Friday, March 3, 2017

Clinical Documentation Tips

ICD-10 Compliance

Specifying anatomical location and laterality required by ICD-10 is easier than you think. This detail reflects how physicians and clinicians communicate and to what they pay attention - it is a matter of ensuring the information is captured in your documentation.

In ICD-10-CM, there are three main categories of changes: 

  • Definition Changes
  • Terminology Differences 
  • Increased Specificity 
For cardiology, the focus is increased specificity and documenting the downstream effects of the patient’s condition.

ACUTE MYOCARDIAL INFARCTION (AMI) 

Definition Change

When documenting hypertension, include the following:

1. Timeframe 
An AMI is now considered “acute” for 4 weeks from the time of the incident, a revised timeframe from the current ICD-9 period of 8 weeks. 

2. Episode of care
 ICD-10 does not capture episode of care (e.g. initial, subsequent, sequelae). 

3. Subsequent AMI 
ICD-10 allows coding of a new MI that occurs during the 4 week “acute period” of the original AMI.

ICD-10 Code Examples

I21.02  - ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery 

I21.4 -  Non-ST elevation (NSTEMI) myocardial infarction 

I22.1  - Subsequent ST elevation (STEMI) myocardial infarction of inferior wall

HYPERTENSION

Definition Change In ICD-10, hypertension is defined as essential (primary). 

The concept of “benign or malignant” as it relates to hypertension no longer exists. 

When documenting hypertension, include the following: 
1. Type e.g. essential, secondary, etc. 
2. Causal relationship e.g. Renal, pulmonary, etc. 

ICD-10 Code Examples
I10  - Essential (primary) hypertension 
I11.9  - Hypertensive heart disease without heart failure 
I15.0  - Renovascular hypertension
 

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