Wiki Guidlines

[dawnstanley1]

I was wondering of anyone had any guidelines they would be willing to share R/T risk adjustment coding. I know the ICD10 book has guidelines but my providers are asking for a more simplified version. I also am wondering If you have any codes you often see your providers are missing. Example amputations, gastrostomies, hemiparesis ETC.

One more question do you have a flow as to how you audit your charts looking for codes that could be captured?

 

[Jennikate]

Hi one area of concern we are working on is our providers forget the follow up code example diabetes w/ CKD they forget add the N18 CKD stage code as well. I made a cheat sheet for them to follow it seems to be helping some. Good luck.

 

[dawnstanley1]

Hi one area of concern we are working on is our providers forget the follow up code example diabetes w/ CKD they forget add the N18 CKD stage code as well. I made a cheat sheet for them to follow it seems to be helping some. Good luck.

Would you be willing to share your cheat sheet? I've been sending the providers helpful hints some choose to use and I think some put it in their trash folder

 

[Jennikate]

• When noting hypertensive with chronic kidney disease need chronic kidney disease with stage noted as well.Example I12.9 hypertensive with CKD stage 1-4 N18.3 CKD stage 3

• When noting Hypertensive with heart failure need the heart failure noted as well. Example I11.0 Hypertensive with heart failure I50.32Chronic diastolic (congestive) heart failure.

• When noting Hypertensive with Heart failure and Chronic kidney disease both heart failure and Chronic Kidney disease codes need to be noted also Example I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease N18.5 chronic Kidney disease stage 5 End stage and I50.32 Chronic diastolic (congestive) heart failure.

• The assessments need to match treatments so if 3 assessments there needs be 3 treatments even if just noted stable.

• Semi Annual visits need to be noted as such in HPI. Not 3 month follow up with labs.

• Depression assessments should be done once a year .

• Z00.01 Should only be used for Annual or Semi Annual not for sick visits or Surgical clearance visits.

• Please don’t add new medications under other we need them linked to diagnosis they are for.

• For patients that are current smokers and have COPD please add T65.222AToxic effect of tobacco cigarettes, intentional self-harm, initial encounter

after first time T65.222D Toxic effect of tobacco cigarettes, intentional self-harm, subsequent encounter F17.218 Nicotine dependence cig with other nicotine induced disorders

Do not code TIA unless you re sending Pt to hospital. Code Z86.73
Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits add code for any hemiplasia ect

 

[dawnstanley1]

• When noting hypertensive with chronic kidney disease need chronic kidney disease with stage noted as well.Example I12.9 hypertensive with CKD stage 1-4 N18.3 CKD stage 3

• When noting Hypertensive with heart failure need the heart failure noted as well. Example I11.0 Hypertensive with heart failure I50.32Chronic diastolic (congestive) heart failure.

• When noting Hypertensive with Heart failure and Chronic kidney disease both heart failure and Chronic Kidney disease codes need to be noted also Example I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease N18.5 chronic Kidney disease stage 5 End stage and I50.32 Chronic diastolic (congestive) heart failure.

• The assessments need to match treatments so if 3 assessments there needs be 3 treatments even if just noted stable.

• Semi Annual visits need to be noted as such in HPI. Not 3 month follow up with labs.

• Depression assessments should be done once a year .

• Z00.01 Should only be used for Annual or Semi Annual not for sick visits or Surgical clearance visits.

• Please don’t add new medications under other we need them linked to diagnosis they are for.

• For patients that are current smokers and have COPD please add T65.222AToxic effect of tobacco cigarettes, intentional self-harm, initial encounter

after first time T65.222D Toxic effect of tobacco cigarettes, intentional self-harm, subsequent encounter F17.218 Nicotine dependence cig with other nicotine induced disorders

Do not code TIA unless you re sending Pt to hospital. Code Z86.73
Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits add code for any hemiplasia ect

Thank you this is awesome.