Neoplasms, Anemia and Hemolytic Anemia Clinical Documentation

Neoplasms

Neoplasms

• Behavior:

    --Malignant (primary, secondary, in-situ)

    --Document any secondary sites

    --Benign

    --Unspecified behavior

    --Of uncertain histological behavior

• Laterality (specify right/left)

• Anatomical site (topography)

• Other condition(s) associated with malignancy (dehydration, anemia,

etc.)

• Complication(s) associated with neoplasm

• Include estrogen receptor status (if applicable)

• History of:

    --Has the malignancy been excised or eradicated?

    --Is there still treatment being provided for the primary and/or

metastatic site?

    --Is there evidence of remaining malignancy at the primary site?

• Document any associated diagnoses/conditions

Anemia

• Documentation of Anemia should include the type of anemia:

    --Nutritional

    --Hemolytic

    --Aplastic

    --Due to blood loss

    --Other (please specify)

• Include in documentation if Anemia is due to nutrition or mineral deficits,

resulting in a nutritional anemia

• Document if the Anemia is due to a neoplasm (primary and/or

secondary)

• Document whether the ANEMIA is “related to or due to” chemo or

radiotherapy treatments

• Document any “cause–and-effect” relationship between the intervention

and the blood or immune disorder

• Document the specific drug if anemia is drug-induced

• Link any laboratory findings to a related diagnosis (if appropriate)

• Document any associated diagnoses/conditions

Hemolytic Anemia

• Due to “Enzyme Disorders”:

    --Glucose-6-phosphate dehydrogenase

    --Glutathion metabolism

    --Glycolytic enzymes

    --Due to nucleotide metabolism

• Thalassemias:

    --Alpha thalassemia

    --Beta thalassemia

    --Delta-beta thalassemia

    --Thalassemia minor

    --Hereditary persistence of fetal hemoglobin

    --Hemoglobin E-beta thalassemia

• Sickle Cell Disorders is present

    --Specify if “With or Without Crisis”

• Sickle Cell thalassemia

    -- Specify if “With or Without Crisis”

• Include documentation of whether the hemolytic anemia is:

    --Hereditary

    --Acquired

    --Enzyme disorder

    --Autoimmune

    --Non-autoimmune

• Document the disorder/condition causing the anemia

• Document any associated diagnoses/conditions

Hepatitis, MRSA/MSSA and Herpes Simplex Documentation

Hepatitis

Hepatitis

 

• Document acuity:

    --Acute

    --Chronic

• Document etiology:

    --Alcoholic

    --Drug (specify)

    --Viral (Type A, B, C, or E)

• Document also:

    --With hepatic coma

    --Without hepatic coma

    --With delta agent

    --Without delta agent

• Document any associated diagnoses/conditions

 

 

MRSA/MSSA

 

Methicillin-resistant Staphylococcus aureus

• Include documentation of “MRSA infection” when the patient has that

condition.

• Document if sepsis and/or septic shock is present.

• Document any associated diagnoses/conditions.

Methicillin susceptible Staphylococcus aureus

• Include documentation of “MSSA infection” when the patient has that

condition.

• Document if sepsis, and/or septic shock is present.

• Document any associated diagnoses/conditions.

Herpes Simplex

• Specify if “Eczema herpeticum” is present.

• Document if “Herpesviral vesicular dermatitis” is present

    --Herpes simplex facialis

    --Herpes simplex labialis

    --Vesicular dermatitis of ear or lip

• Document if “Herpesviral gingivostomatitis and pharyngotonsillitis”

are present

• Document if “Herpesviral meningitis” is present

• Specify if “Herpesviral encephalitis” is present

• Simian B disease

• Document if “Herpesviral ocular disease” is present

    --Herpesviral iridocyclitis

    --Herpesviral keratitis

    --Herpesviral conjunctivitis

• Specify if “Disseminated herpesviral disease” is present

• Document if “Other forms of herpesviral infections” are present

    --Herpesviral hepatitis

    --Herpes simplex myelitis

    --Other herpesviral infection

    --Herpesviral whitlow

• Document any associated diagnoses/conditions

Systemic Infection/Inflammation, Viral and Bacterial Meningitis

Systemic Infection/Inflammation

Systemic Infection

• Bacteremia (positive blood cultures only)

• Urosepsis—MUST specify sepsis with UTI, versus UTI only

• Sepsis—specify causative organism if known

• Sepsis due to:

     --Device

     --Implant

     --Graft

     --Infusion

     --Abortion

• Severe sepsis—sepsis with organ dysfunction

     --Specify organ dysfunction

     --Respiratory failure

     --Encephalopathy

     --Acute kidney failure

     --Other (specify)

• SIRS (Systemic Inflammatory Response Syndrome

     --With or without organ dysfunction

• Document septic shock if present

• Document any associated diagnoses/conditions

Viral Meningitis

• Documentation of “Viral Meningitis” should include the specific viral

organism if known (i.e., adenovirus, enterovirus, chickenpox, measles,

etc.).

• Document any associated diagnoses/conditions

Bacterial Meningitis

• Documentation of “Bacterial meningitis” should include the specific

bacterial organism (i.e., Escherichia coli, bacillus, gram-negative,

Klebsiella, staph, strep, etc.) if known.

• Document if the meningitis is due to “other causes,” which can include

“nonpyogenic meningitis,” “chronic meningitis,” “Benign recurrent

meningitis.”

• Document any associated diagnoses/conditions

ICD-10 for Anesthesia – What you need to Understand

ICD-10 implementation has been delayed till October 1, 2015. But if you have not even yet begun the planning for this change, you are already behind the schedule!  Every specialty, but particularly anesthesiologists, will be immensely affected by the transition from ICD-9 to ICD-10.  The wide range of the diagnoses that bring patients to the surgery that translates to more impact for anesthesiologists. And how well you document for ICD-10 will decide if you will be paid or not.

This article will describe the conversion from ICD-9 to ICD-10.  The article will also highlight diagnosis scenarios for some of the most common diagnoses for anesthesia in ICD-9 and then in ICD-10. This should clearly help in illustrating the differences in the coding and, more importantly for you, in the documentation. In general, a physician’s documentation for ICD-10 will also need to be more specific as well as detailed than is required for ICD-9. This may also mean capturing new information about the patient’s condition that the anesthesiologist has never documented before or updating, modifying and expanding his/her documentation.   Physicians with some good documentation habits will also find the transition much easier than those who use the abbreviations or other shortcuts.

The codes will readily change in many ways, like the longer code structure, usage of laterality, combination of the codes and types of encounters. However, one thing always remains consistent. No code is ever considered valid or even complete unless it’s coded to the highest level of specificity in its very category.

A look at the musculoskeletal system’s diagnosis codes easily explains the complexity as well as the details that an anesthesiologist will really need to document.  To code a fracture in ICD-10 coding for anesthesia the following will be necessary:

• Anatomic site on the bone (proximal, shaft, distal)
• Then laterality (right or left)
• Fracture Type for (displaced, non-displaced, open or closed; if open there are 3 more subsets to choose from)
• Episode of care therefore (initial, subsequent, or sequela)

Let’s just take a look at an example:  – An anesthesia record is presented to a coder with just the diagnosis simply written as “fracture radius shaft”. ICD-9 Coding – Without any further detailing, we can also code this as 813.21 (Fracture of radius and ulna, shaft closed, radius alone). In ICD-10, we just have to code it with the addition of the laterality, the fracture type and the episode of care. There are currently as many as 270 ICD-10 code choices for this injury.   For this example, we will just choose the right side, closed and non-displaced transverse type fracture, with the initial episode of care.

To get anesthesia coding training, learn from the informative audio conferences at AudioEducator.