Mental Health CDI Review AAPC April 2016 Agenda Agenda Discuss LCDs quickly Discuss Chapter 5 Documentation goals Psychiatric Diagnosis Comorbid conditions 1
LCDs Local coverage determinations Medicare Many payers use these as a basis Do find out if your private payer has their own coverage determination policies. Chapter 5 Mental, Behavioral and Neurodevelopmental disorders (F01-F99) F01-F09 F10-F19 F20-F29 F30-F39 F40-F48 F50-F59 F60-F69 F70-F79 F80-F89 F90-F98 F99 Mental disorders due to known physiological conditions Mental and behavioral disorders due to psychoactive substance use Schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders Mood [affective] disorders Anxiety, dissociative, stress-related, somatoform and other nonpsychotic mental disorders Behavioral syndromes associated with physiological disturbances and physical factors Disorders of adult personality and behavior Intellectual disabilities Pervasive and specific developmental disorders Behavioral and emotional disorders with onset usually occurring in childhood and adolescence Unspecified mental disorder 2
Chapter 5 Mental, Behavioral and Neurodevelopmental disorders (F01-F99) a. Pain disorders related to psychological factors Assign code F45.41, for pain that is exclusively related to psychological disorders. As indicated by the Excludes 1 note under category G89, a code from category G89 should not be assigned with code F45.41. Code F45.42, Pain disorders with related psychological factors, should be used with a code from category G89, Pain, not elsewhere classified, if there is documentation of a psychological component for a patient with acute or chronic pain. See Section I.C.6. Pain b. Mental and behavioral disorders due to psychoactive substance use 1) In Remission Selection of codes for in remission for categories F10-F19, Mental and behavioral disorders due to psychoactive substance use (categories F10-F19 with -.21) requires the provider s clinical judgment. The appropriate codes for in remission are assigned only on the basis of provider documentation (as defined in the Official Guidelines for Coding and Reporting). 2) Psychoactive Substance Use, Abuse And Dependence When the provider documentation refers to use, abuse and dependence of the same substance (e.g. alcohol, opioid, cannabis, etc.), only one code should be assigned to identify the pattern of use based on the following hierarchy: If both use and abuse are documented, assign only the code for abuse If both abuse and dependence are documented, assign only the code for dependence If use, abuse and dependence are all documented, assign only the code for dependence If both use and dependence are documented, assign only the code for dependence. 3) Psychoactive Substance Use As with all other diagnoses, the codes for psychoactive substance use (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-, F15.9-, F16.9-) should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis (see Section III, Reporting Additional Diagnoses). The codes are to be used only when the psychoactive substance use is associated with a mental or behavioral disorder, and such a relationship is documented by the provider. Coding Rules Code First - ICD-10-CM Medicare Claims Processing Manual Chapter 3 - Inpatient Hospital Billing (Rev. 3388, 10-30-15)190.5.2 - Application of Code First Diagnosis code F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance is designated as NOT ALLOWED AS PRINCIPAL DX code. The three digit code F02 Dementia in other diseases classified elsewhere, is designated as a Code First diagnosis indicating that all diagnosis codes that fall under the F02 category (codes F02.80 and F02.81) must follow the Code First rule. The 3 digit code F02 Dementia in other diseases classified elsewhere appears in the ICD- 10-CM as follows: Code first the underlying physiological condition, such as: F02.80 Dementia in other diseases classified elsewhere without behavioral disturbance NOT ALLOWED AS PRINCIPAL DX F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance NOT ALLOWED AS PRINCIPAL DX According to Code First requirements, the provider would code the appropriate physical condition first, for example, G20 Parkinson s disease as the principal diagnosis code and F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance as a secondary diagnosis or comorbidity code on the patient claim 6 3
Coding Rules Code First ICD-10-CM The purpose of this example is to demonstrate proper coding for a Code First situation. However, in this case, the principal diagnosis groups to one of the 15 DRGs, or 17 MS-DRGs, for which CMS pays an adjustment. Had the diagnosis code grouped to a non-psychiatric DRG/MS-DRG, the PRICER would search the first of the other diagnosis codes for a psychiatric code listed in the Code First list in order to assign a DRG adjustment. 7 CDC advise for Excludes 1 note Updated October 26, 2015 (Original posting October 19, 2015) There are circumstances that have been identified where some conditions included in Excludes1 notes should be allowed to both be coded, and thus might be more appropriate for an Excludes2 note. However, due to the partial code freeze, no changes to Excludes notes or revisions to the official coding guidelines can be made until October 1, 2016. This new guidance concerning Excludes1 notes is intended to allow conditions to be reported together when appropriate even though they may currently be subject to an Excludes1 note. This coding advice has been approved by the four Cooperating Parties the American Health Information Management Association (AHIMA), the American Hospital Association (AHA), the Centers for Medicare and Medicaid Services (CMS), and the National Center for Health Statistics (NCHS). This advice will also be published in the 4th Quarter 2015 issue of Coding Clinic for ICD-10-CM and ICD-10-PCS. Coding Clinic 4 th quarter, 2015, pg 40. 8 4
ICD vs. Diagnosis Code Number in Lieu of a Diagnosis - Coding Clinic, Fourth Quarter ICD-10 2015 Pages: 34-35 Effective with discharges: November 13, 2015 Regulatory and accreditation directives that require providers to supply documentation to support the code assignment. Providers need to specifically address a patient condition ICD-10-CM, per se, is not a diagnosis. Can contain several different diagnosis in one code number. Providers responsibility to provide clear and legible documentation of a diagnosis which is then translated to and ICD-10-CM code for external reporting purposes. 9 Documentation Goals To clearly address: The condition, which after study occasioned the patient to the facility The comorbid condition(s) which are being treated or affect treatment during the hospital stay The onset and duration and relevant history A treatment plan built from these diagnostic evaluations Specific to the patient s needs and diagnosis Set goals The progress or lack there-of the patient s response to treatment Overall - When closed, the chart should paint a clear picture of the patient s course of care The work toward discharging to the most effective level of care must be documented in the chart, starting on the day of admission Baseline clearly document the patients progress to the baseline 5
Documentation Goals Documentation should avoid: Broad or vague statements toward the disease process NOS (Not Otherwise Specified) This should only be used in extremely short stays/emergent situations Cloning Do not repeat the same information over and over Missing components It is imperative for the physician and the facility that all documentation is complete, clear, concise and legible Diagnosis 6
Major Neurocognitive Disorder AKA Dementia Vascular Dementia Coding: Documentation: F01Vascular dementia Vascular dementia as a result of infarction of the brain due to vascular disease, including hypertensive cerebrovascular disease. Includes: arteriosclerotic dementia Code first the underlying physiological condition or sequelae of cerebrovascular disease The assessment(s) which confirm dementia History of present illness Presences of Cerebrovascular disease Neuroimaging Hx of CVAs Hx of TIAs Major Neurocognitive Disorder AKA Dementia Vascular Dementia Coding: Documentation: F01.50 - Vascular dementia without behavioral disturbance F01.51 - Vascular dementia with behavioral disturbance Vascular dementia with aggressive behavior Vascular dementia with combative behavior Vascular dementia with violent behavior Use additional code, if applicable, to identify wandering in vascular dementia (Z91.83) The presence of behaviors Descriptive as evidenced by Wandering, if present 7
Major Neurocognitive Disorder AKA Dementia (In Other Diseases Classified Elsewhere)(ODCE) Identify if known, the underlying condition Alzheimer's (G30.-) cerebral lipidosis (E75.4) Creutzfeldt-Jakob disease (A81.0-) dementia with Lewy bodies (G31.83) epilepsy and recurrent seizures (G40.-) frontotemporal dementia (G31.09) hepatolenticular degeneration (E83.0) human immunodeficiency virus [HIV] disease (B20) hypercalcemia (E83.52) hypothyroidism, acquired (E00- E03.-) intoxications (T36-T65) Jakob-Creutzfeldt disease (A81.0-) multiple sclerosis (G35) neurosyphilis (A52.17) niacin deficiency [pellagra] (E52) Parkinson's disease (G20) Pick's disease (G31.01) polyarteritis nodosa (M30.0) systemic lupus erythematosus (M32.-) trypanosomiasis (B56.-, B57.-) vitamin B deficiency (E53.8) Major Neurocognitive Disorder AKA Dementia (ODCE) Coding F02.8 - Dementia in other diseases classified elsewhere F02.80 - Dementia in other diseases classified elsewhere without behavioral disturbance Dementia in other diseases classified elsewhere NOS F02.81 - Dementia in other diseases classified elsewhere with behavioral disturbance Dementia in other diseases classified elsewhere with aggressive behavior Dementia in other diseases classified elsewhere with combative behavior Dementia in other diseases classified elsewhere with violent behavior Use additional code, if applicable, to identify wandering in dementia in conditions classified elsewhere (Z91.83) Documentation Extremely important to substantiate the patient s history of the underlying disease. Onset (Alz.Dementia) Early Late unspecified Treatment Neuroimaging When and relevant findings The presence of behaviors Descriptive as evidenced by Wandering, if present 8
Major Neurocognitive Disorder AKA Dementia - Unspecified Coding F03.9 - Unspecified dementia F03.90 - Unspecified dementia without behavioral disturbance Dementia NOS F03.91 - Unspecified dementia with behavioral disturbance Unspecified dementia with aggressive behavior Unspecified dementia with combative behavior Unspecified dementia with violent behavior Use additional code, if applicable, to identify wandering in unspecified dementia (Z91.83) Documentation The presence of behaviors Descriptive as evidenced by Wandering, if present If unsure of cause of dementia, give substantiation: New onset Complicated by other mental/physical factors Major depressive disorder, single episode F32 - Major depressive disorder, single episode Includes: single episode of agitated depression single episode of depressive reaction single episode of major depression single episode of psychogenic depression single episode of reactive depression single episode of vital depression Excludes1: bipolar disorder (F31.-) manic episode (F30.-) recurrent depressive disorder (F33.-) Excludes2: adjustment disorder (F43.2) F32.0 - Major depressive disorder, single episode, mild F32.1 - Major depressive disorder, single episode, moderate F32.2 - Major depressive disorder, single episode, severe without psychotic features F32.3 - Major depressive disorder, single episode, severe with psychotic features Single episode of major depression with moodcongruent psychotic symptoms Single episode of major depression with moodincongruent psychotic symptoms Single episode of major depression with psychotic symptoms Single episode of psychogenic depressive psychosis Single episode of psychotic depression Single episode of reactive depressive psychosis F32.4 - Major depressive disorder, single episode, in partial remission F32.5 - Major depressive disorder, single episode, in full remission F32.8 - Other depressive episodes Atypical depression Post-schizophrenic depression Single episode of 'masked' depression NOS F32.9 - Major depressive disorder, single episode, unspecified Depression NOS Depressive disorder 9
Major depressive disorder, Recurrent Coding F33.0 Major depressive disorder, recurrent, mild F33.1 Major depressive disorder, recurrent, moderate F33.2 Major depressive disorder, recurrent severe without psychotic features F33.3 Major depressive disorder, recurrent, severe with psychotic symptoms F33.4 Major depressive disorder, recurrent, in remission F33.40 Major depressive disorder, recurrent, in remission, unspecified F33.41 Major depressive disorder, recurrent, in partial remission F33.42 Major depressive disorder, recurrent, in full remission F33.8 Other recurrent depressive disorders F33.9 Major depressive disorder, recurrent, unspecified Documentation Specify: Single episode Recurrent Mild Moderate Severe without psychosis Severe with psychosis Reaction to severe stress, and adjustment disorders F43.0 Acute stress reaction Acute crisis reaction Acute reaction to stress Combat and operational stress reaction Combat fatigue Crisis state Psychic shock F43.1 Post-traumatic stress disorder (PTSD) Traumatic neurosis F43.10 Post-traumatic stress disorder, unspecified F43.11 Post-traumatic stress disorder, acute F43.12 Post-traumatic stress disorder, chronic 10
Reaction to severe stress, and adjustment disorders F43.2 Adjustment disorders Culture shock Grief reaction Hospitalism in children Excludes2:separation anxiety disorder of childhood (F93.0) F43.20 Adjustment disorder, unspecified F43.21 Adjustment disorder with depressed mood F43.22 Adjustment disorder with anxiety F43.23 Adjustment disorder with mixed anxiety and depressed mood F43.24 Adjustment disorder with disturbance of conduct F43.25 Adjustment disorder with mixed disturbance of emotions and conduct F43.29 Adjustment disorder with other symptoms F43.8 Other reactions to severe stress F43.9 Reaction to severe stress, unspecified Sleep disorders not due to a substance or known physiological condition Excludes2: organic sleep disorders (G47.-) F51.0 Insomnia not due to a substance or known physiological condition Excludes2: alcohol related insomnia (F10.182, F10.282, F10.982) drug-related insomnia (F11.182, F11.282, F11.982, F13.182, F13.282, F13.982, F14.182,F14.282, F14.982, F15.182, F15.282, F15.982, F19.182, F19.282, F19.982) insomnia NOS (G47.0-) insomnia due to known physiological condition (G47.0-) organic insomnia (G47.0-) sleep deprivation (Z72.820) F51.01 Primary insomnia Idiopathic insomnia F51.02 Adjustment insomnia F51.03 Paradoxical insomnia F51.04 Psychophysiologic insomnia F51.05 Insomnia due to other mental disorder Code also associated mental disorder F51.09 Other insomnia not due to a substance or known physiological condition 11
Sleep disorders not due to a substance or known physiological condition Excludes2: organic sleep disorders (G47.-) F51.1 Hypersomnia not due to a substance or known physiological condition Excludes2: alcohol related hypersomnia (F10.182, F10.282, F10.982) drug-related hypersomnia (F11.182, F11.282, F11.982, F13.182, F13.282, F13.982, F14.182,F14.282, F14.982, F15.182, F15.282, F15.982, F19.182, F19.282, F19.982) hypersomnia NOS (G47.10) hypersomnia due to known physiological condition (G47.10) idiopathic hypersomnia (G47.11, G47.12) narcolepsy (G47.4-) F51.11 Primary hypersomnia F51.12 Insufficient sleep syndrome Excludes1: sleep deprivation (Z72.820) F51.13 Hypersomnia due to other mental disorder Code also associated mental disorder F51.19 Other hypersomnia not due to a substance or known physiological condition F51.3 Sleepwalking [somnambulism] F51.4 Sleep terrors [night terrors] F51.5 Nightmare disorder Dream anxiety disorder F51.8 Other sleep disorders not due to a substance or known physiological condition F51.9 Sleep disorder not due to a substance or known physiological condition, unspecified Emotional sleep disorder NOS Pervasive developmental disorders Use additional code to identify any associated medical condition and intellectual disabilities. F84.0 Autistic disorder Infantile autism Infantile psychosis Kanner's syndrome Excludes1: Asperger's syndrome (F84.5) F84.2 Rett's syndrome Excludes1: Asperger's syndrome (F84.5) Autistic disorder (F84.0) Other childhood disintegrative disorder (F84.3) F84.3 Other childhood disintegrative disorder Dementia infantilis Disintegrative psychosis Heller's syndrome Symbiotic psychosis Use additional code to identify any associated neurological condition. Excludes1: Asperger's syndrome (F84.5) Autistic disorder (F84.0) Rett's syndrome (F84.2) F84.5 Asperger's syndrome Asperger's disorder Autistic psychopathy Schizoid disorder of childhood F84.8 Other pervasive developmental disorders Overactive disorder associated with intellectual disabilities and stereotyped movements F84.9 Pervasive developmental disorder, unspecified Atypical autism 12
Attention-deficit hyperactivity disorders Conduct disorders F90.0 Attention-deficit hyperactivity disorder, predominantly inattentive type F90.1 Attention-deficit hyperactivity disorder, predominantly hyperactive type F90.2 Attention-deficit hyperactivity disorder, combined type F90.8 Attention-deficit hyperactivity disorder, other type F90.9 Attention-deficit hyperactivity disorder, unspecified type Attention-deficit hyperactivity disorder of childhood or adolescence NOS Attention-deficit hyperactivity disorder NOS F91.0 Conduct disorder confined to family context F91.1 Conduct disorder, childhoodonset type Unsocialized conduct disorder Conduct disorder, solitary aggressive type Unsocialized aggressive disorder F91.2 Conduct disorder, adolescentonset type Socialized conduct disorder Conduct disorder, group type F91.3 Oppositional defiant disorder F91.8 Other conduct disorders F91.9 Conduct disorder, unspecified Behavioral disorder NOS Conduct disorder NOS Disruptive behavior disorder NOS Alcohol, Tobacco, and Substance Use Categories F10-F19 Identify specific type of drug or substance Describe usage: Use Abuse Dependence In remission Mode of nicotine use Cigarettes, Chewing tobacco, Pipe, Other Specify intoxication/withdrawal as Uncomplicated or with delirium Document any withdrawal symptoms Document any associated diagnosis/conditions Blood alcohol level, if available State no related complications when applicable Document any related mood disorder Document any: Delusions, hallucinations, anxiety, sleep disorders, sexual dysfunction or other related conditions. List any treatment provided: Detox Counseling Psychotherapy Medication management Pharmacotherapy 13
Alcohol, Tobacco, and Substance Use Chapter order: Abuse Intoxication Uncomplicated or delirium Unspecified Psychotic disorders Delusions or hallucinations Unspecified Other disorders Anxiety or sexual dysfunction Other Dependence Uncomplicated Remission Intoxication Uncomplicated or delirium Unspecified Withdrawal Uncomplicated, delirium or perceptual disturbance Unspecified Induced mood disorder Induced psychotic disorder Delusions or hallucinations Unspecified Induced persisting amnestic disorder Induced persisting dementia Other induced disorders Induced anxiety disorder Induced sexual dysfunction Induced sleep disorder Other induced disorder Unspecified alcohol-induced disorder Alcohol, Tobacco, and Substance Use Use Intoxication Uncomplicated or delirium Unspecified induced mood disorder induced psychotic disorder Delusions or hallucinations Unspecified Induced persisting amnestic disorder Induced persisting dementia Other induced disorders Induced anxiety disorder Induced sexual dysfunction Induced sleep disorder Other induced disorder Unspecified Chapter order: Alcohol Opioids Cannabis Sedative, hypnotic or anxiolytic-related disorders Cocaine Other stimulants Hallucinogen Nicotine (only dependence) Inhalants Other psychoactive substances 14
Alcohol, Tobacco, and Substance Use F10.12 Alcohol abuse with intoxications F10.120 Alcohol abuse with intoxication, uncomplicated F10.121 Alcohol abuse with intoxication delirium F10.129 Alcohol abuse with intoxication, unspecified F14.12Cocaine abuse with intoxication F14.120 - Cocaine abuse with intoxication, uncomplicated F14.121 - Cocaine abuse with intoxication with delirium F14.122 - Cocaine abuse with intoxication with perceptual disturbance F14.129- -Cocaine abuse with intoxication, unspecified Chapter order: Alcohol Opioids Cannabis Sedative, hypnotic or anxiolytic-related disorders Cocaine Other stimulants Hallucinogen Nicotine (only dependence) Inhalants Other psychoactive substances Schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders (F20- F29) F20.0 Paranoid schizophrenia Paraphrenic schizophrenia F20.1 Disorganized schizophrenia F20.2 Catatonic schizophrenia F20.3 Undifferentiated schizophrenia F20.5 Residual schizophrenia F20.8 Other schizophrenia F20.81 Schizophreniform disorder F20.89 Other schizophrenia F20.9 Schizophrenia, unspecified F21 Schizotypal disorder F21 Schizotypal disorder F22 Delusional disorders F23 Brief psychotic disorder F24 Shared psychotic disorder F25 Schizoaffective disorders F25.0 Schizoaffective disorder, bipolar type F25.1 Schizoaffective disorder, depressive type F25.8 Other schizoaffective disorders F25.9 Schizoaffective disorder, unspecified F28 Other psychotic 15
Schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders (F20-F29) Identify type Paranoid Disorganized Catatonic Undifferentiated Residual Other No longer identify state Documentation if present: Delusions Hallucinations Disorganized speech Grossly abnormal psychomotor behavior (catatonia) Comorbidities 16
IPF-PPS Comorbity Comorbidities are specific patient conditions that are secondary to the patient s principal diagnosis and that require treatment during the stay. Diagnoses that relate to an earlier episode of care and have no bearing on the current hospital stay are excluded and must not be reported on IPF claims. Comorbid conditions must exist at the time of admission or develop subsequently, and affect the treatment received, length of stay (LOS), or both treatment and LOS. The physician of record is responsible for connecting any conditions the patient may have with the treatment during the encounter. These conditions, if treated should be well documented throughout the chart, including but not limited to the PE, H&P, Treatment Plan, Nursing/social work notes, dietary and PT notes. It is NOT enough to simply list the name of a condition there MUST be documentation to support the treatment of the condition or how the condition is affecting the therapeutic treatment of the mental condition IPF-PPS Comorbidity CKD Many psychiatric drugs are extremely harsh on the kidneys. Due to the CKD, the pt may need to be treated with a less optimal drug as well as it may increase the time it takes to see improvement. TB/HTN/DM The patient may be convinced the medicine is tainted (someone is trying to harm them) therefore the condition is affecting the psychiatric care. Hep C/HIV/ESRD The patient may be overwhelmed with fear of death. May have overwhelming grief or a strong desire to give up. The condition is affecting psychiatric care. 17
Diabetes E10.65 and E11.65 (with Hyperglycemia) Drug or chemical induced Due to underlying condition Type 1 or 2 Other specified DM Due to genetic defects of beta-cell function Due to genetic defects in insulin action Postpancreatectomy Postprocedureal NOS Identify the body system affected and any manifestations/complications Arthropathy Neuropathic Other Circulatory Peripheral With or without gangrene Other CKD 18
CKD CKD Document the stage of CKD Chronic kidney disease, stage 1 Chronic kidney disease, stage 2 (mild) Chronic kidney disease, stage 3 (moderate) Chronic kidney disease, stage 4 (severe) Chronic kidney disease, stage 5 End-stage renal disease (ESRD) Document any underlying cause of CKD such as Diabetes or Hypertension Document if the patient is dependent on Dialysis Chronic renal failure without a documented stage will be assigned to Chronic kidney disease, unspecified Document any associated diagnoses/conditions 19
Acute Renal Failure Document underlying condition(s) contributing/causing acute renal failure if known or suspected Document if acute kidney injury (AKI) is due to traumatic injury or if due to a non-traumatic event Document if acute renal failure is due to: Acute tubular necrosis (ATN) Acute cal necrosis Acute medullary necrosis Other (specify) Be specific with documentation Acute renal insufficiency and acute kidney disease are not reported as acute renal failure Document any associated diagnoses/conditions COPD/Asthma With Acute lower respiratory infection COPD Chronic obstructive bronchitis Exacerbation Status asthmaticus Severity Mild intermittent Mild persistent Moderate persistent Severe persistent Form or Type Cough variant Childhood Exercise induced bronchospasm Extrinsic allergic Idiosyncratic Intrinsic nonallergic Late-onset Mixed Other (specify) Document any associated diagnoses/conditions 20
Respiratory Failure Document acuity: Acute Chronic Acute on chronic Document inclusion of: Hypoxia Hypercapnia Document tobacco: Use Abuse History of Document any associated diagnoses/conditions Malnutrition The Academy and ASPEN state malnutrition should be diagnosed when providers identify at least two or more of the following six characteristics: Insufficient energy intake Weight loss Loss of muscle mass Loss of subcutaneous fat Localized or generalized fluid accumulation that may sometimes mask weight loss Diminished functional status as measured by hand grip strength Providers must assess these six characteristics in the context of an acute illness or injury, a chronic illness, or a social or environmental circumstances to determine if malnutrition is present and whether it's severe or nonsevere (moderate). 21
Dysphasia Identify if it is a residual of cerebrovascular disease Slurred speech Fluency disorder Hypertension Identify the presence/absence of hypertensive heart and/or chronic kidney disease Identify any: Tobacco use or abuse Environmental exposure to tobacco smoke 22
Gait Identify difficulty walking Gait abnormality Ataxic Paralytic Unsteadiness on feet Unspecified abnormalities or gait or mobility Other Frequent falls Coagulopathy Specify type: Disseminated intravascular coagulation Hereditary factor VIII deficiency Hereditary factor IX deficiency Von Willebrand s disease Hereditary factor XI deficiency Hereditary deficiency of other clotting factors Acquired coagulation factor deficiency Primary thrombophilia Activated protein C resistance Prothrombin gene mutation Other primary thrombophilia Other thrombophilia Antiphospholipid syndrome Lupus anticoagulant syndrome Other Specified coagulation defects Document any associated diagnoses/conditions Hemorrhagic disorder due to circulating anticoagulants Due to intrinsic circulating anticoagulants, antibodies, or inhibitors Acquired hemophilia Antiphospholipid antibody with hemorrhagic disorder Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors Hemorrhagic disorder due to extrinsic circulating anticoagulants Document specific drug, if druginduced 23
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 Hepatitis Identify type Identify acute or chronic With/without coma Document Labs HPI in PE and H&P How it affects the patient s treatment of The disease itself The mental condition which occasioned the patient to the hospital 24
Withdrawal Nicotine dependence Cigarettes Chewing tobacco Other Noncompliance With Dietary Dialysis Medical treatment Medication regimen Underdosing Unintentional Due to age debility Intentional hardship 25
The medical record is a receipt for services provided. Please be clear, concise and accurate. Questions? Heather Greene AVP/Compliance &Process Improvement hgreene@havenllc.com 615.393.8876 26