence (F17.-)
• Tobacco use (Z72.0)
14
Asthma
Other ICD-10-CM documentation considerations
• ICD-10-CM Excludes2 notes – ICD-10-CM does not
provide a code for asthma with COPD (493.2x) but
rather instructs the coder to assign an additional code if
COPD is present
Excludes2 (i.e., not included, may need to code also):
• Asthma with chronic obstructive pulmonary disease
(J44.9)
• Chronic asthmatic (obstructive) bronchitis (J44.9)
• Chronic obstructive asthma (J44.9)
15
Asthma:
Documentation Requirements
• No longer relevant:
– Intrinsic vs. extrinsic
• Specify for ICD-10-CM code assignment:
– Mild, moderate, or severe
– Intermittent or persistent
– With exacerbation (acute) or with status
asthmaticus
– Type: exercise induced, cough variant, other
16
Intermittent Asthma
• Symptoms:
– ≤ 2 days/week
• Nighttime awakenings:
– Ages 0–4: none
– Ages 5 and older: ≤ 2x/month
• Interference with normal activity:
– None
• SABA use for symptom control:
– ≤ 2 days/week
• Lung function:
– Ages 5 and younger: normal FEV1 between exacerbations; > 80%
– Ages 5–11: > 85% FEV1/FVC
– Ages 12 and older: normal FEV1/FVC
Reference: UMHS Asthma Quality Improvement Steering Committee
http://www.med.umich.edu/i/oca/practiceguides
17
Mild Persistent Asthma
• Symptoms:
– > 2 days/week but not daily
• Nighttime awakenings:
– Ages 0–4: 1x–2x/month
– Ages 5 and older: 3x–4x/month
• Interference with normal activity:
– Minor limitation
• SABA use for symptom control:
– > 2 days/week but not daily
• Lung function:
– Ages 5 and younger: > 80% FEV1
– Ages 5–11: > 80% FEV1/FVC
– Ages 12 and older: normal FEV1/FVC
Reference: UMHS Asthma Quality Improvement Steering Committee
http://www.med.umich.edu/i/oca/practiceguides
18
Moderate Persistent Asthma
• Symptoms:
– Daily
• Nighttime awakenings:
– Ages 0–4: 3x–4x/month
– Ages 5 and older: > 1x/week but not nightly
• Interference with normal activity:
– Some limitation
• SABA use for symptom control:
– Daily
• Lung function:
– Ages 5 and younger: 60%–80% FEV1
– Ages 5–11: 75%–80% FEV1/FVC
– Ages 12 and older: reduced 5% FEV1/FVC
Reference: UMHS Asthma Quality Improvement Steering Committee
http://www.med.umich.edu/i/oca/practiceguides
19
Severe Persistent Asthma
• Symptoms:
– Throughout the day
• Nighttime awakenings:
– Ages 0–4: > 1x/week
– Ages 5 and older: often 7x/week
• Interference with normal activity:
– Extremely limited
• SABA use for symptom control:
– Several times daily
• Lung function:
– Ages 5 and younger: < 60% FEV1
– Ages 5–11: < 60% FEV1/FVC
– Ages 12 and older: reduced > 5% FEV1/FVC
Reference: UMHS Asthma Quality Improvement Steering Committee
http://www.med.umich.edu/i/oca/practiceguides
20
Acute Exacerbation
vs. Status Asthmaticus
• Asthma exacerbation
– Also referred to as an asthma attack; airways become
swollen and inflamed causing bronchial tubes to narrow.
As asthma exacerbation may be minor, with symptoms
getting better with prompt home treatment, or more
serious requiring medical emergency. (Mayo Clinic)
• Status asthmaticus
– Life-threatening form of asthma in which progressively
worsening reactive airways are unresponsive to usual
appropriate therapy that can lead to deteriorating clinical
conditions. (S. Agarwal, MD; S. Kache, MD Stanford)
21
Types of Asthma
• Exercise-induced asthma: asthma symptoms
triggered by exercise or physical exertion. Difficulty
in breathing usually subsides within 30 minutes
after stopping exercise.
• Cough-variant asthma: main symptom is a dry,
non-productive cough. Often there are no other
“classic” asthma symptoms such as wheezing or
shortness of breath.
• Allergic asthma: asthma symptoms induced by
allergens.
• Other types: occupational asthma, nocturnal
asthma, etc.
22
Asthma CDI Opportunities
• Look for other possible acute events such as:
–
–
–
–
–
–
–
–
–
Otitis media
Acute respiratory failure
Acidosis and alkalosis (respiratory and/or metabolic)
Dehydration
Underlying heart or pulmonary disease
Apnea
Pneumonia
Immune disorders (compromised)
Other: exposure to tobacco smoke
23
Documentation Requirements:
Respiratory Failure
Specificity available in ICD-9 codes
Specificity available in ICD-10 codes
Documentation required for ICD-10 codes
Relevant clinical indicators (if applicable)
24
Respiratory Failure
ICD-9-CM (518.8x)
• Classified as acute,
chronic, or acute on
chronic
ICD-10-CM (J96.xx)
• Classified as acute,
chronic, acute on chronic,
or unspecified
• Further classified as with
hypoxia, hypercapnia, or
unspecified
25
Respiratory Failure
• ICD-9-CM codes
Total of 3 valid codes
518.81 Acute (unspecified) respiratory failure (MCC)
518.83 Chronic respiratory failure (CC)
518.84 Acute on chronic respiratory failure (MCC)
26
Respiratory Failure
•
ICD-10-CM codes
 Total of 12 valid codes
J96.00 Acute respiratory failure, unspecified whether with hypoxia or hypercapnia
J96.01 Acute respiratory failure with hypoxia
J96.02 Acute respiratory failure with hypercapnia
J96.10 Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia
J96.11 Chronic respiratory failure with hypoxia
J96.12 Chronic respiratory failure with hypercapnia
J96.20 Acute and chronic respiratory failure, unspecified whether with hypoxia or
hypercapnia
J96.21 Acute and chronic respiratory failure with hypoxia
J96.22 Acute and chronic respiratory failure with hypercapnia
J96.90 Respiratory failure, unspecified, unspecified whether with hypoxia or
hypercapnia
J96.91 Respiratory failure, unspecified with hypoxia
J96.92 Respiratory failure, unspecified with hypercapnia
27
Respiratory Failure
Respiratory failure
ICD-9-CM CC codes
518.83 Chronic respiratory
failure
Respiratory failure
ICD-10-CM CC codes
J96.10 Chronic respiratory
failure, unspecified whether
with hypoxia or hypercapnia
J96.11 Chronic respiratory
failure with hypoxia
J96.12 Chronic respiratory
failure with hypercapnia
28
Respiratory Failure
• Respiratory failure ICD-10-CM MCC codes
J96.00 Acute respiratory failure, unspecified whether with
hypoxia or hypercapnia
J96.01 Acute respiratory failure with hypoxia
J96.02 Acute respiratory failure with hypercapnia
J96.20 Acute and chronic respiratory failure, unspecified
whether with hypoxia or hypercapnia
J96.21 Acute and chronic respiratory failure with hypoxia
J96.22 Acute and chronic respiratory failure with hypercapnia
J96.90 Respiratory failure, unspecified, unspecified whether
with hypoxia or hypercapnia
J96.91 Respiratory failure, unspecified with hypoxia
J96.92 Respiratory failure, unspecified with hypercapnia
29
Respiratory Failure:
Documentation Requirements
No longer relevant:
• Respiratory failure that was not specified as acute
or chronic defaulted to acute respiratory failure
Specify for ICD-10-CM code assignment:
• Specify acute or chronic
• Type: hypoxic or hypercapniac
30
Acute vs. Chronic Respiratory
Failure
Acute
• Acute respiratory failure
develops over minutes to
hours
Chronic
• Chronic respiratory failure
develops over several
days or longer
31
Hypoxemic Respiratory Failure
• Hypoxemic respiratory failure
– Also called Type I
– Most common form of respiratory failure
– Characterized by an arterial oxygenation tension (PaO2)
lower than 60 mm Hg with a normal or low PaCO2
– Can be associated with virtually all acute diseases of the
lung, which generally involve fluid filling or collapse of
alveolar units
– Some examples of hypoxemic respiratory failure:
• Cardiogenic or noncardiogenic pulmonary edema
• Pneumonia
• Pulmonary hemorrhage
www.chest.mohealth.gov.eg/mawared/respiratory_failure.doc
32
Common Causes of
Hypoxemic Respiratory Failure
– Bronchitis
– Pneumonia
– Reactive airway
disease
– Pulmonary edema
– Pulmonary fibrosis
– Asthma
– Pneumothorax
– Pulmonary embolism
– Pulmonary arterial
hypertension
– Cyanotic congenital
heart disease
– Bronchiectasis
– Fat embolism
syndrome
– Kyphoscoliosis
– Obesity
www.chest.mohealth.gov.eg/mawared/respiratory_failure.doc
33
Hypercapnic Respiratory Failure
• Hypercapnic respiratory failure
– Also called Type II.
– Characterized by a PaCO2 of more than 50 mm Hg.
– Hypoxemia is common in patients with hypercapnic
respiratory failure who are breathing room air. The
pH depends on the level of bicarbonate, which, in
turn, is dependent on the duration of hypercapnia.
– Common etiologies include: drug overdose,
neuromuscular disease, chest wall abnormalities,
and severe airway disorders (e.g., asthma, COPD).
www.chest.mohealth.gov.eg/mawared/respiratory_failure.doc
34
Common Causes of
Hypercapnic Respiratory Failure
–
–
–
–
–
–
–
–
–
Bronchitis
Reactive airway disease
Severe asthma
Cystic fibrosis
Drug overdose
Poisonings
Polyneuropathy
Poliomyelitis
Primary muscle
disorders
– Porphyria
– Head and cervical cord
injury
– Primary alveolar
hypoventilation
– Pediatric obesity
hypoventilation
syndrome
– Pulmonary edema
– Myxedema
– Tetanus
www.chest.mohealth.gov.eg/mawared/respiratory_failure.doc
35
Documentation Requirements:
Cerebral Palsy
Specificity available in ICD-9 codes
Specificity available in ICD-10 codes
Documentation required for ICD-10 codes
Relevant clinical indicators (if applicable)
36
Cerebral Palsy
Infantile cerebral palsy
ICD-9-CM (343.x)
 Categorized by the level
of palsy or paralysis
Cerebral palsy
ICD-10-CM (G80.x)
 Categorized by the level
of palsy or paralysis
 Paralysis is further
specified as spastic or
unspecified
37
Cerebral Palsy
ICD-9-CM
cerebral palsy codes
343.0 Diplegia
343.1 Hemiplegic
343.2 Quadriplegic
343.3 Monoplegic
343.4 Infantile hemiplegia
343.8 Other specified infantile
cerebral palsy
343.9 Infantile cerebral palsy,
unspecified
ICD-10-CM
cerebral palsy codes
G80.0 Spastic quadriplegic
cerebral palsy
G80.1 Spastic diplegic
cerebral palsy
G80.2 Spastic hemiplegic
cerebral palsy
G80.3 Athetoid cerebral palsy
G80.4 Ataxic cerebral palsy
G80.8 Other cerebral palsy
G80.9 Cerebral palsy,
unspecified
38
Cerebral Palsy
ICD-9-CM
cerebral palsy CC codes
ICD-10-CM
cerebral palsy CC codes
343.0 Diplegic
343.1 Hemiplegic
343.4 Infantile hemiplegia
G80.1 Spastic diplegic
cerebral palsy
G80.2 Spastic hemiplegic
cerebral palsy
G80.3 Athetoid cerebral
palsy
39
Cerebral Palsy
ICD-9-CM cerebral palsy
MCC codes
343.2 Quadriplegic
ICD-10-CM cerebral palsy
MCC codes
G80.0 Spastic quadriplegic
cerebral palsy
40
Cerebral Palsy
• ICD-10-CM documentation considerations:
– Paralysis associated with cerebral palsy must be
specified in the documentation as “spastic” in
order to fall into the more specific codes and
qualify as CC or MCC diagnosis codes
41
Cerebral Palsy:
Documentation Requirements
• Diplegic, hemiplegic, monoplegic, paraplegic,
quadriplegic, and tetraplegic cerebral palsy not
specified as spastic all coded to G80.8, Other
cerebral palsy
• Spastic quadriplegic or tetraplegic CP code to
G80.0 (MCC)
• Spastic diplegic, monoplegic, or paraplegic CP
code to G80.1
• Spastic hemiplegic CP codes to G80.2
42
Cerebral Palsy:
Clinical Indicators/Types
• Athetoid
– Represents approximately 10% of the cases of
cerebral palsy currently (used to be higher)
– Two of the risk factors for this form of CP:
• Hyperbilirubinemia (jaundice)
• RH incompatibility with the mother
http://www.originsofcerebralpalsy.com/
43
Cerebral Palsy:
Clinical Indicators/Types
• Ataxia
– Lack of balance or impairment in the ability to
perform smoothly coordinated voluntary
movements
– Very rare in children with CP though frequently
seen as a contributing difficulty in one of the other
forms of the condition
http://www.originsofcerebralpalsy.com/
44
Cerebral Palsy:
Clinical Indicators/Types
• Mixed
– Term used to describe form of CP that does not fit
neatly into one of the other classifications
– Different types of movement disorders may exist
at the same time
– Healthcare professionals usually classify CP
according to the predominant form of involvement
http://www.originsofcerebralpalsy.com/
45
Cerebral Palsy:
Clinical Indicators/Types
• Spastic
– Characterized by abnormal control of voluntary
limb muscles and by exaggerated reflexes,
sometimes in association with a reduction in
muscle tone in the trunk of the body
– Muscles are stiffly and permanently contracted
http://www.originsofcerebralpalsy.com/
46
Cerebral Palsy:
Clinical Indicators/Types
• Diplegia
– Form of CP primarily affecting the legs
– Arms are less involved & less severe (most children
with CP have some problem with their arms)
– Spasticity; difficulty with balance and coordination
– Leg muscles tend to be short resulting in a decrease
in range of motion as the child grows and joints
become stiff
– Feet and ankles can present problems due to short
tight Achilles tendon, which can lead to toe walking
– Hips are at risk for dislocation in this type of CP
http://www.originsofcerebralpalsy.com/
47
Cerebral Palsy:
Clinical Indicators/Types
• Hemiplegia
– Form of CP affecting one arm and leg on the
same side
– Hemiplegia in the arm is more involved than the
leg usually; end of limbs have more problems
• Wrist and hand have more problems than the
shoulder with the elbow in the middle
• Similarly, the ankle and foot will exhibit more
problems than the knee
http://www.originsofcerebralpalsy.com/
48
Cerebral Palsy:
Clinical Indicators/Types
• Monoplegia
– Involvement of only one limb
– Rare form of the condition and commonly thought
of as hemiplegia with mild involvement of the
other limb on the affected side of the body
http://www.originsofcerebralpalsy.com/
49
Cerebral Palsy:
Clinical Indicators/Types
• Quadriplegia/tetraplegia
– Form of CP affecting all four limbs
– Usually accompanied by more severe motor
dysfunction than the other forms
– If head and neck are involved, terms
“pentaplegia” or “full body involvement” are used
• Full body involvement: often additional complications
with eating and breathing due to lack of muscle control
or inability of muscles to work together in normal
patterns
http://www.originsofcerebralpalsy.com/
50
Cerebral Palsy:
Clinical Indicators/Types
• Triplegia
– Form of CP affecting three limbs; most common
pattern is for both legs and one arm to be
affected
– Often thought of as hemiplegia overlapping with
diplegia due to the primary motor dysfunction
being that of the legs
– This form of CP is thought of as quadriplegia with
less severe involvement of one of the arms
• Physician may need to be queried for a more specific term
as this term is not able to be coded in ICD-10
http://www.originsofcerebralpalsy.com/
51
Documentation Requirements:
Traumatic Fracture Repair
Overview of ICD-10-PCS characters
Specificity available in ICD-9 codes
Specificity available in ICD-10 codes
Documentation required for ICD-10-PCS codes
Relevant clinical indicators (if applicable)
52
Fracture Reduction & Stabilization
ICD-9-CM
• Codes located under
main term reduction
• Location specified by
bone only with some
specificity for location:
proximal, distal, or shaft
ICD-10-CM
• Codes located under the
main term reposition
• Increased specificity for
bone location (body part),
laterality, and fixation
devices
53
Fracture Reduction & Stabilization
ORIF right tibial fracture
ICD-9-CM
Reduction
fracture
tibia (closed) 79.06
with internal fixation
79.16
open 79.26
with internal fixation
79.36
ORIF right tibial fracture
ICD-10-CM
Reposition
Tibia
Left 0QSH
Right 0QSG
54
Fracture Reduction & Stabilization
Section
0 Medical and Surgical
Body system Q Lower Bones
Operation
S Reposition: Moving to its normal location, or other
suitable location, all or a portion of a body part
Body part
6 Upper Femur, R
7 Upper Femur, L
8 Femoral Shaft, R
9 Femoral Shaft, L
B Lower Femur, R
C Lower Femur, L
G Tibia, R
H Tibia, L
J Fibula, R
K Fibula, L
Approach
0 Open
3 Percutaneous
4 Percutaneous
Endoscopic
Device
4 Internal Fixation Device
5 External Fixation Device
6 Internal Fixation Device,
Intramedullary
B External Fixation Device,
Monoplanar
C External Fixation Device, Ring
D External Fixation Device, Hybrid
Z No Device
Qualifier
Z No Qualifier
55
Fracture Reduction & Stabilization
• Specify for ICD-10-CM:
• Identify the bone, including laterality, specific site
on the bone
• Approach: open, external (closed), percutaneous
or percutaneous endoscopic
• Device: specify the device used, if any, to
stabilize the fracture
56
Fracture Reduction & Stabilization
CDI Opportunity
• In children, look for any underlying chronic
conditions that could impact SOI/ROM and/or
MS-DRG. Generally, children with fractures are
healthy; however, there will be some with
conditions that need to be documented.
• If trauma, look for other areas of trauma that
may move to a multiple site trauma & any acute
processes such as acute respiratory failure,
acute renal failure, spleen injury, rib fractures,
etc.
57
Fracture Reduction & Stabilization
CDI Opportunity
• Secondary diagnoses that may exist or appear
during the stay or after surgery:
–
–
–
–
–
–
Hypovolemic
Electrolyte disturbances
Acute blood loss anemia
Metabolic/resp acidosis or alkalosis
Acute respiratory failure
Acute renal failure (with or without acute tubular
necrosis)
– Disseminated intravascular coagulation (DIC)
58
Fracture Reduction & Stabilization
CDI Opportunity
• In adults, osteoporosis is often a query opportunity for
distinguishing a traumatic vs. pathological fracture linkage;
however, in the pediatric clientele:
– CDI should look for comorbid conditions that weaken the bones
and query when a pathological fracture can not be ruled out
• Pathological fractures in children can be due to conditions such
as:
– Metabolic bone disease (i.e., vitamin D deficiency, rickets)
– Benign tumors (i.e., non-ossifying fibroma; osteochondroma)
– Malignant tumors (i.e., osteosarcoma, Ewing’s sarcoma)
– Connective tissue bone disease (i.e., osteogenesis imperfecta,
aka “brittle bone disease”)
– Other etiology (i.e., drug induced)
59
Fracture Reduction & Stabilization
CDI Opportunity
• In traumas, look for opportunities to query, such as
rhabdomyolysis and acute renal failure (with or without
ATN)*
– Rhabdomyolysis is a condition where muscle fiber
breakdown & muscle necrosis releases CPK, potassium,
& myoglobin. Often seen in traumatic falls, prolonged
immobilization, trauma, crush or electrical injury.
• Clinical: CPK increased to > 10,000–100,000 U/L
• CPK accounts for 8%–15% incidence of acute kidney failure
due to acute tubular necrosis as large molecules are filtered
through and damage the nephrons
–
–
–
–
Increased serum creatinine as renal failure progresses
Hypocalcemia
Hypophosphatemia (from renal failure and release from cells)
Positive urine hemoglobin in approx. 50% of patients
*possible but not common
60
Fracture Reduction & Stabilization
CDI Opportunity
• Secondary diagnoses associated with
rhabdomyolysis:
– Hypovolemia
– Hyperkalemia
– Metabolic acidosis
– Acute renal failure (with or without acute tubular
necrosis)
– Disseminated intravascular coagulation (DIC)
61
Documentation for ICD-10 in
Children’s Hospitals
Summary of documentation requirements reviewed
Tips for identifying additional clinical documentation needs
62
Asthma:
Documentation Requirements
• No longer relevant:
– Intrinsic vs. extrinsic
• Specify for ICD-10-CM code assignment:
– Mild, moderate, or severe
– Intermittent or persistent
– With exacerbation (acute) or with status
asthmaticus
– Type: exercise induced, cough variant, other
63
Respiratory Failure:
Documentation Requirements
• No longer relevant:
– Respiratory failure that was not specified as
acute or chronic defaulted to acute respiratory
failure
• Specify for ICD-10-CM code assignment:
– Specify acute or chronic
– Type: hypoxic or hypercapniac
64
Cerebral Palsy:
Documentation Requirements
• ICD-10-CM documentation considerations:
– Paralysis associated with cerebral palsy must be
specified in the documentation as “spastic” in
order to fall into the more specific codes and
qualify as CC or MCC diagnosis codes
65
Cerebral Palsy:
Documentation Requirements
• Diplegic, hemiplegic, monoplegic, paraplegic,
quadriplegic, and tetraplegic cerebral palsy not
specified as spastic all coded to G80.8, Other
cerebral palsy
• Spastic quadriplegic or tetraplegic CP code to
G80.0 (MCC)
• Spastic diplegic, monoplegic, or paraplegic CP
code to G80.1
• Spastic hemiplegic CP codes to G80.2
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Fracture Reduction & Stabilization:
Documentation Requirements
• Specificity for ICD-10-CM:
– Identify the bone, including laterality, specific site
on the bone
– Approach: open, external (closed), percutaneous,
or percutaneous endoscopic
– Device: specify the device used, if any, to
stabilize the fracture
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Identifying Additional Clinical
Documentation Needs for ICD-10
• Tips for your facility:
– Conduct your own mini documentation assessment
• Identify your top 10 pediatric diagnoses and procedures
– Code 10 charts each and recode in ICD-10
– Where are your gaps in specificity? Go from there!
– Educate
• Share the knowledge
– Incorporate templates into your EHR system for the needed
specificity
– Report findings from documentation assessment to your
physician champion
– Email blasts, mini-education sessions at dept. head meetings,
flyers, etc.
– Update queries to promote ICD-10 documentation specificity
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Identifying Additional Clinical
Documentation Needs for ICD-10
• More tips for your facility:
– Use available resources
• CMS website
http://www.cms.gov/icd10manual/version31fullcode-cms/P0001.html
– Appendix G Diagnoses Defined as Complication
or Comorbidities
– Appendix H Diagnoses Defined as Major
Complication or Comorbidities
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Thank you. Questions?
[email protected]
[email protected]
In order to receive your continuing education certificate(s) for this
program, you must complete the online evaluation. The link can be
found in the continuing education section at the front of the
workbook.
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