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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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Clinical documentation improvement

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
Diabetes Mellitus250.00 – 250.93

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


Clinical documentation improvement

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.


Clinical documentation improvement

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


Clinical documentation improvement

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:


Code this one
Code This one. in the "Includes notes" under each DM category.

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.


Clinical documentation improvement

E10.621   Type 1 diabetes mellitus with foot ulcer in the "Includes notes" under each DM category. L97.411   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.


All conditions of dm
All Conditions of DM in the "Includes notes" under each DM category.

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.


Clinical documentation improvement
DM in the "Includes notes" under each DM category.

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.


How did you do
How did you do???? in the "Includes notes" under each DM category.

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.


Atrial fibrillation 427 31
Atrial Fibrillation in the "Includes notes" under each DM category. 427.31

  • Atrial fibrillation and flutter, separate codes for flutter.

  • I48.91 Unspecified atrial fibrillation

  • Documentation needed for AF.: CDI

    • 1. Type: Paroxysmal I48.0

    • 2. Persistent I48.1

    • 3. Chronic I48.2


Hyperlipidemia 272 4
Hyperlipidemia in the "Includes notes" under each DM category. 272.4

E78.4

Other hyperlipidemia, Familial combined hyperlipidemia.

E78.5

Hyperlipidemia, unspecified Try to Avoid!!!


Lipids
LIPIDS in the "Includes notes" under each DM category.

More specific documentation is needed when coding disorders of lipoprotein metabolism and other lipidemia

CDI

E78.0 Pure Hypercholesterolemia

E78.1 Pure hyperglyceridemia

E78.2 Mixed hyperlipidemia

E78.3 Hyperchylomicronemia


Routine general physicals v70 0 v20 2
Routine General Physicals. in the "Includes notes" under each DM category. V70.0/ V20.2

  • Documentation needed for the ICD-10 codes:

  • There are three general medical exams.

  • 1. General Medical Adult exam.

    • A. Z00.00 without abnormal findings.

    • B Z00.01 with abnormal findings.

      Abnormal findings are identify as those found on the exam for that day.


V20 2
V20.2 in the "Includes notes" under each DM category.

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


Immunizations
Immunizations in the "Includes notes" under each DM category.

Also when coding immunizations you will code

Z23 as the diagnosis code.


Sports dot etc v70 3
Sports/DOT/ETC in the "Includes notes" under each DM category. V70.3

  • In ICD-10, these codes are:

    • Z02.0 Encounter for Administrative purposes.

    • Z02.1 Pre-employment

    • Z02.2 Residential institution

    • Z02.3 Recruitment to armed forces

    • Z02.4 Driving License

    • Z02.5 Sports

    • Z02.6 Insurance purpose


Unspecified sinusitis 473 9
Unspecified Sinusitis in the "Includes notes" under each DM category. .473.9

X reference to: J32.9 Unspec. Chronic sinusitis

CDI:

Providers /Staff must Specify:

Acute/Chronic

Site of Sinusitis

Example, Maxillary, frontal, ethmoidal, etc.

Recurrent


Acute sinusitis 461 9
Acute in the "Includes notes" under each DM category. sinusitis461.9

J01.90 Acute sinusitis, unspec.

CDI

Site of Sinusitis

Site of the sinusitis, Example: Maxillary, frontal, ethmoidal, etc.

Recurrent


Pharyngitis and tonsillitis 462 and 463
Pharyngitis and in the "Includes notes" under each DM category. Tonsillitis462 and 463

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


Pharyngitis and tonsillitis 462 and 4631
Pharyngitis and Tonsillitis in the "Includes notes" under each DM category. 462 and 463

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)


Clinical documentation improvement
CDI in the "Includes notes" under each DM category.

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


Otitis media acute 382 00
Otitis in the "Includes notes" under each DM category. Media, Acute382.00

H66.009 Acute suppurative OM w/o spontaneous rupture of ear drum .

CDI

  • Specify where infection: internal vs. external ear (i.e. “media)

  • Acute vs. Chronic or whether it is both (i.e. patient has had multiple episodes visits for Otitis Media and now has a current infection)

  • Which EAR – Right, Left, Bilateral (both)

  • Is the ear draining? Suppurative vs serous

  • Is the drum ruptured? Specify with or without rupture

  • Other manifestation – ESPECIALLY exposure to tobacco smoke


Fatigue and malaise 780 79
Fatigue and Malaise 780.79 in the "Includes notes" under each DM category.

G93.3

Postviral fatigue syndrome

R53.1

Weakness

R53.81

Other malaise

R53.83

Other fatigue


Clinical documentation improvement

CDI: in the "Includes notes" under each DM category.

You would code two codes for this one.


Hypertension 401 0 401 9
Hypertension in the "Includes notes" under each DM category. 401.0 - 401.9

Hypertension, controlled, uncontrolled, benign, arterial, essential, malignant and high blood pressure are all coded to : I10

There are no hypertension table found in

ICD-10 CM.


Clinical documentation improvement

Questions:???????? in the "Includes notes" under each DM category.