Hello
Ensure providers know documentation should be specific and clear regarding certain diseases. Create email or handout to providers with certain ds. in highlights in documentation .Send it out monthly or have lunch and learn with providers every 90 days or so. Does your site have nurses who are CDI experts? They can help you too.
I would suggest be familiar with types of chronic conditions patient can suffer with such as DM, CHF , CA, Dementia, MS, COPD,HTN, Arthritis, BMI, Depression,Etc providers nee dto add to documentation. Also add combo dx codes from differ ICD10 as coding first or additional dx per national convention rules.
If the pt suffers with T.O.A.D in their medical history once provider notes it...add this. TOAD =( transplant organs, ostomies, amputation, or dialysis). Add the Forever Disease if listed in assessments or dx per med record.
Forever diseases such as: Parkinson Ds,Depression, DM Sickle Cell Lupus, HIV, Herpes, Migraines, Paralyzed, Autism, Intell Development to name a few.
Keep in mind hopefully your provider will document differ levels, types, and stages of diseases so can code detailed dx.. Some of the disease in the ICD10 manual with differ stages and levels are CHKD, Hemorrhoids, Sinusitis, Anemia, area of Stomach Pain, Dementia, Depression, Fractures, CVA, Cardiac attacks, CA, DJD just to name a few.
Medication notations....add dx Z79.4 if pt take insulin or dx Z99 if have kidney dialysis and dx Z79.89 cardiac medications on regular basis .
Follow the dx sequence of priority per the documentation and most Z dx are last on claim unless first listed or screening code. If pt has had disease years ago, use proper Z dx code of personal medical history of block Z86 or Z87 . Any past CA disease use dx Z85 if related to treating the current illness. If pt smokes cigarettes then suffers with chronic condition as any Cardiac ds. ,HTN, gastro or any respiratory disease add Z72 or F17 or Z87.89 if mentioned in the medical documentation. Understand how to code pain...read it in ICD10 manual
Well I hope you can find this data helpful in risk coding . You can order books or manuals on RA to assist you too
Lady T