Updates are presented in the same sections as appear in the text:

Transcription

1 Updates ICD-10-CM and ICD-10-PCS Preview Exercises AHIMA Product AC Changes to reflect code updates as of January 2011 Note: Any question or solution that has been updated appears in this list, and this version of the question or solution should be substituted in full for the original question or solution published in the book. To help readers see what changes that have been made, any text that has been added or changed appears in red. In most cases, text that has been deleted is not shown; however, in some instances, for clarity, deleted text is also shown in strikethrough font. Updates are presented in the same sections as appear in the text: Part 1: ICD-9-CM to ICD-10-CM and ICD-10-PCS Transitional Exercises Part 1: Solutions to ICD-9-CM to ICD-10-CM and ICD-10-PCS Transitional Exercises Part 2: Basic ICD-9-CM to ICD-10-CM and ICD-10-PCS Coding Exercises Part 2: Solutions to Basic ICD-9-CM to ICD-10-CM and ICD-10-PCS Coding Exercises

2 Updates to Part 1 Questions: ICD 9 CM to ICD 10 CM and ICD 10 PCS Transitional Exercises 13. Laceration of the left index finger with a knife while slicing meat at work in a restaurant. The patient was in the process of preparation of the meat for cooking. ICD-9-CM: ICD-10-CM: 18. Postoperative pulmonary artery embolism, initial encounter ICD-9-CM: ICD-10-CM: 40. Crush syndrome with hemorrhaging; lacerations of small and large intestines. Ten-year-old patient was rough housing with his brother in the shop and a sheet of drywall accidentally fell on the patient. The patient was immediately sent to the operating room where an open repair of the lacerations of the small and large intestines due to the crushing injury was performed (code both diagnosis and procedure codes) ICD-9-CM: ICD-10-CM: ICD-10-PCS:

3 Updates to Part 1 Solutions: Solutions to ICD 9 CM to ICD 10 CM and ICD 10 PCS Transitional Exercises 1. Decubitus ulcer of the right side of the lower back, Stage III ICD-9-CM ICD-10-CM Code(s) Assigned Pressure ulcer of lower back L Pressure ulcer of right lower back, stage Pressure ulcer stage III Index and Tabular Volumes Ulcer Ulcer decubitus (see also Ulcer, pressure) decubitus see Ulcer, pressure, by site Ulcer pressure back lower stage III Ulcer pressure back L Pressure ulcer Decubitus ulcer Use additional code to identify pressure ulcer stage ( ) Lower back Pressure ulcer stages Code first site of pressure ulcer ( ) Pressure ulcer, stage III One code category for all chronic skin ulcers (decubitus and non-decubitus) Two codes required to completely code a pressure ulcer One code to identify site One code to identify stage Specification that the skin ulcer is a decubitus Specific site of decubitus ulcer Depth of the ulcers (coders will need to be able to recognize what depth is associated with specific stages of ulcers) L89 Pressure ulcers Includes: decubitus ulcers Code Comparisons L89.13 Pressure ulcer of right lower back L Pressure ulcer of right lower back, Stage 3 Three code categories for chronic skin ulcers: L89 pressure ulcer L97 non-pressure chronic ulcer of lower limb, NEC L98.4xx non-pressure chronic ulcer of skin, NEC One code used to classify both the site, including laterality of pressure ulcer, as well as the stage Documentation Needed Specification that the skin ulcer is a decubitus Specific site, including the specific region and left or right side Depth of the ulcer (coders will need to be able to recognize what depth is associated with specific stages of ulcers)

4 5. Appendectomy Supporting documentation: The operative report indicates that the entire appendix was removed via an open abdominal incision ICD-9-CM ICD-10-PCS Code(s) Assigned Other appendectomy 0DTJ0ZZ 0 Medical and surgical section (procedure type) D Gastrointestinal system (body system) T Resection (root operation) J Appendix (body part) 0 Open (approach) Z None (device) Z None (qualifier) Index and Tabular Volumes Appendectomy (with drainage) Appendectomy incidental see Excision, Appendix 0DBJ laparoscopic see Resection, Appendix 0DTJ laparoscopic Resection Appendix 0DTJ 47.0 Appendectomy Laparoscopic appendectomy Other appendectomy Classification of appendectomy is laparoscopic or other with no specific code for an open approach Classification of appendectomy does not provide further specificity as to whether a partial or total procedure was performed Specifies if appendectomy is incidental or not Tabular (Tables): Reference the table for 0DT (see the Excerpt from the ICD-10-PCS Tables) to look up the remaining characters of the code. In this case the specific body part is appendix (J), the approach is open (0), and there is no device or qualifier (Z). Code Comparisons Specificity as to whether appendectomy is partial or total Code includes the operative approach There is no code for an incidental appendectomy Resection is the correct root operation not excision o Resection: cutting out or off, without replacement, all of a body part o Excision: cutting out or off, without replacement, a portion of a body part Documentation Needed Whether the appendectomy was incidental The reason for the appendectomy (incidental or not) Whether it was performed laparoscopically is not a criteria for selection of the code The operative approach must be known (open versus laparoscopic) The coding professional must be able to determine whether the appendix was removed in part or in total

5 Excerpt from the ICD-10-PCS Tables 0: Medical Surgical D: Gastrointestinal system T: Resection: Cutting out or off, without replacement, all of a body part Body Part Character 4 1 Esophagus, upper 2 Esophagus, middle 3 Esophagus, lower 4 Esophagogastric junction 5 Esophagus 6 Stomach 7 Stomach, pylorus 8 Small intestine 9 Duodenum A Jejunum B Ileum C Ileocecal valve E Large intestine F Large intestine, right G Large intestine, left H Cecum J Appendix K Ascending colon L Transverse colon M Descending colon N Sigmoid colon P Rectum Q Anus R Anal sphincter S Greater omentum T Lesser omentum 0 Open Approach Character 5 4 Percutaneous Endoscopic 7 Via Natural or Artificial Opening 8 Via Natural or Artificial Opening Endoscopic 0 Open 4 Percutaneous Endoscopic Z None Z None Device Character 6 Qualifier Character 7 Z None Z None

6 7. Arthroscopic partial meniscectomy, left knee Supporting documentation: The operative report indicates the surgeon utilized an arthroscope to perform a partial meniscectomy of the left knee ICD-9-CM ICD-10-PCS Code(s) Assigned 80.6 Excision of semilunar cartilage of knee 0SBD4ZZ 0 Medical and surgical section (procedure type) S Lower joints (body system) B Excision (root operation) D Knee joint, left (body part) 4 Percutaneous endoscopic (approach) Z None (device) Z None (qualifier) Index and Tabular Volumes Meniscectomy (knee) NEC 80.6 Meniscectomy see Excision, lower joints 0SB see Resection, lower joints OST 80.6 Excision of semilunar cartilage of knee Excision of meniscus of knee Excision Joint Knee Left 0SBD Tabular (Tables): Reference the table for 0SB (see the Excerpt from the ICD-10-PCS Tables) to look up the remaining characters of the code. In this case the specific body part is the left knee joint (D), the approach is arthroscopic (4), and there is no device or qualifier (Z). Code Comparisons Very little specificity, no way to indicate if the meniscectomy was complete or partial Many more characters, appropriate code is built rather than selected in the Tabular The code does not indicate that the procedure was arthroscopic (application of a separate Specificity as to whether meniscectomy is partial or total code to denote this, 80.26, is inappropriate as Code specifies laterality of joint the surgical approach is not reported in ICD-9- Code specifies the operative approach CM) Documentation Needed Documentation of the procedure performed The operative approach must be known (open versus arthroscopic) Whether the meniscus was removed in part or in total

7 Excerpt from the ICD-10-PCS Tables 0: Medical Surgical S: Lower Joints B: Excision: Cutting out or off, without replacement, a portion of a body part Body Part Character 4 Approach Character 5 Device Character 6 0 Lumbar vertebral joint 2 Lumbar vertebral disc 3 Lumbosacral joint 4 Lumbosacral disc 5 Sacrococcygeal joint 6 Coccygeal joint 7 Sacroiliac joint, right 8 Sacroiliac joint, left 9 Hip joint, right B Hip joint, left C Knee joint, right D Knee joint, left F Ankle joint, right G Ankle joint, left H Tarsal joint, right J Tarsal joint, left K Metatarsal-tarsal joint, right L Metatarsal-tarsal joint, left M Metatarsal-phalangeal joint, right N Metatarsal-phalangeal joint, left P Toe phalangeal joint, right Q Toe phalangea joint, left 0 Open 3 Percutaneous 4 Percutaneous Endoscopic Z None Qualifier Character 7 X Diagnostic Z None

8 11. Permanent tracheostomy, open approach ICD-9-CM ICD-10-PCS Code(s) Assigned Other permanent tracheostomy 0B110F4 0 Medical and surgical section (procedure type) B Respiratory system (body system) 1 Bypass (root operation) 1 Trachea (body part) 0 Open (approach) F Tracheostomy (device) 4 Cutaneous (qualifier) Index and Tabular Volumes Tracheostomy (emergency) (temporary) (for Tracheostomy see Bypass, Respiratory assistance in breathing) System 0B1 permanent NEC Bypass Trachea 0B Other permanent tracheostomy Code also any synchronous bronchoscopy if performed ( , 33.27) Excludes: that with laryngectomy ( ) Classifies the anticipated duration of the tracheostomy use, temporary versus permanent and whether the intervention is revision of the tracheostomy Clarity is needed regarding whether the intervention is intended for short term or longterm use Documentation distinguishing the intervention as revising an existing tracheostomy or an initial placement Tabular (Tables): Reference the table for 0B1 (see Excerpt from the ICD-10-PCS Tables) to look up the remaining characters of the code. In this case the specific body part is the trachea (1), the approach is open (0), the device is a tracheostomy device (F), and the qualifier of cutaneous (4) applies. Code Comparisons Distinguishes the opening of the trachea by the surgical approach used Distinguishes the type of device remaining at the end of the procedure Documentation Needed Documentation must specify the approach to accurately assign the fifth character Documentation must specify if a device was left remaining at the end of the procedure and if so the type of device

9 Excerpt from the ICD-10-PCS Tables 0: Medical and Surgical B: Respiratory System 1: Bypass: Altering the route of passage of the contents of a tubular body part Body Part Character 4 Approach Character 5 Device Character 6 Qualifier Character 7 1 Trachea 0 Open D Intraluminal device 6 Esophagus 1 Trachea 0 Open 3 F Tracheostomy device Z No device 4 Cutaneous 1 Trachea 3 Percutaneous 4 Percutaneous Endoscopic F Tracheostomy device Z No Device 4 Cutaneous

10 13. Laceration of the left index finger with a knife while slicing meat at work in a restaurant. The patient was in the process of preparation of the meat for cooking. ICD-9-CM ICD-10-CM Code(s) Assigned Open wound of finger without mention of S61.211A Laceration without foreign body of left complication index finger without damage to the nail, initial E920.3 Accidents caused by knifes, swords, and encounter daggers W26.0xxA Contact with knife, initial encounter E849.6 Place of occurrence, public building Y Restaurant or café as the place of E015.0 Food preparation and clean up occurrence of the external cause E000.0 External cause status, civilian activity done Y93.G1 Activity, food preparation and clean up for income or pay Y99.0 External Cause Status, civilian activity done for income or pay Wound, open finger(s) (nail) (subungual) Index and Tabular Volumes Laceration finger(s) index left S Index to External Causes: Cut by knife E920.3 Accident occurring (at) (in) restaurant E849.6 Activity food preparation and clean up E015.0 External cause status for income E Open wound of finger(s) without mention of complication E920.3 Accidents caused by knives, swords, and daggers E849.6 Place of occurrence, public building Restaurant E015.0 Food preparation and clean up E000.0 External cause status, civilian activity done for income or pay Index to External Causes: Cut, cutting (any part of body) (accidental) see also Contact, with, by object or machine Contact with knife W26.0 Place of Occurrence restaurant Y Activity Food preparation and clean up Y93.G1 External Cause Status Civilian activity done for income or pay Y99.0 S61 Open wound of wrist, hands and finger(s) The appropriate seventh character is to be added to each code from category S61: A initial encounter D subsequent encounter S sequela S Laceration without foreign body of left index finger without damage to nail W26 Contact with knife, sword or dagger The appropriate seventh character is to be added to each code from category W26: A initial encounter D subsequent counter S sequela W26.0 Contact with knife Y Restaurant or café as the place of occurrence of the external cause

11 Y93 Activity codes Y93.G Activities involving food preparation, cooking and grilling Y93.G1 Activities involving food preparation and clean up Y99 External Cause Status Y99.0 Civilian activity done for income or pay Code Comparisons Anatomic location of the wound is nonspecific as Anatomic location of the laceration classifies to which finger Place of occurrence is much less specific Additional codes indicate not only where, but also what the person was doing when injured The site of injury (finger) Whether or not there is delayed healing, delayed treatment, foreign body, or infection of the wound (denoted complicated ) Where the accident occurred and what activity the patient was doing when the injury occurred How the accident occurred Whether the injury was work related, military, or a student specifically which finger (left index) was injured The extension clarifies that this is the initial encounter Additional codes indicate not only where, but also what the person was doing when injured Documentation Needed Specific anatomic site of the injury (laterality and which finger) The extent of the injury, whether or not the nail was involved Whether the encounter is the initial episode, subsequent episode, or for sequela Where the injury occurred and what activity the patient was doing when the injury occurred Whether the injury was work related, military, or a student

12 15. Common bile duct exploration, open approach ICD-9-CM ICD-10-PCS Code(s) Assigned Other incision of bile duct, exploration of 0FJB0ZZ common duct 0 Medical and surgical section (procedure type) F Hepatobiliary system and pancreas (body system) J Inspection (root operation) B Hepatobiliary Duct 0 Open (approach) Z None (device) Z None (qualifier) Exploration see also Incision common bile duct Other incision of bile duct Exploration of common duct No further classification as to operative approaches Documentation specifying the common bile duct was explored Index and Tabular Volumes Exploration see Inspection Inspection Duct Hepatobiliary 0FJB Tabular (Tables): Reference the table for 0FJ (see the Excerpt from the ICD-10-PCS Tables) to look up the remaining characters of the code. In this case the specific body part is the hepatobiliary duct (9), the approach is open (0), and there is no device or qualifier (Z). Code Comparisons The code specifies that the inspection of the common bile duct was done during an open approach Documentation Needed Documentation must clearly describe the approach to accurately assign the fifth character Definition of inspection

13 Excerpt from the ICD-10-PCS Tables 0: Medical and Surgical F: Hepatobiliary System and Pancreas J: Inspection: Visually and/or manually exploring a body part Body Part Character 4 0 Liver 1 Liver, right lobe 2 Liver, left lobe 3 Liver, caudate lobe 4 Gallbladder G Pancreas 5 Hepatic duct, right 6 Hepatic duct, left 7 Hepatic duct, caudate 8 Cystic duct 9 Common bile duct B Hepatobiliary duct C Ampulla of Vater D Pancreatic duct F Pancreatic duct, Accessory Approach Character 5 0 Open 3 Percutaneous 4 Percutaneous Endoscopic X External 0 Open 2 3 Percutaneous 4 Percutaneous Endoscopic 7 Via Natural or Artificial Opening 8 Via Natural or Artificial Opening Endoscopic Device Character 6 Z No Device Z No Device Qualifier Character 7 No Qualifier Z No Qualifier

14 17. Coronary artery bypass graft (CABG) x 3 using saphenous vein grafts, with cardiopulmonary bypass ICD-9-CM ICD-10-PCS Code(s) Assigned (Aorto)coronary bypass of three coronary W arteries 0 Medical and surgical section (procedure type) Cardiopulmonary bypass 2 Heart and great vessels (body system) 1 Bypass (root operation) 2 Coronary arteries, three sites (body part) 0 Open (approach) 9 Autologous venous tissue (device) W Aorta (qualifier) Bypass aortocoronary (catheter stent) (with prosthesis) (with saphenous vein graft) (with vein graft) three coronary vessels Bypass cardiopulmonary A1221Z 5 Extracorporeal Assistance and Performance (procedure type) A Physiological Systems (body system) 1 Performance (root operation) 2 Cardiac (body part) 2 Continuous (duration) 1 Output (device) Z None (qualifier) 5A1935Z 5 Extracorporeal Assistance and Performance (procedure type) A Physiological Systems (body system) 1 Performance (root operation) 9 Respiratory (body part) 3 Less than 24 Consecutive Hours (duration) 5 Ventilation (function) Z No Qualifier (qualifier) Index and Tabular Volumes Bypass by Body Part Artery Coronary, Three Sites 0212 Extracorpeal Assistance and Performance see Performance Performance Cardiac Continuous Output 5A1221Z Performance Respiratory Less than 24 consecutive hours, ventilation 5A1935Z

15 36.1 Bypass anastomosis for heart revascularization Code also any: Cardiopulmonary bypass (39.61) (Aorta)coronary bypass of three coronary arteries Extracorporeal circulation auxiliary to open heart surgery Code Comparisons One subcategory: 36.1x Differentiated by number of grafts only Additional code required for cardiopulmonary bypass Number of aortocoronary grafts Use of cardiopulmonary bypass Tabular (Tables): Reference the table for 021 (see the Excerpt from ICD-10-PCS Tables) to look up the remaining characters of the code. In this case the specific body part is coronary arteries, three (2), the approach is open (9), the device is autologous venous tissue (saphenous vein grafts) (9), and the qualifier is the aorta (W). Reference the table for 5A1 (see the Excerpt from the ICD-10-PCS Tables) to look up the remaining characters of the code. In this case the body part is cardiac (2), the duration is continuous (2), the function is output (1), and the qualifier is none (Z). Lastly reference the table for 5A1 (see the Excerpt from the ICD-10-PCS Tables) to look up the remaining characters of the code. In this case the body part is respiratory (9), the duration is less than 24 consecutive hours (3), the function is ventilation (5) and the qualifier is none (Z). Four subcategories: 0210 (one coronary artery) 0211 (two coronary arteries) 0212 (three coronary arteries) 0213 (four or more coronary arteries) Differentiated by number of grafts, open versus percutaneous endoscopic and type of graft Additional code required for cardiopulmonary bypass Documentation Needed Number of aortocoronary grafts Open versus closed Use of cardiopulmonary bypass Type of graft used Excerpt from ICD-10-PCS Tables 0: Medical and Surgical 2: Heart and Greater Vessels 1: Bypass Altering the route of passage of the contents of a tubular body part Body Part Character 4 Approach Character 5 Device Character 6 0 Coronary Artery, One Site 1 Coronary Artery, Two Sites 2 Coronary Artery, Three Sites 3 Coronary Artery, Four or More Sites 0 Open 9 Autologous Venous Tissue A Autologous Arterial Tissue J Synthetic Substitute K Nonautologous Tissue Substitute Qualifier Character 7 3 Coronary Artery 8 Internal Mammary, Right 9 Internal Mammary, Left C Thoracic Artery F Abdominal Artery W Aorta

16 Excerpt from ICD-10-PCS Tables 5: Extracorporeal Assistance and Performance A: Physiological Systems 1: Performance Completely taking over a physiological function by extracorporeal means Body Part Character 4 Duration Character 5 Device Character 6 2 Cardiac 0 Single 1 Output 2 Manual Qualifier Character 7 2 Cardiac 1 Intermittent 3 Pacing Z No Qualifier 2 Cardiac 2 Continuous 1 Output Z No Qualifier 3 Pacing 9 Respiratory 3 Less than 24 Consecutive Hours Consecutive Hours 5 Greater than 96 Consecutive Hours 5 Ventilation Z No Qualifier

17 18. Postoperative pulmonary artery embolism, initial encounter ICD-9-CM ICD-10-CM Code(s) Assigned Iatrogenic pulmonary embolism and T81.718A Complication of other artery following a infarction procedure, not elsewhere classified, initial encounter I26.99 Other pulmonary embolism without acute cor pulmonale Embolism pulmonary (artery) (vein) postoperative Complication respiratory postoperative NEC Index and Tabular Volumes Embolism postoperative artery specified NEC T Embolism pulmonary (artery)(vein) I Iatrogenic pulmonary embolism and infarction Respiratory complications Excludes: iatrogenic pulmonary embolism (415.11) T81 Complications of procedures, not elsewhere classified The appropriate seventh character is to be Added to each code from category T81: A initial encounter D subsequent encounter S sequela T Complication of other artery following a procedure, not elsewhere classified I26 Pulmonary embolism Excludes 2: pulmonary embolism due to complications of surgical and medical care (T80.0, T81.7-, T82.8-) Code Comparisons Classified as a disease of pulmonary system Classified as a complication of surgical and (section ) Code description specifically denotes pulmonary embolism Diagnosis of pulmonary embolism specified as postoperative medical care (Section T80 T88) Code description does not specifically denote pulmonary embolism Seventh character specifies the episode of care (encounter) Documentation Needed Diagnosis of pulmonary embolism following a surgical procedure Indication of the episode of care (encounter)

18 19. Aftercare encounter for management of a subtrochanteric fracture of the left femur. Patient fell and fractured the left femur two weeks earlier. ICD-9-CM ICD-10-CM Code(s) Assigned V54.13 Aftercare for healing traumatic fracture of S72.22xD Displaced subtrochanteric fracture of left hip femur, subsequent encounter for closed fracture with routine healing W19.xxxD Fall, falling (accidental) Aftercare fracture healing traumatic hip V54.13 Index and Tabular Volumes Aftercare fracture code to fracture with extension D Fracture, traumatic femur subtrochanteric (region) (section) (displaced) S72.2- External Cause Index Fall, falling (accidental) W19 V54.13 Aftercare for healing traumatic fracture of hip S72 Fracture of femur A fracture not indicated as displaced or nondisplaced should be coded as displaced A fracture not designated as open or closed should be coded to closed The appropriate seventh character is to be added to each code from category S72 (following is part of list of seventh character): A initial encounter for closed fracture D subsequent encounter for closed fracture with routine healing K subsequent encounter for closed fracture with nonunion P subsequent encounter for closed fracture with malunion S sequela S72.22 Displaced subtrochanteric fracture of left femur W19 Unspecified fall The appropriate 7 th character is to be added to code W19: A initial encounter D subsequent encounter S - sequelae

19 Code Comparisons Traumatic fractures are coded using the acute Codes that represent reasons for encounters are fracture codes ( ) while the patient is Z codes not V codes receiving active treatment for the fracture Z codes for aftercare are not used if treatment is Fractures are coded using aftercare codes directed at the current injury instead, the injury (subcategories V54.0, V54.1, V54.2, or V54.8) code should be reported with a seventh for encounters after the patient has completed character extension to signify subsequent active treatment of the fracture and is receiving encounter routine care for the fracture during the healing The injury code specifies laterality or recovery phase Subcategories V54.1 (aftercare for healing traumatic fracture) and V54.2 (aftercare for healing pathologic fracture) have been created to identify the fracture site being treated Extension codes must always be the seventh character; to apply an extension to a code that is not a full six characters, a lower case x is utilized as a placeholder Documentation Needed The purpose for the encounter (that is, initial The purpose for the encounter (that is, initial encounter versus subsequent) encounter versus subsequent) The general type and location of the fracture The specific type and location of the fracture 21. Diagnostic left-heart catheterization ICD-9-CM ICD-10-PCS Code(s) Assigned Left heart cardiac catheterization 4A023N7 4 Measurement and monitoring (procedure type) A Physiological systems (body system) 0 Measurement (root operation) 2 Cardiac (body system) 3 Percutaneous (approach) N Sampling and pressure (function/device) 7 Left heart (qualifier) Index and Tabular Volumes Catheterization cardiac Catheterization left Heart, see Measurement, Cardiac 4A02 Measurement Cardiac Sampling and Pressure Left Heart 4A Diagnostic procedures on heart and pericardium Left heart cardiac catheterization Tabular (Tables): Reference the table for 4A0 (see the Excerpt from ICD-10-PCS Tables) to look up the remaining characters of the code. In this case the approach is percutaneous (3), the function/device is sampling and pressure (N), and the qualifier is the left heart (7).

20 Code Comparisons One code category; 37 Other operations on Fourth character classifies body system (cardiac) heart and pericardium Fifth character classifies the approach Third digit classification based on the type of Sixth character for function/device used operation performed Seventh character classifies area of heart that Fourth digit differentiates the part of heart; left was catheterized (left, right, bilateral) or right Documentation Needed Type of procedure performed Reason for procedure Side of the heart procedure performed on: Type of procedure performed o Left Approach used o Right o Open o Combined o Percutaneous Side of the heart procedure performed on o Left o Right o Bilateral Function or type of device used Excerpt from ICD-10-PCS Tables 4: Measurement and Monitoring A: Physiological Systems 0: Measurement Determining the level of a physiological or physical function at a point in time Body System Character 4 Approach Character 5 Function/Device Character 6 Qualifier Character 7 2 Cardiac 0 Open 3 Percutaneous 2 Cardiac 0 Open 3 Percutaneous 4 Electrical Activity 9 Output C Rate F Rhythm H Sound P Action Currents N Sampling and Pressure 2 Cardiac X External 4 Electrical Activity 9 Output C Rate F Rhythm H Sound P Action Currents Z No Qualifier 6 Right Heart 7 Left Heart 8 Bilateral Z No Qualifier 2 Cardiac X External M Total Activity 4 Stress

21 22. Down s syndrome ICD-9-CM ICD-10-CM Code(s) Assigned Down s syndrome Q90.9 Down s syndrome, unspecified Down s disease or syndrome (mongolism) Index and Tabular Volumes Down syndrome Q90.9 Syndrome Down s (mongolism) Syndrome Down (see also Down syndrome) Q Chromosomal anomalies Use additional codes for conditions associated with the chromosomal anomalies Down s syndrome Mongolism Translocation Down s Syndrome Trisomy: 21 or 22 G Q90 Down Syndrome Q90.0 Trisomy 21, nonmosaicism Q90.1 Trisomy 21, mosaicism Q90.2 Trisomy 21, translocation Q90.9 Down s syndrome, unspecified Code Comparisons One category, 758, Chromosomal abnormalities Multiple categories (Q90 Q99) for chromosomal Classification based on the Trisomy number abnormalities Documentation Needed Documentation of type of chromosomal Documentation of type of chromosomal abnormality abnormality 27. Left liver lobectomy, open Supporting documentation: The operative report indicates the surgeon removed the entire left lobe of the liver ICD-9-CM ICD-10-PCS Code(s) Assigned 50.3 Lobectomy of liver 0FT20ZZ 0 Medical and surgical section (procedure type) F Hepatobiliary system and pancreas (body system) T Resection (root operation) 2 Liver, left lobe (body part) 0 Open (approach) Z None (device) Z None (qualifier)

22 Lobectomy liver (with partial excision of adjacent lobes) Lobectomy of liver Total hepatic lobectomy with partial excision of other lobe Index and Tabular Volumes Lobectomy see Resection, Hepatobiliary Systems and Pancreas Resection Liver Left lobe 0FT2 Tabular (Tables): Reference the table for 0FT (see the Excerpt from ICD-10-PCS Tables) to look up the remaining characters of the code. In this case the specific body part is the left lobe of the liver (2), the approach is open (0), and there is no device or qualifier (Z). Code Comparisons Lobe laterality not defined Approach of the procedure is defined in the Approach not defined code, open versus percutaneous endoscopic Code includes partial lobectomy of another lobe of the liver Lobe laterality is required for proper code assignment Documented Needed The entire lobe was removed Laterality of lobe that was removed The approach used to remove the lobe Whether or not the entire lobe (resection) or part of the lobe (excision) was removed Excerpt from ICD-10-PCS Tables 0: Medical and Surgical F: Hepatobiliary System and Pancreas T: Resection Cutting out or off, without replacement, all of a body part Body System Character 4 Approach Character 5 Device Character 6 Qualifier Character 7 0 Liver 1 Liver, Right Lobe 2 Liver, Left Lobe 4 Gallbladder G Pancreas 0 Open 4 Percutaneous Endoscopic Z No Device Z No Qualifier

23 29. Excision of fallopian tubes, bilateral, endoscopic ICD-9-CM ICD-10-PCS Code(s) Assigned Bilateral excision of fallopian tubes 0UT74ZZ 0 Medical and surgical section (procedure type) U Female reproductive system (body system) T Resection (root operation) 7 Fallopian tubes, bilateral (body part) 4 Percutaneous endoscopic (approach) Z None (device) Z None (qualifier) Index and Tabular Volumes Salpingectomy (bilateral) (total) (transvaginal) Salpingectomy see Excision, Female Reproductive System 0UB see Resection, Female Reproductive System 0UT Resection Fallopian Tubes, Bilateral 0UT Total bilateral salpingectomy Removal of both fallopian tubes at same operative episode Tabular (Tables): Reference the table for 0UT (see the Excerpt from ICD- 10-PCS Tables) to look up the remaining characters of the code. In this case, the specific body part is the fallopian tubes, bilateral (7), the approach is percutaneous endoscopic (4), and there is no device or qualifier (Z). Code Comparisons Differentiated by single, bilateral tube removal The specific approach for the procedure is identified The approach is not identified Identifies bilateral or unilateral removal of tube Documentation Needed Total or partial excision Total (resection) or partial (excision) removal Diagnostic reason for excision Bilateral or unilateral excision; if unilateral then right Bilateral or unilateral excision or left Operative approach

24 Excerpt from ICD-10-PCS Tables 0: Medical and Surgical U: Female Reproductive System T: Resection Cutting out or off, without replacement, all of a body part Body System Character 4 Approach Character 5 Device Character 6 Qualifier Character 7 0 Ovary, Right 1 Ovary, Left 2 Ovaries, Bilateral 5 Fallopian Tube, Right 6 Fallopian Tube, Left 7 Fallopian Tubes, Bilateral 9 Uterus 0 Open 4 Percutaneous Endoscopic 7 Via Natural or Artificial Opening 8 Via Natural or Artificial Opening Endoscopic F Via Natural or Artificial Opening With Percutaneous Endoscopic Assistance Z No Device Z No Qualifier 31. Right kidney transplantation, open, zooplastic donor ICD-9-CM ICD-10-PCS Code(s) Assigned Other Kidney Transplantation 0TY00Z2 0 Medical and surgical section (procedure type) T Urinary system (body system) Y Transplantation (root operation) 0 Kidney, right (body part) 0 Open (approach) Z None (device) 2 Zooplastic (qualifier) Index and Tabular Volumes Transplant, Transplantation Transplantation kidney NEC Kidney Right 0TY00Z 55.6 Transplant of kidney Note: To report donor source see codes Other kidney transplantation Tabular (Tables): Reference the table for 0TY (see the Excerpt from ICD-10-PCS Tables) to look up the remaining characters of the code. In this case the specific body part is the right kidney (0), the approach is open (0), the devices is none (Z), and the qualifier is zooplastic donor (2).

25 Code Comparisons Only one code is offered for a kidney Multiple codes are included for kidney transplantation (55.69 NEC). transplantation Additional codes for donors only include Code distinguishes which kidney was transplants from live related donor, live transplanted nonrelated donor, and from a cadaver. Code specifies the approach Nonspecific as to type of approach More options for donor source are available and Nonspecific as to which kidney is included in the code eliminating the need for a transplanted (right or left) second code Documentation Needed Organ that was transplanted Which organ was transplanted including if it was Donor source right or left Approach used Donor source Excerpt from ICD-10-PCS Tables 0: Medical and Surgical T: Urinary System Y: Transplantation Putting in or on all or a portion of a living body part taken from another individual or animal to physically take the place and/or function of all or a portion of a similar body part. Body System Character 4 Approach Character 5 Device Character 6 Qualifier Character 7 0 Kidney, Right 1 Kidney, Left 0 Open Z No Device 0 Allogeneic 1 Syngeneic 2 Zooplastic

26 33.Classical migraine ICD-9-CM Classical migraine, without mention of intractable migraine, without mention of status migrainosus Migraine classic(al) Code(s) Assigned Index and Tabular Volumes ICD-10-CM G Migraine with aura, not intractable, without status migrainosus Migraine Classical see Migraine, with aura 346 Migraine The following fifth-digit subclassification is for use with category 346: 0 without mention of intractable migraine without mention of status migrainosus 1 with intractable migraine, so stated without mention of status migrainosus 2 without mention of intractable migraine with status migrainosus 3 with intractable migraine, so stated, with status migrainosus Migraine with aura (acute-onset) (prolonged) (typical) (without headache) G G43 Migraine G43.10 Migraine, with aura, not intractable Classic migraine G Migraine, with aura, not intractable, without status migrainosus Migraine with aura Classic migraine Code Comparisons One code category with subcategories at the fourth digit level for the type of migraine Fifth digit specifies with or without intractable migraine and with or without status migrainosus Documentation Needed Diagnosis of migraine Diagnosis of migraine Documentation of whether migraine is intractable and status migrainosius One combination code which classifies the type of migraine, whether or not intractable and whether or not with status migrainosus Documentation of whether migraine is intractable and status migrainosis

27 35. Macular degeneration, atrophic ICD-9-CM ICD-10-CM Code(s) Assigned Exudative senile macular degeneration H35.30 Unspecified macular degeneration (agerelated) Alphabetical Index: Degeneration, degenerative macula (acquired) (senile) atrophic Degeneration of macula and posterior pole Nonexudative senile macular degeneration Index and Tabular Volumes Alphabetical Index: Degeneration, degenerative macula, macular (acquired) (atrophic) (exudative) (senile) H35.30 H35.3 Degeneration of macula and posterior pole H35.30 Unspecified macular degeneration (age related) Code Comparisons One code subcategory for degeneration of One code subcategory for degeneration of macula and posterior pole macula and posterior pole Fifth digit provides further specification of Fifth character provides further specification of complications complications Some codes are further subdivided with a sixth character specifying right, left, bilateral, or unspecified eye Documentation Needed Any complications or manifestations of the Any complications or manifestations of the degeneration degeneration Type of degeneration Type of degeneration Which eye(s) has manifestation or unspecified

28 36. Cervical esophagostomy, open ICD-9-CM ICD-10-PCS Code(s) Assigned Cervical esophagostomy 0D110Z4 0 Medical and surgical (procedure type) D Gastrointestinal system (body system) 1 Bypass (root operation) 1 Esophagus, upper (body part) 0 Open (approach) Z None (device) 4 Cutaneous (qualifier) Alphabetical Index: Esophagostomy cervical Esophagostomy cervical esophagostomy One code category with subcategories at the fourth character level for further specification Classification does not specify the approach Index and Tabular Volumes Alphabetical Index: Esophagostomy see Bypass, Gastrointestinal System 0D1 Bypass Esophagus Upper 0D11 Documentation Needed Location or site of the esophagostomy Tabular (Tables): Reference the table for 0D1 (see Excerpt from the ICD-10-PCS Tables) to look up the remaining characters of the code. In this case the specific body part is esophagus upper (1), the approach is open (0), the device is none (Z), and the qualifier is cutaneous (4). Code Comparisons Classification differentiates the three sections of the esophagus (upper, middle, and lower) Code specifies the operative approach Code specifies any devices remaining at the end of the operation Code specifies the destination of the bypass (qualifier) Location or site of the esophagostomy Operative approach Any devices remaining at the end of the operation The destination of the bypass

29 Excerpt from ICD-10-PCS Tables 0: Medical and Surgical D: Gastrointestinal System 1: Bypass: Altering the route of passage of the contents of a tubular body part Body System Character 4 Approach Character 5 Device Character 6 Qualifier Character 7 1 Esophagus, upper 2 Esophagus, middle 3 Esophagus, lower 5 Esophagus 0 Open 4 Percutaneous Endoscopic 8 Via Natural or Artificial Opening Endoscopic 7 Autologous Tissue Substitute J Synthetic Substitute K Nonautologous Tissue Substitute Z No Device 4 Cutaneous 6 Stomach 9 Duodenum A Jejunum B Ileum

30 40. Crush syndrome with hemorrhaging; lacerations of small and large intestines. Ten-year-old patient was rough housing with his brother in the shop and a sheet of drywall accidentally fell on the patient. The patient was immediately sent to the operating room where an open repair of the lacerations of the small and large intestines due to the crushing injury was performed (code both diagnosis and procedure codes) ICD-9-CM ICD-10-CM Traumatic anuria Hemorrhage, unspecified Injury to small intestine, with open wound into cavity, unspecified site Injury to colon, with open wound into cavity, unspecified site E916 Struck accidently by falling object E849.3 Place of occurrence, industrial place and premises E029.2 Rough housing and horseplay E000.8 Other external cause status Syndrome Crush Diagnosis Code(s) Assigned T79.5xxA Traumatic anuria, initial encounter R58 Hemorrhage, not elsewhere classified S36.439A Laceration of unspecified part of small intestine, initial encounter S36.539A Laceration of unspecified part of colon, initial encounter W20.8xxA Other cause of strike by thrown, projected, or falling object Y Shop as the place of occurrence of the external cause Y93.83 Activity, rough housing and horseplay Y99.8 Other external cause status Index and Tabular Volumes Syndrome Crush T79.5 Hemorrhage, hemorrhagic Laceration internal organ (abdomen) (chest) (pelvic) NEC see Injury, internal, by site Injury Internal intestine NEC large NEC with open wound into cavity small NEC with open wound into cavity Index to External Causes: Hit, hitting by object falling E916 Accident (to) occurring shop E849.3 Hemorrhage, hemorrhagic R58 Laceration intestine large colon S small S Index to External Causes: Struck by object falling W20.8 Place of occurrence shop Y92.513

31 Activity rough housing and horseplay E029.2 External Cause Status specified NEC E Certain early complications of trauma Traumatic anuria Crush syndrome 459 Other disorders of circulatory system Hemorrhage, unspecified Internal Injury of Thorax, Abdomen, and Pelvis ( ) Includes: laceration of internal organs 863 Injury to gastrointestinal tract Small intestine, with open wound into cavity Small intestine, unspecified site Colon or rectum, with open wound into cavity Colon, unspecified site E916 Struck accidentally by falling object E849 Place of occurrence E849.3 Industrial place and premises Shop E029 Other Activity E029.2 Rough housing and horseplay E000 External cause status E000.8 Other external cause status Activity rough housing and horseplay Y93.83 External Cause Status specified NEC Y99.8 T79 Certain early complications of trauma, not elsewhere classified The appropriate seventh character is to be added to each code from category T79: A initial encounter D subsequent encounter S sequela T79.5 Traumatic anuria Crush syndrome R58 Hemorrhage, not elsewhere classified Includes: hemorrhage NOS Excludes 1: hemorrhage included with underlying conditions, such as: acute duodenal ulcer with hemorrhage (K26.0) acute gastritis with bleeding (K29.01) ulcerative enterocolitis with rectal bleeding (K51.01) S36 Injury of intra-abdominal organs Code also any associated open wound (S31.-) The appropriate seventh character is to be added to each code from category S36: A initial encounter D subsequent encounter S sequela S36.4 Injury of small intestine S36.43 Laceration of small intestine S Laceration of unspecified part of small intestine S36.5 Injury of colon S36.53 Laceration of colon S Laceration of unspecified part of colon W20 Struck by thrown, projected, or falling object The appropriate seventh character is to be added to each code from category W20: A initial encounter D subsequent encounter S sequela W20.8 Other cause of strike by thrown, projected, or falling object

32 Y Shop as the place of occurrence of the external cause Y93 Activity Codes Y93.8 Activities, other specified Y93.83 Activity, rough housing and horseplay Laceration of an internal organ is classified as injury of the organ with open wound into the cavity Y99 External Cause Status Y99.8 Other external cause status Code Comparisons Laceration of an internal organ is classified as a laceration to that internal organ with a separate code for any associated open wound of the abdominal wall Documentation Needed Documentation of site of laceration Documentation of specific site of large and small External cause of the injury and place of intestine that were lacerated occurrence in additional to type of activity being Whether or not there was an associated open performed wound of the abdominal wall External cause of the injury and place of occurrence in addition to type of activity being performed ICD-9-CM ICD-10-PCS Procedure Code(s) Assigned Suture of laceration of small intestine Suture of laceration of large intestine 0DQ80ZZ Repair of small intestines 0 Medical and surgical section (procedure type) D Gastrointestinal system (body system) Q Repair (root operation) 8 Small intestines (body part) 0 Open (approach) Z None (device) Z None (qualifier) 0DQE0ZZ Repair of large intestines 0 Medical and surgical section (procedure type) D Gastrointestinal system (body system) Q Repair (root operation) E Large intestine (body part) 0 Open (approach) Z None (device) Z None (qualifier)

33 Repair laceration see Suture, by site Suture (laceration) intestine large small Index and Tabular Volumes Suture Laceration repair see Repair Repair Intestine Large 0DQE Small 0DQ Other repair of intestine Suture of laceration of small intestine, except duodenum Suture of laceration of large intestine Tabular (Tables): Reference the table for 0DQ (see the Excerpt from ICD-10-PCS Tables) to look up the remaining characters of the code. In this case the specific body parts are the large intestine (E) and small intestine (8), the approach is open (0), and there is no device or qualifier (Z). Code Comparisons Classification only provides three codes for suture repair of laceration of small and large Classification provides a code for each specific body part of the small intestine and large intestines intestine: Classification includes the approach o Small intestines o Large intestines o Duodenum Classification does not provide the ability to differentiate suture repair of specific parts of small and large intestines except for duodenum Classification does not differentiate the approach Documentation Needed Location of laceration and suture repair Location of laceration and suture repair Approach

34 Excerpt from ICD-10-PCS Tables 0: Medical and Surgical D: Gastrointestinal System Q: Repair Restoring, to the extent possible, a body part to its normal anatomic structure and function Body System Character 4 Approach Character 5 Device Character 6 Qualifier Character 7 1 Esophagus, Upper 2 Esophagus, Middle 3 Esophagus, Lower 4 Esophagogastric Junction 5 Esophagus 6 Stomach 7 Stomach, Pylorus 8 Small Intestine 9 Duodenum A Jejunum B Ileum C Ileocecal Valve E Large Intestine F Large Intestine, Right G Large Intestine, Left H Cecum J Appendix K Ascending Colon L Transverse Colon M Descending Colon N Sigmoid Colon P Rectum 0 Open 3 Percutaneous 4 Percutaneous Endoscopic 7 Via Natural or Artificial Opening 8 Via Natural or Artificial Opening Endoscopic Z No Device Z No Qualifier

35 42. Laparoscopic cholecystectomy, converted to an open procedure ICD-9-CM ICD-10-PCS Code(s) Assigned V64.41 Laparoscopic surgical procedure 0FT40ZZ converted to open procedure 0 Medical and surgical section (procedure type) Cholecystectomy F Hepatobiliary system and pancreas (body system) T Resection (root operation) 4 Gallbladder (body part) 0 Open (approach) Z None (device) Z None (qualifier) Alphabetic Index (Diseases): Laparoscopic surgical procedure converted to open procedure V FJ44ZZ 0 Medical and surgical section (procedure type) F Hepatobiliary System and Pancreas (body system) J Inspection (root operation) 4 Gallbladder (body part) 4 Percutaneous endoscopic (approach) Z None (device) Z None (qualifier) Index and Tabular Volumes Cholecystectomy see Resection, Gallbladder 0FT4 Alphabetic Index (Procedures): Cholecystectomy (total) Resection Gallbladder 0FT4 Inspection Gallbladder 0FJ4 Tabular (Diseases): V64.41 Laparoscopic surgical procedure converted to open procedure Tabular (Procedures): 51.2 Cholecystectomy Cholecystectomy Tabular (Tables): Reference the table for 0FT (see the Excerpt from ICD-10-PCS Tables) to look up the remaining characters of the code. In this case the specific body part is the gallbladder (4), the approach is open (0), and there is no device or qualifier (Z). Reference the table for 0FJ (see the Excerpt from ICD-10-PCS Tables) to look up the remaining characters of the code. In this case the specific body part is the gallbladder (4), the approach is percutaneous endoscopic (4), and there is no device or qualifier (Z).

36 Code Comparisons In ICD-9-CM when a laparoscopic procedure In ICD-10-PCS when a laparoscopic procedure is converted to an open procedure, the is converted to an open procedure, the coding coding rule is to only code the open rule is to code an endoscopic inspection (for procedure and assign V64.41 as an laparoscopic procedure) and then code the additional diagnosis code actual open procedure Type of approach is not classified except for Approach is specified laparoscopic Fourth digit indicates laparoscopic partial or total or other partial cholecystectomy Documentation Needed Laparoscopic procedure converted to open Laparoscopic procedure converted to open Whether total or partial excision Approach for the procedure Whether total (resection) or partial (excision) Excerpt from ICD-10-PCS Tables 0: Medical and Surgical F: Hepatobiliary System and Pancreas T: Resection Cutting out or off, without replacement, all of a body part Body System Character 4 Approach Character 5 Device Character 6 0 Liver 1 Liver, Right Lobe 2 Liver, Left Lobe 4 Gallbladder G Pancreas 0 Open 4 Percutaneous Endoscopic Qualifier Character 7 Z No Device Z No Qualifier Excerpt from ICD-10-PCS Tables 0: Medical and Surgical F: Hepatobiliary System and Pancreas T: Inspection Visually and/or manually exploring a body part Body System Character 4 Approach Character 5 Device Character 6 0 Liver 1 Liver, Right Lobe 2 Liver, Left Lobe 4 Gallbladder G Pancreas 0 Open 3 Percutaneous 4 Percutaneous Endoscopic X External Qualifier Character 7 Z No Device Z No Qualifier

37 44. Atherosclerotic heart disease of native coronary artery; unstable angina pectoris ICD-9-CM ICD-10-CM Code(s) Assigned Atherosclerotic heart disease of native I Atherosclerotic heart disease of native coronary artery coronary artery with unstable angina pectoris Unstable angina Atherosclerosis see Arteriosclerosis Arteriosclerosis, arteriosclerotic heart (disease) (see also Arteriosclerosis, coronary) coronary (artery) native artery Angina Unstable Coronary atherosclerosis: Arteriosclerotic heart disease [ASHD] Atherosclerotic heart disease Coronary (artery): arteriosclerosis arteritis or endarteritis atheroma sclerosis stricture Use additional code, if applicable, to identify chronic total occlusion of coronary artery (414.2) Of native coronary artery Intermediate coronary syndrome: Impending infarction Preinfarction angina Preinfarction syndrome Unstable angina Index and Tabular Volumes Atherosclerosis see also Arteriosclerosis coronary artery I25.10 with angina pectoris see also Arteriosclerosis, coronary (artery) Arteriosclerosis, arteriosclerotic coronary (artery) I25.10 native vessel with angina pectoris I specified type NEC I unstable I I25.1 Atherosclerotic heart disease of native coronary artery Atherosclerotic cardiovascular disease Coronary (artery) atheroma Coronary (artery) atherosclerosis Coronary (artery) disease Coronary (artery) sclerosis Excludes2: atheroembolism (I75.-) atherosclerosis of coronary artery bypass graft(s) and transplanted heart (I25.7-) I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris Atherosclerotic heart disease NOS I25.11 Atherosclerotic heart disease of native coronary artery with angina pectoris I Atherosclerotic heart disease of native coronary artery with unstable angina pectoris Excludes 1: unstable angina without atherosclerotic heart disease (I20.0)