Amputations, Debridement and Spinal Fusion Clinical Documentation

Amputations

 

• Lower Body (include laterality)
    --Hindquarter
    --Femoral Region
    --Knee Region
    --Upper/Lower Leg
       °°High (proximal)
       °°Mid (mid portion)
       °°Low (distal)
    --Foot
       °°Complete or partial ray(s)/metatarsal(s)
    --Toe
       °°High (proximal phalanx)
       °°Mid (PIP joint or middle phalanx)
       °°Low (DIP joint or distal phalanx)
• Upper Body (include laterality)
    --Forequarter
    --Shoulder Region
    --Elbow Region
    --Upper/Lower Arm
       °°High (proximal)
       °°Mid (mid portion)
       °°Low (distal)
• Hand
    --Complete or partial ray(s)/metacarpal(s)
• Thumb/Finger
    --High (proximal phalanx)
    --Mid (PIP joint or middle phalanx)
    --Low (DIP joint or distal phalanx)

Debridement

• Depth:
    --Skin
    --Subcutaneous tissue/fascia
    --Muscle
    --Joint
    --Bone
• Type:
    --Excisional/Sharp
    --Non-excisional
• Specify the type of instrument used

Spinal Fusion

• Column fused
    --Anterior (rounded, smooth portion of spine)
    --Posterior (pedicle, lamina, facet, transverse process of spine)
• Approach
    --Anterior
    --Lateral
    --Posterolateral
    --Posterior
    --Lateral transverse
• Type of device(s) used
    --Interbody fusion device
    --Autologous bone graft
    --Nonautologous bone graft
    --Etc.
• Number of joints fused
    --L1–L3
    --L5–S1
    --Etc.

Lymph Node Chains, Omentectomy and CABG Clinical Documentation

Lymph Node Chains

                                  Lymph Node Chains

 

• Document extent of excision/resection:
    --Entire lymph node chain
    --Portion of lymph node chain
• Document site:
    --Head
    --Right/Left neck
    --Right/Left upper extremity
    --Right/Left axillary
    --Thorax
    --Right/Left internal mammary
    --Mesenteric
    --Pelvis
    --Aortic
    --Right/Left lower extremity
    --Right/Left inguinal

Omentectomy

• Document the body part being resected/excised:
    --Greater omentum
    --Lesser omentum

Lysis of Adhesions

• Document the body part being released/freed, examples:
    --Jejunum
    --Ascending Colon
    --Gallbladder
    --Peritoneum
    --Document the severity of adhesions, such as, complicated,
extensive, etc.

Cleft Palate Repair

• Specify the following:
    --Palate description Hard/Soft/Both
    --Bilateral/Unilateral
    --Complete/Incomplete
    --With/without Cleft Lip Involvement
    --If Cleft Lip involvement—Bilateral/Unilateral

CABG

• Origination/Destination of graft(s)
    --Examples: aorta to RCA, LIMA to LAD (indicate if the LIMA was
used as a pedicle graft)
• Type of graft(s) used
    --Examples: autologous artery, autologous vein, etc.
• Number of sites bypassed
    --Examples: one, two, three, or four, or more
• Excision of autologous graft
    --Identify the vessel
       °°Examples: greater/lesser saphenous vein (left/right), radial artery
(left/right)

Mechanical Device Complications and Socioeconomic Circumstances

Mechanical Device Complications

Mechanical Device Complications

• Body system
• Type of device
• Specific complication
    --Breakdown
    --Displacement
    --Leakage
    --Infection
    --Hemorrhage
    --Pain
    --Embolism
    --Fibrosis
    --Other
• Episode of care
    --Initial encounter
    --Subsequent encounter
    --Sequela
• Document any associated
diagnoses/conditions

Socioeconomic and Psychosocial Circumstances

• Document problems related to:
    --Education/literacy
    --Employment/unemployment
    --Occupational exposure (specify)
    --Housing & Economic
    --Social environment
    --Upbringing
    --Primary support group/Family circumstances
    --Other psychosocial circumstances

Body Mass Index

• Adult BMI (21 years +):
    --19 or less
    --20.0–20.9
    --21.0-21.9
    --60.0–69.9
    --70+
• Document any associated diagnoses/conditions, such as morbid obesity,
malnutrition, etc.
• Pediatric BMI (ages 2–20):
    --Less than fifth percentile for age
    --Fifth percentile to less than 85th percentile for age
    --85th percentile to less than 95th percentile for age
    --Greater than or equal to 95th percentile for age

Reproductive Services

• Document reason for visit:
    --Contraceptive management (specify type)
    --Procreative management (specify type)
    --Pregnancy test or childbirth instruction
    --Pregnancy state, incidental
    --Elective termination of pregnancy
    --Supervision of normal pregnancy (specify trimester)
    --Antenatal screening of mother

Contact with and Exposure To

• Specify what the patient came into contact with, such as:
    --AIDS virus
    --Anthrax
    --Varicella
    --Mold
    --Second-hand tobacco smoke
    --Other (specify)

Retained Foreign Body, Encounter For and External Cause

Retained Foreign Body

Retained Foreign Body

 

• Specify type of foreign body retained, examples:
    --Glass
    --Metal
    --Radioactive
    --Tooth
    --Other (specify)

External Cause

• Document “how” an injury occurred, such as fall, motor vehicle
accident, etc.
• Document “where” an injury occurred, such as home, work, school, etc.
• Document “activity”, such as skiing, ironing, gardening, etc.
• Document “status”:
    --Civilian
    --Military
    --Volunteer
    --Other (specify)
• Important Notes:
    --No national requirement for external cause reporting
    --Some states and payers require external cause codes

Encounter For

• Document the reason for encounter, such as:
    --Examination
    --Pregnancy
    --Adjustment/removal of device
    --Suspected condition, ruled out
    --Other (specify)

History (Personal and Family)

• Document any relevant personal/family history, such as:
    --Malignant neoplasm (specify type)
    --Congenital malformations/deformations (specify type)
    --Allergies (specify type)
    --Chemotherapy
    --Radiation therapy
    --Surgical history
    --Other (specify)

Genetic Carrier/Susceptibility

• Specify genetic carrier of:
    --Cystic fibrosis
    --Hemophilia A
    --Other (specify)
• Susceptibility to disease:
    --Malignant neoplasm (specify type)
    --Multiple endocrine neoplasia
    --Other (specify)

Fractures, Burns and Underdosing Clinical Documentation

Fractures

Fractures

 

• Cause:
    --Traumatic
    --Stress
    --Pathologic
• Location:
    --Which bone?
    --Which part of the bone?
    --Laterality (right, left, or bilateral)
• Type:
    --Non-displaced
    --Displaced
    --Open (Gustilo classification where applicable)
    --Closed (Greenstick, spiral, etc.)
    --Salter-Harris (specify type)
• Encounter:
    --Initial
    --Subsequent
       °°For routine healing
       °°For delayed healing
       °°For non-union
       °°For malunion
    --Sequela (such as bone shortening)
• Include the external cause of the fracture, such as fall while skiing, motor
vehicle accident, tackle in sports, etc.
• Document any associated diagnoses/conditions

Burns

• Type:
    --Corrosion
    --Thermal
• Site:
    --Specify body part
    --Include laterality
• Degree:
    --First
    --Second
    --Third
• Document total body surface area (TBSA) burned (percentage)
• Specify the percentage of third degree burns
• Include the external cause of the burn, such as house fire, stove, acid, etc.
• Document any associated diagnoses/conditions

Underdosing

• Using a prescribed medication less frequently than prescribed, in small
doses, or not using the medication as instructed should be documented
as “underdosing” by the provider
• If the reduction in the prescribed dose of the medication results in a
relapse or an exacerbation of the medical condition for which the drug is
prescribed, the medical condition must also be documented

Coma, Cleft Palate and Gustilo Classification Documentation

Coma

 

• Document:
    --Somnolence, drowsiness
    --Stupor, catatonic stupor, or semicoma
    --Coma, unconsciousness
    --Include any associated skull fracture or intracranial injury if present
• Document the Glasgow (coma scale) score
    --(Typically reported as a total score 0–15)
    --Higher the score = higher functioning
• Also document each assessment area:
    --Eye opening
    --Verbal response
    --Motor response

Cleft Palate

• Specify palate involvement:
    --Hard
    --Soft
    --Hard with Soft
    --Medial
    --Uvula
• Document cleft lip involvement:
    --Unilateral cleft lip
    --Bilateral cleft lip
    --Median cleft lip
• Document any associated diagnoses/conditions

Gustilo Classification

• Specificity for open fractures of the forearm, femur, and lower leg
will require provider documentation to specify Gustilo Type l through
Type lllC:
    --TYPE l: The wound is smaller than 1 cm, clean, and generally caused by
a fracture fragment that pierces the skin.
    --TYPE II: The wound is longer than 1 cm, not contaminated, and without
major soft tissue damage or defect. This is also a low energy injury.
    --TYPE III: The wound is longer than 1 cm., with significant soft tissue
disruption. The mechanism often involves high-energy trauma, resulting
in a severely unstable fracture with varying degrees of fragmentation.
    --IIIA: The wound has sufficient soft tissue to cover the bone without the
need for local or distant flap coverage.
    --IIIB: Disruption of the soft tissue is extensive, such that local or distant
flap coverage is necessary to cover the bone. The wound may be
contaminated, and serial irrigation and debridement procedures are
necessary to ensure a clean surgical wound.
    --IIIC: Any open fracture associated with an arterial injury that requires
repair is considered IIIC. Involvement of a vascular surgeon is generally
required.
• NOTE: Even though the fracture may be described using the terminology
found in the Gustilo classification the provider must document the type
of Gustilo fracture present; coder CANNOT code based on the fracture
description.

OB/Pregnancy, Newborn and Congenital Foot Deformities

OB/Pregnancy

 

Pregnancy

• Specify trimester
    --First (less than 14 weeks, 0 days)
    --Second (14 weeks, 0 days to less than 28 weeks, 0 days)
    --Third (28 weeks until delivery)
• Specify preterm labor/delivery
• Gestational Diabetes needs documentation specification of diet
controlled or insulin controlled
• Document any associated diagnoses/conditions

Newborn

• Birth:
    --In hospital
       °°Specify delivery type
    --Outside hospital
• Document any maternal conditions affecting the newborn
• Specify gestational age and weight of newborn
• Specify congenital vs. acquired conditions
• Document any associated diagnoses/ conditions

Congenital Foot Deformities

• Specify “Congenital” or “Acquired”
• Specify type:
    --Talipes equinovarus
    --Talipes calcaneovarus
    --Metatarsus varus
    --Talipes calcaneovalgus
    --Pes planus (left vs. right)
    --Pes cavus
    --Vertical talus deformity (left vs. right)
    --Other (specify)
• Document any associated diagnoses/conditions