Complex Coding Decisions Using ICD-10-PCS, Part 4

Transcription

1 Complex Coding Decisions Using ICD-10-PCS, Part 4 Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA Kuehn Consulting, LLC Waukesha, WI (262) LKuehn1@wi.rr.com

2 Learning Objectives At the conclusion of this program, you will be able to: Describe the system design for ICD-10-PCS Compare and contrast the root operation groups Differentiate between similar root operations using critical thinking skills Identify the root operations assigned for 10 common PCS cases Determine the remaining characters in each code for 10 common PCS cases 2

3 PCS Files Download the PCS files from: 10/2015-ICD-10-PCS-and-GEMs.html 2015 Code Tables and Index 2015 Official ICD-10-PCS Coding Guidelines 2015 ICD-10-PCS Reference Manual Use electronic version too big to print 3

4 Code Structure Section Root Operation Approach Qualifier Body System Body Part Device 4

5 ICD-10-PCS Index Provides the first three or four characters of the code Refers the coder to the correct code table The code tables must always be used to obtain the complete code 5

6 ICD-10-PCS Tables Each table contains four columns and a varying numbers of rows Column: Row: Specifies the allowable values for characters 4 through 7 Specifies the valid combinations of values 6

7 Root Operations Alteration Bypass Change Control Creation Destruction Detachment Dilation Division Drainage Excision Extirpation Extraction Fragmentation Fusion Insertion Inspection Map Occlusion Reattachment Release Removal Repair Replacement Reposition Resection Restriction Revision Supplement Transfer Transplantation 7

8 Nine Root Operation Groups Root operations that take out some or all of a body part Root operations that take out solids, fluids, or gases from a body part Root operations that involve cutting or separation only Root operation that put in, put back, or move some or all of a body part 8

9 Nine Root Operation Groups Root operations that alter the diameter or route of a tubular body part Root operations that always involve a device Root operations that involve examination only Root operations that define other repairs Root operations that define other objectives 9

10 What is the intent of the procedure? 10

11 Take Out Group 11

12 To determine whether it s Excision or Resection, always start in the Index under the heading Resection. All body parts can be Excised. 12

13 Resection vs Excision 1. Excision of left lobe of thyroid gland 2. Excision of apex of tongue 3. Excision pylorus of stomach 4. Excision of left testis 13

14 Answers 1. Excision of left lobe of thyroid gland Resection 2. Excision of apex of tongue Excision 3. Excision pylorus of stomach Resection 4. Excision of left testis Resection

15 Table 0BT 15

16 Answers Resection Excision Resection x 2

17 Case #1 He presents with a right upper lobe pulmonary nodule. The patient was taken to the OR and an incision was made over the sixth rib. The lung was explored and only the single lung nodule was found. The wedge resection was performed using a tissue stapler, removing the lesion and a 2 cm margin. The specimen was sent for frozen section. The findings returned as metastatic colon cancer, with clear margins in the specimen. The ribs were approximated and the chest wall was closed in layers. The subcutaneous tissue and skin were approximated. 17

18 Decision to be made? 18

19 Case #1 Poll Question Which root operation is it? 1. Excision 2. Resection 3. Extraction 19

20 Case #1 Which root operation? Excision Which body part value will we pick? Right upper lobe of the lung 20

21 Case #1 0BBC0ZX 21

22 Gunk Group 22

23 Excision and Extraction removes body parts Extirpation removes foreign objects from a body part 23

24 Case #2 PREOPERATIVE DIAGNOSIS: Abnormal EKG suggestive of anterior ischemia. POSTOPERATIVE DIAGNOSIS: 1.Coronary artery disease 2. Thrombus in proximal diagonal branch with severe stenosis PROCEDURES: 1. Left heart catheterization with pressure readings 2. Left ventricular angiography, right and left coronary angiography using Isovue Diagonal branch mechanical thrombectomy, angioplasty and stenting with a 2.5 x 12 mm long Promus Element DES stent 4. Angio-seal deployment for hemostasis 24

25 Case #2 Root operations to assign? Extirpation Dilation Measurement Fluoroscopy 25

26 Case #2 02C03ZZ, Z 26

27 Case #2 4A023N7, B2151ZZ, B2111ZZ 27

28 Case #2 02C03ZZ Z 4A023N7 B2151ZZ B2111ZZ Thrombectomy (Extirpation) PTCA (Dilation) with Drugeluting stent Left heart catheterization Left ventriculogram with low osmolar contrast Coronary angiogram (multiple) with low osmolar contrast 28

29 Cutting Group 29

30 Fasciotomy is a surgical procedure where the fascia is cut to relieve tension or pressure and restore circulation to an area of tissue or muscle. 30

31 Case #3 PREOPERATIVE DIAGNOSIS: Left lower extremity with ischemic leg. POSTOPERATIVE DIAGNOSIS: Ischemic leg with diseased left common femoral artery. OPERATION: 4-Compartment left lower extremity fasciotomy PROCEDURE AS FOLLOWS: The patient was taken to the operating room, placed on the operating room table in the supine position. After an adequate level of general endotracheal anesthesia was obtained, his left lower extremity was prepped and draped in the usual sterile fashion with Chloraprep. Intravenous antibiotics were provided. Four compartment fasciotomies were performed through medial and lateral incisions exposing the musculature of both the lateral, anterior, and both the deep and superficial posterior compartments and these were viable. Due to lack of additional significant swelling, the skin was closed utilizing staples. Patient was awakened, extubated, and transferred to recovery room in stable condition. He has a palpable left dorsalis pedis pulse that is 1+, mildly diminished. He tolerated the procedure well. 31

32 Case #3 Poll Question Which root operation is it? 1. Division 2. Release 3. Excision 32

33 Case #3 Which root operation is it? Release Which body part? Muscle, lower leg 33

34 Release 0KNT0ZZ x4 34

35 Repair Group 35

36 Repair tables always say No Device in the Device character. Why? 36

37 0TQ versus 0TU 37

38 Device Group 38

39 The Device Group root operation must always involve a device. Removal and revision are only coded for devices. 39

40 AV Fistula vs AV Graft Device 40

41 Not a Native Vessel All work done to fix the graft itself is coded in the Device Group 41

42 Case #4 DIAGNOSIS: Thrombosed right arm arteriovenous Gortex graft. PROCEDURE: Balloon catheter thrombectomy of right lower arm arteriovenous graft and angiojet thrombectomy of right lower arm arteriovenous graft. DESCRIPTION OF OPERATION: A Glidewire and then a 6- French sheath was inserted into the graft and then a 5 mm x 2 cm balloon catheter was passed over the Glidewire into the graft and a thrombectomy was performed. Thrombectomy was not complete. At this point, an AngioJet thrombectomy catheter was advanced over the Glidewire and two passes of the AngioJet was performed. Satisfied with the thrombectomy results, the sheaths were removed and pressure held over the puncture site. The patient tolerated the procedure well. 42

43 Case #4 Which root operation is it? 1. Extirpation 2. Extraction 3. Revision 43

44 Which root operation is it? Revision Which body part? Case #4 Upper artery 44

45 Case #4 03WY3JZ 45

46 Supplement is the partner root operation to Repair. Supplement is repair of a body part using a device. 46

47 Case #5 Pre-operative Diagnosis: Atrial septal defect Post-operative Diagnosis: Atrial septal defect Procedure: ASD repair with pericardial patch Summary: The patient s chest is opened via midline sternotomy. A portion of pericardium is harvested and prepared for patching. The patient is placed on CP Bypass and the heart is opened. The defected is repaired by sewing the patch over the hole. CP Bypass is concluded. The pericardium, sternum and chest wall are closed. 47

48 Case #5 What is the root operation(s)? Supplement Excision Which body part values will we pick? Atrial septum Pericardium 48

49 Case #5 02U507Z, 02BN0ZZ + CP Bypass 5A1221Z 49

50 Tubular Group 50

51 If the body part is a tube, start here first. 51

52 Case #6 DIAGNOSIS: A 7 cm infrarenal abdominal aortic aneurysm. OPERATION: Abdominal aortic aneurysm repair using a 22 mm Hemashield Dacron tube graft. DESCRIPTION OF PROCEDURE: After adequate general endotracheal anesthesia, the abdomen was entered and the infrarenal abdominal aortic aneurysm was identified. The neck of the aneurysm was encircled with an umbilical tape. Both common iliac arteries were isolated with umbilical tapes as well. IV hperarin sulfate 5000 units administered. After clamping, the aneurysm was opened and the neck of the aneurysm was cut into a T fashion. A 22 mm Hemashield Dacron tube graft was brought into the field and cut to the desired length and shape. The proximal anastomosis was then performed using 3-0 Prolene in a running fashion. Hemostasis was obtained. The distal anastomosis was next performed in a similar fashion. The distal neck was cut into a T fashion and the graft was cut to the desired length and shape. The anastomosis was performed using 3-0 Prolene in a running fashion. There were strong femoral pulses at the end of the procedure. The heparin was then reversed. The aneurysm sac was closed over the graft using 0 Vicryl in a running fashion. The incision was closed in layers. 52

53 Abdominal Aortic Aneurysm 53

54 Case #6 Poll Question What root operation is it? 1. Occlusion 2. Restriction 3. Supplement 54

55 Case #6 Which root operation is it? Restriction Which body part? Abdominal aorta 55

56 Case #6 04V00DZ 56

57 To be used as, and coded as a device, the tissue must become completely separated from the body. 57

58 Case #7 Procedure: CABG Description of Procedure: The chest was opened through a median sternotomy incision. The pericardium was opened. Cardiopulmonary bypass was initiated. The greater saphenous vein was harvested via incision from the left lower extremity. The patient was cooled and cross-clamped. The cold blood cardioplegia solution was administered. Individual segments of saphenous vein were sewn to the obtuse marginal, to the posterolateral branch of the circumflex artery, and to the distal right coronary artery respectively. Each of these anastomoses were carried out with running sutures of 7-0 Prolene. At the termination of this, warm blood cardioplegia was administered and the aortic cross-clamp was then released. A partial occluding clamp was placed on the aorta. Three buttons of aortic tissue were excised and used as three proximal anastomoses for the saphenous grafts which were carried out with running sutures of 6-0 Prolene. With the patient fully re-warmed, the heart resumed a good contractility and resumed a normal sinus rhythm. The patient was weaned from cardiopulmonary bypass. The chest was closed in layers in the usual fashion and dry sterile dressing was applied. 58

59 Vein Harvesting for a Graft Source: 59

60 Case #7 How many procedures must be coded? Three What are the root operations? Bypass Excision Performance 60

61 Case # W, 06BQ0ZZ, 5A1221Z 61

62 Moving Group 62

63 Reposition only involves body parts, not devices. Reattachment is coded when a body part has become separated from the body (not by the surgeon). 63

64 Case #8 Procedure: Left Triceps Brachii Distal Tendon Repair With the patient under general anesthesia, a straight posterior midline incision was performed with the patient in the lateral decubitus position and the arm over a tibial post. Dissection was performed through skin and subcutaneous tissues, identifying the triceps tendon. The edges of the ruptured triceps tendon were debrided, and a #5 Ethibond suture was inserted through the tendon using a Bunnell stitch technique. Next, needles were drilled through the olecranon in a crossed pattern. To improve fixation, 2 to 3 suture anchors were drilled into the olecranon for augmentation of the reattachment; the sutures of the bone anchors were passed through the tendon in a horizontal mattress pattern. The Ethibond suture was inserted into the holes of the Keith needles and advanced through the olecranon by advancing the needles. With the elbow in extension, the tendon was reattached to the olecranon; the Ethibond sutures were tied first, followed by the bone anchor sutures. Stability of the reattachment was evaluated intraoperatively by moving the elbow through its total range of motion. The wound was irrigated and closed in layers. 64

65 Case #8 65

66 What is the root operation? Reattachment Case #8 What is the body part? Upper arm tendon 66

67 Case #8 0LM40ZZ 67

68 Case #9 Preoperative Diagnosis: Pacemaker malfunction Postoperative Diagnosis: Same Anesthesia: Local Operation Performed: Repositioning of pacemaker electrode Procedure: The patient was positioned on the fluoroscopy table and the right chest was prepared and draped. Local anesthesia was obtained with 1% lidocaine with epinephrine. The pocket was opened and the right ventricular lead was identified and disconnected from the generator. The lead was gently advanced under fluoroscopy until it was properly situated in the ventricle. It was sutured in place using 2-0 silk and reconnected to the generator. Hemostasis was achieved. The wound was closed using 3-0 Vicryl for subcutaneous tissue and 3-0 nylon for skin. Dry dressings were applied, and the patient was returned to the recovery room in satisfactory condition. 68

69 Case #9 What root operation is it? Revision Which body part is assigned? Heart 69

70 Case #9 02WA3MZ 70

71 Case #10 Poll Question The patient has a perforated duodenal ulcer. The surgeon explores the abdomen and performs a Graham omentoplasty by sewing a flap of omentum over the ulcer. 1. Transfer 2. Supplement 3. Repair 71

72 Transfer? No omentum body part Qualifier isn t appropriate 72

73 Supplement? Not Supplement, if not free omental graft Repair is the only option 73

74 Case #10 0DQ90ZZ 74

75 You ve learned: Summary Determining the group and the root operation is based on the intent To tell the difference between root operations that seem similar and why To assign root operations and codes to 10 complex ICD-10-PCS Next Step: Use these skills to code! 75

76 Questions? 76

77 Thank you! Contact Information: Contact Information: Jennifer Frank, Vice President Education Wisconsin Hospital Association O: F: Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA President Kuehn Consulting, LLC Waukesha, WI O: F: