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29 Cards in this Set
- Front
- Back
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ICD -10
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International Classification of Disease
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Clinical Condition
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Nonspecific medical name of disease -hypertension |
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Clinical impression
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A specific final diagnosis -essential hypertension, well-controlled |
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Clinical concept
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Documentation that describes the clinical condition and supports the clinical impression
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ICD-10 is a set of ___________ and procedure codes used in medical documentation around the world
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Diagnosis
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What are two problems with ICD-9 that ICD-10 will solve?
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1) Outdated 2) Lacks specificity -only contains the diagnosis -no customization of codes |
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Name 4 factors that the new diagnoses will allow providers to specify. (ICD-10)
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-comorbidities -causation -complications -location -sequelae -severity -type or stage of disease |
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When must all U.S. healthcare organizations transition to ICD-10?
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October 1, 2015
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T/F Every word in the ICD-10 diagnosis must be supported by your documentation.
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True |
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Fill in the blank
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Unspecified
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The doctor assigns a diagnosis of H65.06 - Acute otitis media, recurrent, left ear. Brainstorm items that you must document in the HPI and physical exam in order to support the diagnosis |
HPI- recent onset, prior Hx of similar left ear PE- Erythematous/ bulging left TM |
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Give two examples of the clinical concept "type" |
2) Cancer (breast, lung, liver, etc.) |
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What does the "stage" of disease indicate? |
Severity
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What is laterality and what clinical concept is it a part of? |
Right or left. Included in the clinical concept "location" |
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Name an associated symptom that may be documented for a patient with hypertension
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Headache, dizziness
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You notice your provider chose a clinical impression that is unsupported by your documentation. What is the correct way to address this?
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"I noticed you chose _________ for the clinical impression and I'd like to make sure its supported by my documentation. Would you like me to add________?"
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Clinic is running very behind with four patients waiting t to be seen, but did not catch the type of congestive heart failure on the previous patient. What should you do? |
Make a note of the clinical concept needed and ask during downtime or at the end of the shift |
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T/F It is best to remind your provider of the clinical concepts while in the patients room so you can document them real-time |
False.
Always wait until exiting the room to ask the provider for clarification. |
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Your physician chooses the following ICD-10 diagnosis for the patient: 1) Chronic severe bronchitis w/associated bronchospasm 2) Tobacco use disorder Which clinical concepts must you document? |
-risk factors -associated symptoms -onset -severity |
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What two factors will make an ICD-10 diagnosis non-compliant |
1) Too general 2) Lacks supporting documentation elsewhere in the chart |
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Which clinical concepts are documented in the following HPI: Pt is a 6g y/o female presenting for evaluation of chronic type 2 diabetes. She has associated hypoglycemic episodes w/ light-headed dizziness |
-onset -type -associated symptoms |
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Aftereffects of a disease process |
Sequelae |
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Why are clinical concepts important for ICD-10 documentation? |
Clinical concepts help to support the appropriate ICD-10 diagnosis to avoid it being downcoded to a lesser diagnosis |
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Name the six clinical concepts |
1) severity 2) location 3) associated symptoms 4) type 5) onset 6) risk factors |
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What is the definition of laterality in regards to ICD-10? |
Right vs. left
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What is the best phrase that best describes a compliant clinical expression |
Specific and supported |
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You notice your provider chose a clinical impression unsupported by the documentation. What should you do? |
Outside the patients room mention to the provider that the ICD-10 diagnosis is missing |
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When describing severity, does "end-stage" refer to a mild, moderate, or severe state of a disease? |
Severe |
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? |
?? |
