Improving clinical documentation: ICD-10 tips on influenza


As you may have heard, the implementation of ICD-10 has been delayed until at least October 2015.  Although our leadership team is refining the hospital’s global strategy based on the new timeline, the physician champion team will maintain its focus on improved clinical documentation.

From the time we began planning for the implementation of ICD-10, we maintained the position that our mission is to help providers become better documenters, not coders. Complete, accurate and timely documentation promotes patient safety, effective communication and appropriate reimbursement.

To that end, Akron Children’s introduced the Clinical Documentation Improvement (CDI) team. CDI specialists perform concurrent and retrospective reviews of inpatient medical records looking for inaccurate, ambiguous, conflicting, incomplete or nonspecific provider documentation. To accomplish this, they often query providers.

Dr. David Chand

Dr. David Chand

What is a query?

It’s a process to obtain clarification and ensure that all diagnoses and treatments are documented to the highest level of specificity substantiated by the patient’s clinical presentation and corresponding treatment.

As opposed to the current state where most reviews are done retrospectively, concurrent reviews can increase the accuracy of a provider’s documentation since the provider is at the highest degree of familiarity with the details of a case. By working collaboratively with the CDI team, we can all reach our goal of effective documentation.

ICD-10 Topic for April: Influenza

As a reminder, the ICD-10 Code Structure is:

  • Characters 1-3: Category
  • Characters 4-6: Etiology, anatomic site, severity or other clinical detail
  • Characters 7: Extension

In ICD-10-CM, there are 3 basic categories to report influenza:

    • J09: Influenza due to certain identified influenza viruses.
      • Includes influenza documented as avian/bird, swine, other animal origin or A/H5N1.
        •  A positive laboratory test is not required.
        • Assignment is based on the physician’s diagnostic statement.
  •  J10: Influenza due to other identified influenza virus.
  •  J11: Influenza due to unidentified influenza virus.
    • Assigned when the specific type of influenza is documented as “suspected,” “possible” or “probable” avian, other novel type A or other specified type.

ICD-10-CM requires more documentation with respect to manifestations.

There are codes for influenza with pneumonia, with any associated pleural effusion or sinusitis, other respiratory manifestations such as laryngitis or pharyngitis, otitis media, gastrointestinal manifestations, encephalopathy, myocarditis and manifestations not otherwise specified.

Documentation of any associated drug resistance and the classification of drug is required in ICD-10-CM.

When pulmonary manifestations are associated with influenza, ICD-10-CM asks if the patient was exposed to environmental tobacco smoke, has a history of tobacco use or is currently a smoker.

About David Chand, MD

Dr. David Chand is a pediatric hospitalist and Lean Six Sigma deployment leader at Akron Children's Hospital. He has a special interest in eliminating waste in healthcare and uses Lean Six Sigma principles to improve patient care and efficiency.

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