ICD-10 Documentation Training: Urgent Coding for Emergent Conditions

Transcription

1 ICD-10 Documentation Training: Urgent Coding for Emergent Conditions Presented by Brenda Edwards, CPC, CPB, CPMA, CPC-I, CEMC, CRC AAPC ICD-10-CM/PCS Training Expert Copyright 2014 AAPC Disclaimer This course was current at the time it was published. This course was prepared as a tool to assist the participant in understanding how to prepare for ICD-10-CM. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility of the use of this information lies with the student. AAPC does not accept responsibility or liability with regard to errors, omissions, misuse, and misinterpretation. AAPC employees, agents, and staff make no representation, warranty, or guarantee that this compilation of information is error-free and will bear no responsibility, or liability for the results or consequences of the use of this course. AAPC does not accept responsibility or liability for any adverse outcome from using this study program for any reason including undetected inaccuracy, opinion, and analysis that might prove erroneous or amended, or the coder s misunderstanding or misapplication of topics. Application of the information in this text does not imply or guarantee claims payment. Inquiries of your local carrier(s) bulletins, policy announcements, etc., should be made to resolve local billing requirements. Payers interpretations may vary from those in this program. Finally, the law, applicable regulations, payers instructions, interpretations, enforcement, etc., may change at any time in any particular area. This manual may not be copied, reproduced, dismantled, quoted, or presented without the expressed written approval of the AAPC and the sources contained within. No part of this publication covered by the copyright herein may be reproduced, stored in a retrieval system or transmitted in any form or by any means (graphically, electronically, or mechanically, including photocopying, recording, or taping) without the expressed written permission from AAPC and the sources contained within. 2

2 Commonly Treated Conditions in Urgent Care Abdominal pain Asthma Back pain Bronchitis Dermatitis Headache Injuries Sinusitis URI 3 Clinical Concepts Type Temporal factors Caused by/ Contributing factors Symptoms/Findings/ Manifestations Localization/Laterality Anatomy Associated with Severity Episode Remission status History of Morphology Complicated by External Cause Activity Place of Occurrence Loss of Consciousness Substance Number of Gestations Outcome of Delivery BMI 4

3 Abdominal Pain Temporal factors Laterality Anatomy Acute, Chronic Rebound Tenderness Right Left Right upper quadrant Left upper quadrant Right lower quadrant Left lower quadrant 5 Abdominal Pain 6

4 Asthma Temporal factors Severity Associated with Complicated by Contributing factors Acute Chronic Exacerbation Persistent Mild Moderate Severe Status asthmaticus Exercise induced Cough variant Exposure to tobacco smoke, dependence or use 7 Asthma 8

5 Back Pain Anatomy Cervical Sciatic Lumbar Low back Thoracic Laterality Right Left 9 Back Pain 10

6 Bronchitis Temporal factors Caused by / Contributing Factors Acute, Chronic Simple Allergic Chemical, gas, fumes, vapors Complicated by Exposure to environmental smoke Exposure to tobacco smoke in perinatal period History of tobacco use Occupational exposure to environmental tobacco smoke Tobacco dependence Tobacco use 11 Bronchitis 12

7 13 Dermatitis Type Caused by / Contributing Factor Manifestation Atopic Seborrheic Diaper Allergic Irritant Due to Adverse effect 14

8 Dermatitis 15 Headache Type Hemiplegic, cyclical, ophthalmoplegic, periodic, abdominal, menstrual Temporal factors Persistent, chronic Localization / Laterality Associated With Right, left Aura, status migrainosus, intractable, cerebral infarction 16

9 Headache 17 Injuries Type Location/Laterality Anatomy Episode Activity Place of Occurrence Status Abrasion, blood vessel, contusion, fracture, muscle, nerve, superficial Left, right, unilateral, bilateral Specific location of injury Initial, subsequent, sequela What patient was doing at time of injury Where patient was at time of injury Patient s employment, volunteer, student status at time 18

10 1 Injuries 19 2 Injuries 20

11 3 Injuries 21 Sinusitis Temporal factors Acute, chronic, rebound, tenderness Laterality Right Left Associated with Allergies, altitude Anatomy Frontal, maxillary, sphenoid, pansinusitis, ethmoid 22

12 Sinusitis 23 Upper Respiratory Infections Temporal factors Acute Chronic Associated with Influenza Rhinovirus Syncytial virus Anatomy Upper Lower 24

13 Upper Respiratory Infection 25 Conclusion Assess your utilization Assess your records Receive documentation education Adjust your documentation when necessary Reassess and start again 26