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ICD-10-PCS Top Reported Surgical & Non-Surgical Procedures Sara Clark, RHIA, MLS Provider Consulting Solutions, Inc. March 19, 2015
3 Objective Objective proficiency coding common procedures Proficiency = Accuracy and productivity Common procedures Surgical Non-surgical
4 Agenda 1. Other Fetal Monitoring 2. Repair OB Laceration 3. Manually Assisted Delivery NOS 4. Low Cervical C-section 5. Venous Catheter NEC 6. Circumcision 7. Left Heart Catheterization 8. Hemodialysis 9. Procedure on Single Vessel 10.Artificial Rupture of Membrane NEC 11.EGD with Closed Biopsy 12.Percutaneous Transluminal Coronary Angioplasty
Proc #1 75.34 Other Fetal Monitoring 75.34 in ICD-9 maps to 63 codes in ICD-10 A few examples are: 4A1HXHZ: Monitoring of POC, Cardiac Sound, Extern Approach 4A1H7CZ: Monitoring of POC, Cardiac Rate, Via Natural/Artificial Opening 4A0H8FZ: Measurement of POC, Cardiac Rhythm, Endo 4A0JX2Z: Measurement of POC, Nervous Conductivity, External Approach
Procedure #2 Repair Obstetric Laceration Repair of obstetric lacerations Episiotomy 1 st 4 th degree
Episiotomy=Division An episiotomy is a surgical incision used to enlarge the vaginal opening to help deliver a baby. The mediolateral cut is angled down, away from the vagina and the perineum, into the muscle. Index: Division/perineum/female Root Operation: Division Body System: Anatomical Regions General 0W8NXZZ Note: DO NOT CODE THE REPAIR (EPISIORRHAPHY) 0WQNXZZ
Coding Perineal Laceration: 1 st Degree First-degree tears are the least severe, involving only the skin around the vaginal opening. ICD-10-PCS root operation table 0HQ would be used to report the repair of the perineum skin. (0HQ9XZZ) This is different than a high vaginal laceration wall tear.
Coding Perineal Laceration: 1 st Degree
10 Coding Perineal Laceration: 2 nd Degree Second-degree vaginal tears involve vaginal tissue and the perineal muscles the muscles between the vagina and anus that help support the uterus, bladder and rectum. 2 nd degree should be coded as 0KQM0ZZ (Muscles, Repair, Perineum Muscle, Open)
11 2 nd Degree Laceration Repair Second degree perineum lacerations: -Involves: - Vaginal tissue - Underlying tissue - Pelvic floor muscles -Requires stitches
12 2 nd Degree Laceration Repair Guideline ICD-10-PCS Official Coding Guideline B3.5: Overlapping body layers: If the root operations Excision, Repair or Inspection are performed on overlapping layers of the musculoskeletal system, the body part specifying the deepest layer is coded
13 Approach: 2 nd Degree Laceration Repair Approach Approach Open: Cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure The laceration has cut through the external body layers exposing the muscle
Coding Perineal Laceration: 2nd Degree
15 Coding Perineal Laceration: 3rd Degree Third-degree vaginal tears involve the vaginal tissues, perineal muscles and the muscle that surrounds the anus (anal sphincter) 3 rd degree perineal laceration repair requires 2 codes and should be coded as: 0KQM0ZZ (Muscles, Repair, Perineum Muscle, Open) and 0DQR0ZZ (Gastrointestinal System, Repair, Anal Sphincter, Open)
Coding Perineal Laceration: 3rd Degree 16
17 Coding Perineal Laceration: 4th Degree Fourth-degree vaginal tears are the most severe. They involve the perineal muscles and anal sphincter as well as the tissue lining the rectum. Fourth-degree tears usually require repair in an operating room rather than the delivery room and might take months to heal. 4 th degree perineal laceration repair requires 3 codes and should be coded as: 0KQM0ZZ (Muscles, Repair, Perineum Muscle, Open), 0DQR0ZZ (Gastrointestinal System, Repair, Anal Sphincter, Open) 0DQP0ZZ (Gastrointestinal System, Repair, Rectum, Open)
Coding Perineal Laceration: 4th Degree 18
Proc #3 73.59 Manual Assisted Delivery 10E0XZZ Index look up: Delivery Cesarean see Extraction, Products of Conception 10D0 Forceps see Extraction, Products of Conception 10D0 Manually assisted 10E0XZZ
Proc #3 Manual Assisted Delivery 10E0XZZ - Table
Proc #4 74.1 Low Cervical C-Section 10D00Z1 Low cervical is also known as transverse The 7th character (qualifier) for classical and extraperitoneal c-sections is different be careful on table
Proc #4 Low Cervical C-Section 10D00Z1 Index look up: Extraction continued Products of Conception continued Ectopic 10D2 Extraperitoneal 10D00Z2 High Forceps 10D07Z5 Internal Version 10D07Z7 Low Cervical 10D00Z1 Low Forceps 10D07Z3 Mid Forceps 10D07Z4
Proc #4 Low Cervical C-Section 10D00Z1 - Table
Proc #5 38.93 Venous Cath NEC In ICD-10, 38.93 can map up to 28 codes 38.93 commonly reported for PICC line placement 02HV33Z (insertion of infusion device into superior vena cava, percutaneous approach)
Proc #5 Venous Cath NEC Root operation is Insertion. Note that the index instructs you to use a device for PICC. USE is different than SEE.
Proc #7 Venous Cath NEC
Proc #6-64.0 CIRCUMCISION 0VTTXZZ Index look up: Resection continued Toe Left 0QTR0ZZ Right 0QTQ0ZZ Pharynx 0CTM Pineal Body 0GT1 Prepuce 0VTT Products of Conception, Ectopic 10T2 Prostate 0VT0
Proc #6 - CIRCUMCISION 0VTTXZZ Table
Proc #7 37.22 Left Heart Cardiac Catheterization 4A023N7 (LT heart) The root operation for a heart catheterization is Measurement with the code for a left heart catheterization being 4A023N7. The seventh character identifies if the procedure is performed on the left, right, or is bilateral. Unlike ICD-9-CM, ICD-10-PCS differentiates the various approaches to performing this procedure with the fifth character capturing the approach.
Proc #7 - Left Heart Cardiac Catheterization 30
Proc #8 39.95 Hemodialysis 5A1D00Z Hemodialysis is under root operation PERFORMANCE. Definition of performance = completely taking over a physiological function by extracorporeal means Index look up: Dialysis Hemodialysis 5A1D00Z Peritoneal 3E1M39Z
Proc #8 - Hemodialysis 5A1D00Z Table
Procedure #9 Procedure on Single Vessel ICD-9-CM code is 00.40 Commonly used to report the number of vessels involved when doing a PTCA There is no code in ICD-10-PCS that matches this code In ICD-10-PCS we would code multiple procedures if multiple body parts are involved
Proc #10 Artificial Rupture of Membranes NEC AROM = when a women s membranes are ruptured by a health care provider to induce or accelerate their labor Root operation = DRAINAGE
Proc #10 Artificial Rupture of Membranes NEC ICD-9 code is 73.09 Maps to 2 ICD-10 codes: 10907ZC: Drainage of Amniotic Fl, Therapeutic from POC, Via Natural or Artificial Opening 10908ZC: Drainage of Amniotic Fluid, Therapeutic from POC, Via Natural or Artificial Opening Endoscopic
Proc #10 Artificial Rupture of Membranes NEC 2 Index lookups Drainage
Proc #10 Artificial Rupture of Membranes NEC
Proc #11 45.13 Small Bowel Endoscopy NEC This is commonly referred to as an Esophagogastroduodenoscopy (EGD). This is a procedure in which a thin scope with a light and camera at its tip is used to look inside the upper digestive tract -- the esophagus, stomach, and first part of the small intestine, called the duodenum.
Proc #11 Small Bowel Endoscopy NEC 0DJ08ZZ: Inspection of Upper Intestinal Tract 2 options for Index look ups:
Proc #11 - Small Bowel Endoscopy NEC 0DJ08ZZ: Inspection of Upper Intestinal Tract Note body part choice is limited and not the same as an EGD with biopsy.
Proc #11 45.16 EGD with biopsy 0DB68ZX: Excision of Stomach EGD with stomach biopsy = Excision (doctor will remove a small tissue sample for further study)
Proc #12 Percutaneous Transluminal Coronary Angioplasty ICD-9 code is 00.66 Maps to 8 ICD-10 codes Examples: 1027034Z: Dilation of Coronary Artery 1 site, intraluminal device, drug eluting, Percutaneous 1027134Z: Dilation of Coronary Artery 2 sites, intraluminal device, Percutaneous
Proc #12 Percutaneous Transluminal Coronary Angioplasty Medical and Surgical Section Guidelines (section 0) B4.4 Body Part Guidelines Coronary arteries The coronary arteries are classified as a single body part that is further specified by number of sites treated and not by name or number of arteries. Separate body part values are used to specify the number of sites treated when the same procedure is performed on multiple sites in the coronary arteries.
Proc #12 Percutaneous Transluminal Coronary Angioplasty
Thank you! Sara Clark, RHIA, MLS, AHIMA Approved ICD-10-CM/PCS Trainer Provider Consulting Solutions, Inc 3 Corporate Drive, Suite 201 Clifton Park, New York 1265 Phone: (518)-371-3036 ext. 420 Web: providercs.com Questions? sclark@providercs.com
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