Clinical Documentation Improvement. (CDI). Objectives. !. What is CDI and why is it associated with ICD-10? 2. How to share information with physicians. 3.Longer time frame now. Delayed 10/1/2015 4. Will it be ICD-10 or ICD-11. Diabetes Mellitus 250.00 – 250.93.
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!. What is CDI and why is it associated with ICD-10?
2. How to share information with physicians.
3.Longer time frame now. Delayed 10/1/2015
4. Will it be ICD-10 or ICD-11
Diabetes Mellitus Coding in ICD-10CMThe codes for diabetes mellitus have expanded in ICD-10-CM into five categories of codes. The codes were made into combination codes that bundle in the type, the body system affected, and any complications of the body system. The five categories are as follows:
E08 Diabetes mellitus due to an underlying conditionE09 Drug or chemically induced diabetes mellitusE10 Type 1 diabetes mellitusE11 Type 2 diabetes mellitusE13 Other specified diabetes mellitus
Notice that there is no unspecified diabetes mellitus code category. According to the guidelines (I.C.4.a.2), if the type of diabetes mellitus is not documented in the medical record the default is E11, Type 2 diabetes mellitus.
The differences from ICD-9-CM include the fact that the codes do not include the fact that the codes do not include "uncontrolled" and "not stated as uncontrolled" in the descriptors any longer. Instead, the codes are listed as with and without complications. The second difference is the combination of the complication into the code
Definitions for the types of diabetes mellitus are located in the "Includes notes" under each DM category. Physicians and other providers should be instructed to document the type of diabetes as type 1 or type 2, when appropriate, and not insulin and non-insulin dependent as these terms are no longer used in the coding world.
Our first CDI:
Paulette, a type 1 diabetic, comes in today for a recheck of her diabetic right heel ulcer. Upon examination, it is healing well, with the breakdown limited to the skin.
E10.621 Type 1 diabetes mellitus with foot ulcerL97.411 Non-pressure chronic ulcer of right heal and midfoot limited to breakdown of skin
Did you get it right???
Notice that although combination codes exist, more than one code is still necessary to indicate the site, laterality, and severity of the ulcer.
If the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, a code from category E11 should be assigned. Code Z79.4, Long-term (current) use of insulin, should also be assigned to indicate that the patient uses insulin.
Mary is a type 2 diabetic that presents to the clinic. She is doing well with her diet and exercise routine. She uses Lantus at bedtime and has her diabetes under good control. She will remain on same medication regimen and come for follow-up in three months.
ICD-10-CM Codes:E11.9 Type 2 diabetes mellitus without complicationsZ79.4 Long=term (current) use of insulin
Rationale: Although the patient is using insulin, it cannot be assumed that she is a type 1 diabetic. This example brings in two guidelines. Guideline I.C.4.a.2 states if the type of diabetes mellitus is not documented in the medical record the default is E11, Type 2 diabetes mellitus. The second is regarding the use of insulin. Guideline I.C.4.a.3 states if the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, code Z79.4, Long-term (current) use of insulin, should also be assigned to indicate that the patient uses insulin.
Other hyperlipidemia, Familial combined hyperlipidemia.
Hyperlipidemia, unspecified Try to Avoid!!!
More specific documentation is needed when coding disorders of lipoprotein metabolism and other lipidemia
E78.0 Pure Hypercholesterolemia
E78.1 Pure hyperglyceridemia
E78.2 Mixed hyperlipidemia
Abnormal findings are identify as those found on the exam for that day.
2. Encounter for newborn, infant, & child exam.
A.Z00.110 Newborn, under 8 days.
B. Z00.111 Newborn 8 to 28 days.
3. Encounter for Routine Child Health Exam.
A. Z00.121 with abnormal findings.
B. Z00.129 without abnormal findings
Also when coding immunizations you will code
Z23 as the diagnosis code.
X reference to: J32.9 Unspec. Chronic sinusitis
Providers /Staff must Specify:
Site of Sinusitis
Example, Maxillary, frontal, ethmoidal, etc.
J01.90 Acute sinusitis, unspec.
Site of Sinusitis
Site of the sinusitis, Example: Maxillary, frontal, ethmoidal, etc.
J03.00 – Acute Streptococcal tonsillitis
J03.01 - Acute recurrent streptococcal tonsillitis
J03.80 – Acute tonsillitis due to other specify organisms (additional code must be used to identify infectious agent)
J03.81 – – Acute recurrent tonsillitis due to other specified organism
(additional code must be used to identify infectious agent)
J03.90- Acute tonsillitis, unspec
J03.91-Acute recurrent tonsillitis, unspecAvoid
J02.0 –Acute Streptococcal pharyngitis
J02.8 – Acute pharyngitis due to other specified organism(additional code must be used to identify infectious agent)
J02.9 Acute pharyngitis, unspec. (Avoid)
1. Specify acute vs. Chronic (Chronic will code a different path i.e. tonsillitis, adenoid involvement, etc.)
2. What Organism. Streptococcal, mono, coxsacki, herpes simplex, unknown, etc.
Admin staff: When scheduling appointment for sore throat ask how long they have had symptoms
Nursing staff: 1-Make sure surgical history accurately reflects if patient has had tonsils or adenoids removed
H66.009 Acute suppurative OM w/o spontaneous rupture of ear drum .
Postviral fatigue syndrome
You would code two codes for this one.
Hypertension, controlled, uncontrolled, benign, arterial, essential, malignant and high blood pressure are all coded to : I10
There are no hypertension table found in