ICD 10 Documentation Specialty Introduction - PowerPoint Presentation

ICD 10 Documentation Specialty Introduction ICD 10 is being mandated by CMS. Compliance date is set at October 2015. ICD-9 Diagnosis Codes = 14,000 ICD-10 Diagnosis Codes = 69,000 ICD-9 Procedure Codes = 3,800 ICD-10 Procedure Codes = 71,000 The CDI team is here to help with inpatient provider documentation specificity needed in I-10. Based on Conifer ICD 10 Updated queries, the attached pages will assist with the documentation needed in I-10.

Table of contents Anemia 3 Atrial Fib 4 BMI – high 5BMI –low 6Cellulitis 7Cirrhosis of Liver 8Colitis 9Coma 10Crohn’s Disease / Regional Enteritis 11Debridement 12Dementia 13Diabetes 14Diverticulitis 15Dysphasia 16Encephalopathy 17Functional Quadriplegia 18Gastroparesis 19Gastrointestinal Ulcer- Upper 20GERD 21Heart failure- acute 22Heart failure-chronic 23HIV-AIDS 24Hypertension 25Hyponatremia 26Mental Status- Altered 27Metabolic—acidosis/ alkalosis 28 Neoplasm 29 Non pressure ulcer 30 Malnutrition 31 Pancreatitis 32 Personal Injury 33 Pneumonia- Aspiration 34 Pneumonia- Hypostatic /passive/ stasis 35 Pneumonia-Specificity 36 Pressure Ulcer 37 Pulmonary embolism 38 Renal Failure—acute 39 Renal failure-chronic 40 Respiratory- COPD 41 Respiratory- Emphysema 42 Respiratory failure 43 Respiratory failure post op 44 Sepsis 45 Shock 46 Substance abuse 47 Urosepsis 48 UTI 49 Hospital specific Documentation Specialists contact info 50-57

ICD10 documentation specificity needed ICD9 Documentation Anemia [ ] Acute blood loss anemia[ ] Post-op anemia related to acute blood loss[ ] Anemia: [ ] Aplastic [ ] Nutritional [ ] Drug induced (specify)________ [ ] Hemolytic: [ ] Hereditary [ ] Acquired [ ] Autoimmune [ ] Non-autoimmune [ ] Enzyme disorder[ ] Anemia due to Neoplasm: [ ] Primary [ ] Secondary [ ] Due to Chemotherapy [ ] Due to Radiotherapy [ ] Chronic anemia – other etiology: ICD10 Documentation Needed Same as in ICD 9

ICD10 documentation specificity needed ICD9 Documentation A fib ICD10 Documentation NeededIDENTIFY TYPE[ ] Paroxysmal Atrial Fibrillation[ ] Persistent Atrial Fibrillation [ ] Chronic Atrial Fibrillation ( includes permanent Atrial Fibrillation) [ ] Unspecified Atrial Fibrillation

ICD10 documentation specificity needed ICD9 Documentation BMI > 40 with associated diagnosis of:[ ] Morbid (Severe) Obesity[ ] Overweight [ ] Obesity (unspecified)ICD10 Documentation NeededMorbidly Obese [ ] Morbid (Severe) Obesity [ ] Due to excess calories [ ] Familial [ ] Endocrine [ ] with Alveolar Hypoventilation (Pickwickian syndrome) [ ] Drug-induced ( Name of drug : _____)

ICD10 documentation specificity needed ICD9 Documentation BMI < 19 with associated diagnosis of: (check one) [ ] Underweight [ ] Protein Calorie Malnutrition: [ ] Mild [ ] Moderate [ ] Severe [ ] Unspecified [ ] Cachexia [ ] Emaciation due to malnutritionICD10 Documentation Needed Same as ICD 9

ICD10 documentation specificity needed ICD9 Documentation Cellulitis ICD10 Documentation NeededIdentify location, laterality and if related toLocation: _________________Laterality:[ ] Left [ ] Right [ ] Bilateral [ ] Upper [ ] Lower [ ] Cheek-internal [ ] Cheek-external [ ] N/A_____ [ ] Bacterial - Causative Agent ( if known): ____[ ] Viral [ ] R/T Lymphangitis ( chronic / subacute ) [ ] R/T Venous Stasis ulcer with PVD [ ] Manifestation of Diabetes [ ] Does not apply to this patient – no cellulitis

ICD10 documentation specificity needed ICD9 Documentation Cirrhosis of Liver ICD10 Documentation NeededIdentify if alcoholic or non-alcoholic, if congenital, biliary obstructive, laennec’s and if portal [ ] Alcoholic [ ] Non-alcoholic [ ] Congenital ____ (underlying disease) [ ] Biliary / Obstructive: [ ] Primary [ ] Secondary [ ] Laennec’s: [ ] Alcoholic with: [ ] dependence [ ] non-dependence [ ] Non-alcoholic [ ] Portal: [ ] Alcoholic [ ] Non-alcoholic

ICD10 documentation specificity needed ICD9 Documentation Colitis ICD10 Documentation NeededIdentify Site, Type and ComplicationsSite (if applicable): [ ] Small Intestine [ ] Large Intestine [ ] Other site __Type: [ ] Colitis due to radiation [ ] Ulcerative Colitis [ ] Infectious Colitis [ ] Toxic Colitis [ ] Ischemic Colitis [ ] Colitis due to ___________________ [ ] Chronic Colitis Complications: [ ] Rectal Bleeding [ ] Intestinal Obstruction [ ] Fistula [ ] Abscess [ ] Other complication _________________ [ ] Unspecified complication

ICD10 documentation specificity needed ICD9 Documentation Coma ICD10 Documentation NeededIdentify specificity[ ] Coma / Comatose[ ] Persistent vegetative state[ ] Stupor[ ] Drowsiness[ ] Somnolence [ ] Catatonic stupor[ ] Semicoma[ ] Associated injury (skull fracture, intracranial injury) _________________________________ [ ] Glasgow coma score_____________ Eye opening describe ________ Verbal response describe _________ Motor functioning describe_________

ICD10 documentation specificity needed ICD9 Documentation Crohn’s Disease / Regional EnteritisICD10 Documentation NeededIdentify specificity, site and associated diagnosis [ ] Abscess [ ] Fistula [ ] Intestinal obstruction [ ] Rectal bleeding [ ] Other (specify) _______________ Site: [ ] Small Intestine [ ] Large Intestine [ ] both small and large intestines Associated diagnoses / conditions (specify)________

ICD10 documentation specificity needed ICD9 Documentation Debridement [ ] Excisional Debridement: [ ] Excised [ ] Removed [ ] Cut away [ ] Other: ________ Depth / layer: (deepest layer of debridement): [ ] Skin/SubQ [ ] Fascia [ ] Muscle [ ] Bone  Margins: ( please specify ): ___ / __ x __ x ___  Instruments used: [ ] Scissors [ ] Scalpel [ ] Curette [ ] Tweezers/forceps [ ] Soft tissue clipper [ ] Other: _____ [ ] Non- excisional Debridement - Removal by flushing , brushing, or washing   [ ] Incision and Drainage only ( No Debridement ): Depth: [ ] Skin & Sub Q only [ ] Into soft tissue [ ] Escharectomy ICD10 Documentation Needed Same as ICD 9

ICD10 documentation specificity needed ICD9 Documentation Dementia ICD10 Documentation NeededIdentify type and accompanying behaviorsType of Dementia (check all appropriate):[ ] Vascular (due to cerebrovascular infarct or HTN) [ ] Frontotemporal [ ] Pick’s Disease [ ] In Substance Use/Abuse/Dependence Specify substance: ____________________ [ ] With Lewy Bodies ( in Parkinson’s Disease ) [ ] In other specified diseases ( such as Alzheimer’s, , Parkinson’s, or other degenerative nervous system disease ) [ ] Unspecified ( such as Senile or Pre-senile ) [ ] Unable to determine type of Dementia Accompanying Behaviors (check all appropriate): [ ] Behavioral disturbances ( aggressive, combative, violent ) [ ] Psychosis [ ] Delirium [ ] Delusions [ ] Hallucinations [ ] Depression [ ] Wandering [ ] Other behaviors: ___________________

ICD10 documentation specificity needed ICD9 Documentation Diabetes ICD10 Documentation NeededIDENTIFY TYPE, ETIOLOGY, CONTROL and any MANIFESTATIONSTYPE: [ ] Type I [ ] Type II [ ] Insulin Use Etiology : [ ] Drug / chemical induced [ ] Due to underlying condition (specify)________ [ ] Other specified type_____ Control: [ ] Inadequate [ ] Out of control [ ] Poor [ ] Hypoglycemia [ ] Hyperglycemia Manifestation: [ ] Ketoacidosis [ ] Neurological complications (specify) __ [ ] Kidney complication (specify) ______________ [ ] Skin complication (specify) ____________________ [ ] Other (specify)________________________ [ ] Gastropathy/ Gastroparesis [ ] Osteomyelitis [ ] Cellulitis [ ] CKD

ICD10 documentation specificity needed ICD9 Documentation Diverticulitis ICD10 Documentation NeededIDENTIFY Acuity, Severity, Site and TypeAcuity: [ ] Acute [ ] Chronic [ ] Acute on ChronicSeverity: [ ] Bleeding [ ] No bleeding [ ] Abscess [ ] No abscess [ ] Perforation [ ] No perforation Site: [ ] Ileum [ ] Small Intestine [ ] Large Intestine [ ] Unspecified Intestine Type: [ ] Meckel’s diverticulum with diverticulitis [ ] Meckel’s diverticulum without diverticulitis

ICD10 documentation specificity needed ICD9 Documentation Dysphagia ICD10 Documentation NeededIDENTIFY PHASE, TYPE and ACUITYPhase: [ ] Oral [ ] Oropharyngeal [ ] Pharyngeal [ ] Pharyngoesophageal Type: [ ] Cervical [ ] Functional [ ] Hysterical [ ] Nervous [ ] Neurogenic [ ] Siderpenic [ ] Spastica Following Non-Traumatic: [ ] SAH [ ] Intracerebral Hemorrhage [ ] Intracranial Hemorrhage [ ] CVA Acuity: [ ] Acute [ ] Chronic [ ] Acute on Chronic [ ] Other specified Dysphagia:___________ [ ] Unspecified Dysphagia

ICD10 documentation specificity needed ICD9 Documentation Encephalopathy ICD10 Documentation NeededIDENTIFY Acuity, Etiology and SeverityAcuity: [ ] Acute [ ] Subacute [ ] ChronicEtiology: [ ] Hypertensive [ ] Metabolic [ ] Toxic [ ] Toxic Metabolic [ ] Hepatic [ ] Hypoxic [ ] Septic [ ] Alcohol [ ] Drugs (specify)_______________ [ ] Post procedural (specify)______________ Severity: [ ] with coma [ ] without coma

ICD10 documentation specificity needed ICD9 Documentation Functional Quadriplegia [ ] Functional quadriplegia (complete immobility) [ ] Immobilization syndrome (impaired mobility)ICD10 Documentation NeededSame as ICD 9

ICD10 documentation specificity needed ICD9 Documentation Gastroparesis ICD10 Documentation NeededIdentify if related to diabetes and if underlying disease[ ] Gastroparesis related to Diabetes[ ] Gastroparesis in underlying disease/process (please state: ______________)

ICD10 documentation specificity needed ICD9 Documentation Upper Gastrointestinal Ulcer ICD10 Documentation NeededIdentify acuity, type and any related or contributing diseaseAcuity: [ ] Acute [ ] Chronic [ ] Hemorrhage -or- [ ] No Hemorrhage [ ] Perforation -or- [ ] No Perforation Type: [ ] Gastric Ulcer [ ] Esophageal Ulcer [ ] Duodenal, Duodenum [ ] Other location ________________ [ ] Any related or contributing disease(s) Alcohol or drugs: _________________

ICD10 documentation specificity needed ICD9 Documentation GERD ICD10 Documentation NeededIDENTIFY GERD WITH OR WITHOUT ESOPHAGITISGastro esophageal reflux disease (GERD) with Esophagitis Gastro esophageal reflux disease (GERD) without Esophagitis

ICD10 documentation specificity needed ICD9 Documentation ACUTE HEART FAILURE [ ] Acute Systolic Heart Failure [ ] Acute Diastolic Heart Failure [ ] Acute Systolic and Diastolic Heart Failure ACUTE ON CHRONIC HEART FAILURE [ ] Acute On Chronic Systolic Heart Failure [ ] Acute On Chronic Diastolic Heart Failure [ ] Acute On Chronic Systolic and Diastolic Heart FailureICD10 Documentation Needed SAME as ICD 9 with the addition OTHER ETIOLOGIES OF HEART FAILURE [ ] Heart Failure Due To Valvular Disease [ ] Right Heart Failure / Acute Cor Pulmonale [ ] Right Heart Failure / Chronic Cor Pulmonale [ ] Rheumatic Heart Disease [ ] Endocarditis (valvular) [ ] Myocarditis [ ] Pericarditis

ICD10 documentation specificity needed ICD9 Documentation CHRONIC HEART FAILURE[ ] Chronic Systolic Heart Failure[ ] Chronic Diastolic Heart Failure[ ] Chronic Systolic and Diastolic Heart FailureICD10 Documentation Needed SAME as ICD 9 with the addition of etiology Etiologies: [ ] Hypertension [ ] Valvular disease [ ] Rheumatic heart disease

ICD10 documentation specificity needed ICD9 Documentation HIV-AIDS[ ] HIV infection/disease symptomatic related condition[ ] AIDS[ ] Non-HIV related condition[ ] Asymptomatic HIV infection status[ ] Non-specific serologic evidence of HIVICD10 Documentation NeededSimilar to ICD 9

ICD10 documentation specificity needed ICD9 Documentation Hypertension [ ] Malignant Hypertension[ ] Accelerated Hypertension[ ] Benign Hypertension[ ] Unspecified HypertensionICD10 Documentation NeededSame as ICD 9

ICD10 documentation specificity needed ICD9 Documentation Hyponatremia ICD10 Documentation NeededIdentify specificity[ ] Hyponatremia, unknown cause[ ] Hyponatremia due to Sodium Deficiency[ ] Hyponatremia due to SIADH (Syndrome of Inappropriate Secretion of Antidiuretic Hormone)[ ] Insignificant lab value

ICD10 documentation specificity needed ICD9 Documentation Altered Mental Status ICD10 Documentation NeededIDENTIFY SPECIFICITYAltered Mental Status: [ ] Delirium [ ] Mild Cognitive Impairment [ ] Drug-Induced Delirium [ ] Mental Disorder (Specify): __________ [ ] Other (Specify): ________ Altered Level of Consciousness: [ ] Coma [ ] Somnolence [ ] Persistent Vegetative State [ ] Stupor (Catatonic) [ ] Transient Alteration of Awareness Encephalopathy: [ ] Alcoholic [ ] Due to Drugs [ ] Hepatic [ ] Hypertensive [ ] Anoxic / hypoxic [ ] Other (Specify): ___________ [ ] Metabolic / Septic [ ] Traumatic [ ] Hypoglycemic

ICD10 documentation specificity needed ICD9 Documentation Acidosis/Alkalosis ICD10 Documentation NeededIdentify Type of Acidosis or Alkalosis[ ] Acidosis: [ ] Metabolic [ ] Respiratory [ ] Lactic [ ] Renal[ ] Alkalosis: [ ] Metabolic [ ] Respiratory

ICD10 documentation specificity needed ICD9 Documentation Neoplasm ICD10 Documentation NeededIdentify Site, Laterality, Type, Malignancy and associated conditionsSite: Identify:_______________Laterality: [ ] Right [ ] Left [ ] Bilateral Type: [ ] Primary [ ] Secondary [ ] In situ [ ] Overlapping primary [ ] Secondary sites [ ] Malignant [ ] Benign [ ] Unspecified Behavior [ ] Other__________Malignancy: [ ] Excised [ ] Eradicated [ ] Treatment still provided for primary and/or metastatic site [ ] Evidence of remaining malignancy at primary site [ ] Conditions associated with neoplasm : (Specify) ____________________________ [ ] Any associated diagnoses / condition ____________________________________

ICD10 documentation specificity needed ICD9 Documentation Non Pressure Ulcer ICD10 Documentation NeededIdentify Location, laterality, depth, type and gangrenousLocation [ ] Back [ ] Buttock [ ] Lower limb [ ] Ankle [ ] Calf [ ] Heel/ midfoot [ ] Thigh [ ] Other__________ Laterality [ ] Left [ ] Right [ ] Bilateral [ ] Upper [ ] Lower [ ] N/A Depth [ ] Skin only [ ] Fat exposed [ ] Muscle Necrosis [ ] Bone Necrosis Type [ ] Diabetic [ ] Vascular r/t PVD [ ] Varicose [ ] Atherosclerosis of lower limb [ ] Postphlebitic syndrome [ ] Postthrombotic syndrome [ ]Chronic venous hypertension [ ] Other (specify) ______ Gangrene [ ] Yes [ ] No

ICD10 documentation specificity needed ICD9 Documentation Malnutrition [ ] Under-nutrition / Malnutrition: [ ] Mild [ ] Moderate [ ] Severe [ ] Unspecified[ ] Protein Calorie Malnutrition: [ ] Mild [ ] Moderate [ ] Severe [ ] Unspecified[ ] Marasmus [ ] Nutritional Edema[ ] Other Malnutrition (please specify) _______________________________ ICD10 Documentation Needed Same as ICD 9

ICD10 documentation specificity needed ICD9 Documentation Pancreatitis ICD10 Documentation NeededIdentify acuity, cause, gangrenous and alcohol induced[ ] Acute: [ ] Gallstone [ ] Biliary [ ] Idiopathic [ ] Other [ ] Chronic: [ ] Cystic [ ] Infectious [ ] Interstitial [ ] Recurrent [ ] Gangrenous [ ] Alcohol-induced: [ ] Abuse [ ] Dependence

ICD10 documentation specificity needed ICD9 Documentation Injury ICD10 Documentation NeededFor this injury _________, please document the following information: How the injury occurred (i.e. fall, MVA, etc.) ___________________Location where the injury occurred (i.e. home, work, school, etc.) ____________________________ Activity at time of injury (i.e. running, gardening, skating, etc.) ______________________________ Status at time of injury (i.e. civilian, military, volunteer, etc.) ______________________________

ICD10 documentation specificity needed ICD9 Documentation Aspiration Pneumonia ICD10 Documentation NeededIDENTIFY SPECIFICITY and any associated illnesses[ ] Aspiration Bronchitis[ ] Pneumonia secondary to______ (specify organism / underlying disease) [ ] Community Acquired (simple) Pneumonia [ ] Healthcare / Hospital Acquired Pneumonia (outside facility / prior hospitalization) [ ] Ventilator associated [ ] Radiation induced [ ] Associated illness: [ ] Respiratory failure [ ] Sepsis [ ] Underlying lung disease [ ] Other specify)_____ [ ] Pneumonia of unknown etiology [ ] Infiltrates without evidence of Pneumonia

ICD10 documentation specificity needed ICD9 Documentation Hypostatic Passive/ Stasis Pneumonia [ ] Hypostatic Passive/ Stasis Pneumonia[ ] Pneumonia due to (specify organism/ underlying disease)_____________[ ] Ventilator-associated[ ] Radiation induced[ ] Associated illness: [ ] Respiratory Failure [ ] Underlying lung disease [ ] Other (specify)________________ ICD10 Documentation Needed Same as ICD 9

ICD10 documentation specificity needed ICD9 Documentation Pneumonia- identify specificity [ ] Gram Negative Pneumonia [ ] Gram Positive Pneumonia[ ] MRSA Pneumonia [ ] MSSA Pneumonia[ ] Pneumonia due to ________ (specify organism / underlying disease)(e.g. E. Coli, Klebsiella, Pneumococcus, Pseudomonas, Other Staph)[ ] Community acquired (simple) Pneumonia[ ] Healthcare / Hospital Acquired Pneumonia (outside facility / prior hospitalization) [ ] Aspiration pneumonia[ ] Ventilator – associated pneumonia[ ] Radiation induced pneumonia [ ] Associated illness: [ ] Respiratory failure [ ] Sepsis [ ] Underlying lung disease [ ] Other _______________ [ ] Pneumonia of unknown etiology [ ] Infiltrates without evidence of Pneumonia ICD10 Documentation Needed Similar to ICD 9

ICD10 documentation specificity needed ICD9 Documentation Pressure Ulcer ICD10 Documentation NeededIdentify Location, stage, laterality, POA and gangrene presentDecubitus Ulcer: Location: __________ POA: [ ] Yes [ ] No [ ] Unable to determineStage (I to IV): _______ Laterality: Left_____ Right_____ Bilateral_____ N/A_____ [ ] Gangrene present [ ] Yes [ ] No ( Stage I : Erythema ; Stage II: Partial thickness; Stage III: Full thickness; Stage IV : Necrosis to muscle/bone )

ICD10 documentation specificity needed ICD9 Documentation Pulmonary Embolism ICD10 Documentation NeededIdentify acuity, type and if associated acute cor pulmonaleAcuity: [ ] Acute [ ] Chronic Type: [ ] Saddle [ ] Septic [ ] Other___ [ ] Pulmonary Embolism with associated Acute Cor Pulmonale

ICD10 documentation specificity needed ICD9 Documentation Acute Renal Failure (ARF) / Acute Kidney Injury (AKI) [ ] Prerenal Azotemia (dehydration, shock, CHF, renal obstruction, creatinine responds to IV fluid)[ ] Acute Tubular Necrosis (ATN) (nephrotoxicity, extended decreased renal perfusion, increasing creatinine (0.5 / day) not responding to fluids , low urine output ) [ ] Acute Interstitial Nephritis (AIN) ( nephritis in which the interstitial connective tissue is chiefly affected) [ ] Acute cortical necrosis [ ] Acute medullary necrosis [ ] Acute kidney injury [ ] traumatic injury [ ] Nontraumatic injury [ ] Other Etiology or underlying conditions related to the diagnosis of ARF/ AKI:________________ [ ] Acute on Chronic Renal Failure please specify Type of ARF (above) and Stage of CKD ________ ICD10 Documentation Needed Same as ICD 9

ICD10 documentation specificity needed ICD9 Documentation Chronic Renal Failure [ ] Chronic Renal Failure (CRF) / Chronic Kidney Disease (CKD) Stage: _______ (I to V or ESRD—see below)  Dialysis dependent [ ] Yes [ ] No CKD- National Kidney Foundation Guidelines for CKD Staging Stage I Kidney damage with normal or increased GFR GFR > 90 Stage II Kidney damage with mildly decreased GFR GFR 60-89 Stage III Kidney damage with moderately decreased GFR GFR 30-59 Stage IV Kidney damage with severely decreased GFR GFR 16-29 Stage V Kidney failure GFR<15 ESRD End Stage Renal Disease On dialysis  ICD10 Documentation Needed Same as ICD 9

ICD10 documentation specificity needed ICD9 Documentation COPD  ICD10 Documentation NeededIdentify Acuity[ ] Acute exacerbation of COPD [ ] Acute exacerbation of Asthma[ ] COPD – Chronic and stable

ICD10 documentation specificity needed ICD9 Documentation   EmphysemaICD10 Documentation NeededIdentify Acuity and TypeAcuity: [ ] Acute exacerbation of Emphysema [ ] Chronic and stable EmphysemaType: [ ] Unilateral: [ ] Sawyer-James Syndrome [ ] Unilateral Hyper-Lucent Lung [ ] Unilateral Pulmonary Artery Functional Hypoplasia [ ] Pan lobular [ ] Centrilobar

ICD10 documentation specificity needed ICD9 Documentation Respiratory Failure ICD10 Documentation NeededIDENTIFY TYPE, ACUITY and ETIOLOGYAcute Respiratory Failure: [ ] with Hypoxia [ ] with Hypercapnia Acute On Chronic Respiratory Failure: [ ] with Hypoxia [ ] with Hypercapnia Acute Respiratory Failure caused by: _____ (etiology) [ ] Acute Respiratory Insufficiency following [ ] trauma [ ] other

ICD10 documentation specificity needed ICD9 Documentation Post op Respiratory Issues ICD10 Documentation NeededIdentify Acuity and surgery type[ ] Post-op Acute pulmonary insufficiency [ ] Thoracic surgery [ ] Non-Thoracic surgery[ ] Post-op Acute respiratory failure [ ] Thoracic surgery [ ] Non-Thoracic surgery  [ ] Post-op Chronic pulmonary insufficiency[ ] Post-op Chronic respiratory failure[ ] Hypoxia [ ] Respiratory failure not related to surgical procedure [ ] Acute [ ] Chronic [ ] Acute on Chronic

ICD10 documentation specificity needed ICD9 Documentation Sepsis ICD10 Documentation Needed Identify causative agent, due to, name organ dysfunction- if applicable [ ] Sepsis (include causative agent if known) _________ Due to: [ ] Device [ ] Implant [ ] Graft [ ] Infusion [ ] Abortion [ ] SIRS due to non-infectious process [ ] with organ dysfunction [ ] without organ dysfunction [ ] Severe sepsis with acute organ dysfunction of: __________________________________________ (Examples: respiratory failure, encephalopathy, acute kidney failure, other) [ ] SIRS due to infection or infectious process [ ] with organ dysfunction [ ] without organ dysfunction [ ] Septic shock [ ] Sepsis related to a device ( i.e. port, IV line, pacer / ICD leads, Foley, etc . ) _______________________

ICD10 documentation specificity needed ICD9 Documentation SHOCK [ ] Hypovolemic shock[ ] Hemorrhagic shock[ ] Cardiogenic shock [ ] Septic shock (Circulatory failure associated with severe sepsis, represents organ failure)ICD10 Documentation Needed Same as ICD 9

ICD10 documentation specificity needed ICD9 Documentation Substance Abuse ICD10 Documentation Needed Identify substance, status, complication and any induced disordersSubstance(s): [ ] Alcohol [ ] Opioid [ ] Cannabis [ ] Sedative, Hypnotic, Anxiolytic [ ] Cocaine [ ] Other stimulant [ ] Hallucinogenic [ ] Inhalant-related [ ] Other psychoactive drug: __________ [ ] Unspecified drug   Status : [ ] Use [ ] Abuse [ ] Dependence  Complications: [ ] Intoxication [ ] Withdrawal [ ] In remission [ ] Uncomplicated[ ] Other complication: ____________ [ ] Unspecified complication  Substance-Induced Disorders : [ ] Psychosis : [ ] Delirium [ ] Delusions [ ] Hallucinations [ ] Perceptual Disturbances: [ ] Anxiety Disorder [ ] Sexual Dysfunction [ ] Sleep Disorder [ ] Unspecified substance-induced disorder [ ] Other substance-induced disorder: ________________________________ [ ] No substance-induced disorder

ICD10 documentation specificity needed ICD9 Documentation UROSEPSIS- codes to UTI, please state if [ ] Sepsis from a urinary source Related to: [ ] Urinary obstruction [ ] Indwelling catheter [ ] Self-catheterization [ ] Suprapubic catheter [ ] Localized urinary tract infection (without sepsis)ICD10 Documentation Needed Same as ICD 9

ICD10 documentation specificity needed ICD9 Documentation UTI ICD10 Documentation NeededIdentify acuity, site and due toAcuity: [ ] Acute [ ] Chronic [ ] Acute on ChronicSite: [ ] Kidney [ ] Ureter [ ] Bladder [ ] Urethra [ ] Other site __________ [ ] Unable to determine [ ] UTI due to or related to: [ ] Indwelling catheter [ ] Self-catheterization [ ] Neurogenic bladder [ ] Suprapubic catheter

Questions—contact your Clinical Documentation Specialists at your hospital Jewish Hospital- --502-587-2833 CDI office for all specialists Jewish Shelbyville -- 502-587-2833 CDI office Clinical Documentation Specialists --Candy RickardPeggy BarlarCharlotte HopewellSusan HinkleDale CrosbyBecki FudgeSara Goff Manager- Sandy Hodge- Bowman 502-409-2673Supervisor- Kristen Boles 859-421-1542

Sts. Mary and Elizabeth Clinical Documentation Specialists Mickey Decker– 502-361-6125 Cheryl Brooks-502-361-6549Annette Majors- 502-361-6495Manager- Sandy Hodge- Bowman 502-409-2673Supervisor- Kristen Boles 859-421-1542Questions—contact your Clinical Documentation Specialists at your hospital

University of Louisville Clinical Documentation Specialists Katie Hernandez– 502-562-2895 Hilda Meehan—502-562-3801Olga Soukhanova—502-562-3152Cheryl Ward—502-562-3539Peggy Fields—502-562-3730Manager- Sandy Hodge- Bowman 502-409-2673Supervisor- Kristen Boles 859-421-1542Questions—contact your Clinical Documentation Specialists at your hospital

St Joe Main Clinical Documentation Specialists Michelle Ahady—859-313-2178 Tina Baker—859-313-2254Lynnette Tuttle—859-313-1925Ann Spero—859-313-2254Teressa Cozine—859-313-2178Trudy Paynter—859-313-1927Karen Browning—859-313-1925Manager- Sandy Hodge- Bowman 502-409-2673Supervisor- Kristen Boles 859-421-1542Questions—contact your Clinical Documentation Specialists at your hospital

St. Joe EastClinical Documentation Specialists Kimberly Gilbert-Morrison—502-316-5220 Kelly Geers—502-750-2329 Manager- Sandy Hodge- Bowman 502-409-2673Supervisor- Kristen Boles 859-421-1542Questions—contact your Clinical Documentation Specialists at your hospital

FlagetClinical Documentation Specialist Cheryl Mitchell--502-350-5247 Manager- Sandy Hodge- Bowman 502-409-2673Supervisor- Kristen Boles 859-421-1542Questions—contact your Clinical Documentation Specialists at your hospital

St Joe LondonClinical Documentation Specialists Katrina Henson—606-330-6759 Sherry Mills—606-330-6000Manager- Sandy Hodge- Bowman 502-409-2673Supervisor- Kristen Boles 859-421-1542Questions—contact your Clinical Documentation Specialists at your hospital

St. Joe Mt. SterlingClinical Documentation Specialists Lori Barry—859-497-5458 Manager- Sandy Hodge- Bowman 502-409-2673 Supervisor- Kristen Boles 859-421-1542Questions—contact your Clinical Documentation Specialists at your hospital