2By attending this workshop, participants will Identify theSettings that will require ICD-10-PCSKnowledge that coders will need to apply ICD-10-PCSKey components required for “building” ICD-10-PCS CodesReceiveICD-10-PCS Coding Examples and CasesICD-10-PCS Resources Listing for future use
3ICD-10-PCS DevelopmentWHO permitted creation of ICD-10-PCS as successor to Vol. 3, ICD-9-CMICD-10-CM does NOT have procedure codesCMS issued contract3M Health Information Systems in 1993Design & develop procedure classification system to replace Volume 3 of ICD-9-CM,ONLY used in United States
4Development Goals Attribute Completeness Expandability Multiaxial DefinitionCompletenessA unique code for each substantially different procedure ExpandabilityStructure should allow easy expansionMultiaxialShould contain independent characters, & an individual axis that maintains its meaning across ranges of codesStandardized TerminologyDefinitions are well defined, with no multiple meanings, and each term assigned a specific meaning
5Other Development Guidelines Diagnostic Information NOT Included in Procedure DescriptionExplicit Not Otherwise Specified (NOS) Options are NOT ProvidedLimited Use of Not Elsewhere Classified (NEC) OptionLevel of Specificity = GranularityGreater granularity = Deeper level of detail
6Control of ICD-10-PCS Developed & Maintained by CMS Cooperating PartiesSame as for ICD-10-CMAHAAHIMACMSNCHSICD-10-PCS
7ICD-10-PCS Replaces Volume 3 of ICD-9-CM Code structure INPATIENT Procedures ONLYCode structureMulti-axial 7-characterAlphanumeric code structureUnique codes for proceduresNew codes for new proceduresEasy to incorporate into system
8Components of ICD-10-PCS Index (Do NOT have to start here)Used to access Root Operations TablesDetachment, Ring finger 0X6----Tables (1st 3 characters at top) 0X6Provide valid values available for code construction4 columnsVarying number of rowsEach row gives valid choices for characters 4-7List of Codes
9ICD-10-PCS Guidelines A. Conventions…………………….....1 B. Medical & Surgical SectionGuidelines ....……………………...42. Body System……………………3. Root Operation…………………..…...54. Body Part …………………….……....95. Approach………………………….….126. Device………………………………....13C. Obstetrics Section Guidelines...14
10Code descriptions Standardized Do NOT include (Smaller Index) Provide precise and stable definitionsDo NOT include (Smaller Index)EponymsCommon procedure namesAcronymsVery few codes for multiple procedures
11Coders and AttributesICD-10-PCS should allow coders to construct accurate codes with minimal effortLogical, consistent coding processCodes are CONSTRUCTED/BUILTValues (individual letters & numbers) selected in sequencePlaced in 7 spaces (Characters) of code
12Standardized Terminology Example:Excision = documentation of wide variety of surgical proceduresIn ICD-10-PCSExcision = cutting out or off, without replacement, a portion of a body partONLY definition for this word in ICD-10-PCS
13ICD-10-PCS DefinitionsCharacter – One of 7 components that comprise an ICD-10-PCS procedure codeProcedure – Complete specification of seven charactersSection (1st character) – Defines general type of procedureValue – Individual units defined for each character & represented by number OR letter
14Possible Values 34 values Definition of each character of code Numbers 0 thru 9Letters A-Z, BUT NOT I and ODefinition of each character of codeFunction of its physical position in codeSame value in different position= Different meaningEx: Value 0 in 1st character means something different than Value 0 in 2nd characterCharacters 2-7 in each section always same meaning, but maybe NOT same in another
16Med/Surg Section Largest section in ICD-10-PCS About 86% of all codesMajority of codes used for Inpatient coding2-7 Characters in this sectionSpecific to this sectionConsistent meanings throughout this section
17ICD-10-PCS Definitions (Med/Surg) Body System (2nd character)DefinesGeneral physiological system on which procedure performed ORAnatomic region where procedure performedRoot Operation/Type (3rd character)Defines objective of procedureBody Part or Region (4th character)Defines specific anatomical site where procedure performed
18ICD-10-PCS Definitions (Med/Surg) Approach (5th character)– Technique used to reach procedure siteDevice (6th character)Material or appliance that remains in/on body at end of procedureQualifier (7th character)Additional attribute of procedure performed, IF applicable
19Code Structure in Medical-Surgical Section Character 1SectionCharacter 2Body SystemCharacter3RootOperationCharacter 4BodyPartCharacter 5ApproachCharacter 6DeviceCharacter 7QualifierALL ICD-10-PCS codes are 7 characters long
20Body System Subdivisions Character 2 Body PartsBranches or portions of body part that don’t have more specific designationEach Section’s Tables include all body parts values for that designated body system
21General vs Specific Body Part Character 3 General Body part assigned ONLY when documentation does not support more specific codeEx: Liver - Right Lobe, Left LobeWhen specified Portion of Body Part NOT designated in ICD-10-PCS, use whole body partEx: Alveolar process of mandibleAssign value for Mandible (R or L)
22Peri- Body PartIF a body part with prefix PERI- does not have an assigned value, use value for body partSome do, such as pericardium
23Body Part Key (Table)Arteries, Bones, Glands, Muscles, Veins, etc.
24Root Operation Character 4 KEY to identifying correct ICD-10-PCS codeMain Term for procedure is most often a Root OperationMany fewer Main Terms in IndexOnly Objective of ProcedureComponents of procedures NOT indexedEx: Reduction (see), Anastomosis (no entry)
25Root Operation Accurately identifies objective of procedure Familiarity with these definitions is critical to success in ICD-10-PCS codingConstructing correct codes relies on correct interpretation & understanding of these definitions
26Index and Root Operations Common Procedure terms may referAmputation – see DetachmentArthrectomy – see Excision, ResectionArthrocentesis – see DrainageArthrodesis – see FusionArthrolysis – see ReleaseBiopsy – see Drainage, see ExcisionDebridement – see Excision or ExtractionSuture – see Repair
27Med Surg Root Operations Select root operation matching specific objective of documented procedureDivided into 9 groups that share similar attributesCoders MUST understand definitions before starting coding process (HO)
289 Root Operation Groups Taking out some/all of body part DestructionDetachmentExcisionExtractionResectionTaking out solids/fluids/gases from body partDrainageExtirpationFragmentation
299 Root Operation Groups Involving cutting or separation only DivisionReleasePutting in/back or moving some/all of body partReattachmentRepositionTransferTransplantationAltering diameter/route of tubular body partBypassDilationOcclusionRestriction
309 Root Operation Groups Always involving a device ChangeInsertionRemovalReplacementRevisionSupplementFor other objectivesAlterationCreationFusionInvolving examination onlyInspectionMapInvolving other repairsControlRepair
31Approach – Character 5 Technique used to reach site of procedure 0 Open Cutting through skin or mucous membrane & any other body layers necessary to expose site of procedure3 Percutaneous Entry, by puncture or minor incision, of instrumentation through skin or mucous membrane and any other body layers necessary to reach site of procedure4 Percutaneous Endoscopic Entry, by puncture or minor incision, of instrumentation through skin or mucous membrane and any other body layers necessary to reach and visualize site of procedure7 Via Natural or Artificial Opening Entry of instrumentation through a natural or artificial external opening to reach site of procedure
32Approach – Character 58 Via Natural or Artificial Opening Endoscopic Entry of instrumentation through a natural or artificial external opening to reach and visualize site of procedureF Via Natural or Artificial Opening with Percutaneous Endoscopic Assistance Entry of instrumentation through natural or artificial external opening and entry, by puncture or minor incision, of instrumentation through skin or mucous membrane and any other body layers necessary to aid in performance of procedureX External Procedures performed directly on skin or mucous membrane and procedures performed indirectly by application of external force through skin or mucous membrane
33Device – Character 6 Device values fall into 4 basic categories Grafts and ProsthesesImplantsSimple or Mechanical AppliancesElectronic Appliances
34Devices* – Character 6 0 Drainage Device 2 Monitoring Device 3 Infusion Device7 Autologous Tissue SubstituteC Extraluminal DeviceD Intraluminal DeviceJ Synthetic SubstituteK Nonautologous Tissue SubstituteL Artificial SphincterM Stimulator LeadY Other DeviceZ No Device*MUST Remain after procedure completed
35Types of Devices Biological/Synthetic replacement Biological/Synthetic assists/prevents functionTherapeutic, not absorbed, eliminated, incorporated into body partMechanical/Electronic appliancesY = Other Device = NEW device NOT yet in ICD-10-PCS
36When to code DeviceIF device means by which procedural objective accomplished, then specific device value coded as 6th characterA coder should askIs this material central to achieving objective of procedure, or does it only support performance of procedure?Device stays in specific locationDevice is technically removeable
37When to code DeviceDevice - intended to maintain fixed location at procedure site where putSubstance - intended to disperse or be absorbed in the
40Device ExampleTotal L hip replacement w/metal on plastic (polyethylene) prosthesisValueCharacter DefProcedureSectionMed/SurgSBody SystemLower JointsRRoot OperationReplacementBBody PartL Hip JointApproachOpen2DeviceSynthetic Substitute, Metal on PolyethyleneZQualifierNo Qualifier9 CementedA UncementedZ No QualifierNote: Qualifier has 3 choices; check MR
41Device Example One-Row Table 0 Medical and Surgical H Skin and Breast 2 Change Taking out or off a device from a body part and puttingback an identical or similar device in or on the samebody part without cutting or puncturing the skin or amucous membraneBody PartCharacter 4ApproachCharacter 5DeviceCharacter 6QualifierCharacter 7P SkinT Breast, RightU Breast, LeftX External0 DrainageY Other DeviceZ No QualifierOne-Row Table
42NOT Devices Instruments used only during procedure ForcepsVacuum extractorDrillBurrInstruments to visualize site (Approach)ArthroscopeIncidental materialsClipsStaplesSutures & suture alternatives (fibrin glue, dermabond, etc.)
43Devices & Root Operations Root Operations that ALWAYS have deviceChangeInsertionRemovalReplacementRevisionRoot Operations that MAY have deviceAlterationBypassCreationDilationDrainageFusionOcclusionRepositionRestriction
44Qualifier 7th character Information on attributes NOT captured in 1st 6 charactersMost root operations DO NOT have a specific qualifier valueZ
45Qualifier* – Character 7 0 Allogeneic1 Syngeneic2 Zooplastic3 Kidney Pelvis, Right3 Full Thickness4 Kidney Pelvis, Left4 Partial Thickness6 Ureter, Right7 Ureter, Left8 Colon9 ColocutaneousA IleumB BladderC IleocutaneousD CutaneousX DiagnosticZ No Qualifier*Unique values for individual procedures
46Qualifier – Character 7Qualifier choices vary depending on previous values selectedWhen constructing code from a Table, MUST stay in the same row, once you have selected the 4th character
47Skin and Breast 0H0 – 0HY 0 Medical and Surgical H Skin and Breast 0 AlterationBody PartCharacter 4ApproachCharacter 5DeviceCharacter 6QualifierCharacter 7T Breast, RightU Breast, LeftV Breast, Bilateral0 Open3 PercutaneousX External7 Autologous Tissue SubstituteJ Synthetic SubstituteK Nonautologous Tissue SubstituteZ No DeviceZ No qualifier
48Value Z – as Device & Qualifier Character Device and Qualifier charactersDo NOT have specific value for EVERY procedureNOT every procedure has device/qualifierZ as 6th character = NO device used/left inZ as 7th character = NO add’l attributes
4931 Body Systems in ICD-10-PCS Med/Surg Body Parts for MSK – MusclesL – TendonM – Bursa and LigamentsN – Head and Facia BonesP – Upper BonesQ – Lower BonesR – Upper JointsS – Lower JointsBody Parts for SkinH – Skin and BreastJ – SubQ Tissue & Fascia
50MS Code Example L B 5 Z Excision of R lower arm and wrist tendon, open Character SectionCharacter 2Body SystemCharacter 3Root OperationCharacter 4Body PartCharacter 5ApproachCharacter 6DeviceCharacter 7QualifierMedical and SurgicalTendonsExcisionLower Arm and Wrist,RightOpenNo DeviceNo QualifierLB5ZExcision of R lower arm and wrist tendon, open
51Integumentary Code Example Character 1SectionCharacter 2Body SystemCharacter 3Root OperationCharacter 4Body PartCharacter 5ApproachCharacter 6DeviceCharacter 7QualifierMedical & SurgicalSkin & BreastTransferSkin, ChestExternalNo DeviceNo QualifierHX5ZClosure, complex wound, right chest using adjacent skin transfer flap
5210 Top Documentation Issues in ICD 10 Diabetes mellitusInjuriesSize/depthDrug underdosingReasonCerebral infarctionsAMINeoplasmsMusculoskeletal conditionsEx: Pathological Fxs8 codes in ICD-9-CM150 in ICD-10-CMPregnancyRespiratory/ventsICD-10-PCSEverything!
53Interpreting Documentation Coding Guideline A11Many of the terms used to construct PCS codes are defined within the system. It is the coder’s responsibility to determine what the documentation in the medical record equates to in the PCS definitions. The physician is not expected to use the terms used in PCS code descriptions, nor is the coder required to query the physician when the correlation between the documentation and the defined PCS terms is clear.
54Needed Documentation Specificity Laterality Medical and Surgical Section – MusculoSkeletal ExampleICD-10-PCSDescriptionICD-9-CM0MN14ZZRight shoulder arthroscopy with coracoacromial ligament release80.41Release of ligament, shoulderSpecificityLaterality
55Body Part Laterality Separate body part values for R and L Few bilateral body part valuesIF no bilateral value, assign two codes
56“Unspecified” Codes AVOID Must have specificity in codesJustification for better reimbursementBad effect on Severity of Illness and Risk Scores76875
57Other Specificity Time Frames Severity MS-DRGs Some codes require Number of hoursVentilationSeverityAsthma – level requiredRespiratory failure – requiredMS-DRGsCMS will be making future changesRequire more in-depth documentation
58Joints Complex structures Body Part values for components AND joints Articulating bonesTendons, LigamentsBursae, FasciaBody Part values for components AND jointsFocus on component = Component valueFocus on joint (capsule/articular cartilage)= Joint value
59Muscle Procedures 1st Two characters = 0K Common Root Operations ExcisionReattachmentTransferBody PartEx:ValueBody Part(Listed in Tables)Included Structures(NOT in Tables)Head MuscleAuricularis muscleMasseter musclePterygoid muscleSplenius capitus muscleTemporalis muscleTemporoparietalis muscle
60Tendon Procedures 1st Two characters = 0L Common Root Operations DivisionReleaseTransferBody PartEx:ValueBody PartIncluded StructuresLUpper Leg Tendon, RRightAdductor brevis tendonAdductor longus tendon
61Bursae and Ligaments 1st Two Characters = 0M Common Root Operations DrainageRepositionSupplementBody PartEx:ValueBody PartIncl. Structures3Elbow Bursa & Ligament, RRightAnnular ligamentOlecranon bursaRadial collateral ligamentUlnar collateral ligament
62Head Bones 1st Two Characters = 0N Common Root Operations Body Part DivisionExcisionRepositionBody PartEx:ValueBody PartIncl. StructuresVMandible, LLeftAlveolar process of mandibleCondyloid processMandibular notchMental foramen
63Upper Bones 1st Two Characters = 0P Common Root Operations Body Part DivisionInsertionRepositionBody PartEx:ValueBody PartIncluded StructuresNCarpal, LLeftCapitate boneHamate boneLunate bonePisiform boneScaphoid boneTrapezium boneTrapezoid boneTriquetral bone
64Lower Bones 1st Two Characters = 0Q Common Root Operations Body Part InsertionRepositionSupplementBody PartEx:ValueBody PartIncluded StructuresMTarsal, LLeftCalcaneusCuboid boneIntermediate cuneiform boneLateral cuneiform boneMedial cuneiform boneNavicular boneTalus bone
65Upper Joints 1st Two Characters = 0R Common Root Operations Body Part InspectionRepairReplacementBody PartEx:ValueBody PartIncluded Structures6Thoracic Vertebral JointCostotransverse jointCostovertebral jointThoracic facet joint
66Lower Joints 1st Two Characters = 0S Common Root Operations Body Part FusionRemovalReplacementBody PartEx:ValueBody PartIncluded StructuresGAnkle Joint, LeftLeftInferior tibiofibular jointTalocrural joint
67Integumentary Procedures Body PartsSkin, R Hand – L HandSkin, RU Leg - LU LegSkin, RL Leg – LL LegSkin, R Foot - L FootSkinFinger Nail - Toe NailHairBreast, R – Breast LBreast, BilateralNipple, R – Nipple LSupernumerary BreastBody PartsSkin, ScalpSkin, FaceSkin, R Ear – L EarSkin, NeckSkin, ChestSkin, BackSkin, AbdomenSkin, ButtockSkin, PerineumSkin, GenitaliaSkin, R U Arm - LU ArmSkin, RL Arm - LL Arm
68Subcutaneous and Fascia Body Parts Similar to Skin and BreastAnterior/Posterior NeckTrunkLower – Upper ExtremityBody Part Key
69Common Medical-Surgical Root Operations MS and IntegumentaryHand Out = Complete List
70Alteration (0)Modifying the anatomic structure of a body part without affecting the function of the body partExplanation - Principal purpose is to improve appearanceExamples - Face lift, breast augmentationUSED FOR COSMETIC PROCEDURES ONLY
71Detachment (6)Cutting off all or part of the upper or lower extremitiesExplanation - The body part value is the site of the detachment, with a qualifier if applicable to further specify the level where the extremity was detachedExamplesBelow knee amputation, disarticulation of shoulder
74Division (8)Cutting into a body part without draining fluids and/or gases from the body part in order to separate or transect a body partExplanationAll or a portion of body part is separated into two or more portionsExamplesOsteotomy, Spinal cordotomySacral rhizotomy for pain control, percutaneous
75Drainage (9)Taking or letting out fluids and/or gases from a body partExplanationThe qualifier DIAGNOSTIC is used to identify drainage procedures that are biopsiesExamplesArthrocentesisOpen R hip arthrotomy with drain placementBreast cyst aspiration biopsy
76Excision (B)Cutting out or off, without replacement, a portion of a body partExplanationThe qualifier DIAGNOSTIC is used to identify excision procedures that are biopsiesExamplesPercutaneous biopsy of R gastrocnemius muscleOpen excision of lesion from R Achilles tendon
77Fusion (G)Joining together portions of an articular body part rendering articular body part immobileExplanationBody part joined together by fixation device, bone graft, or other meansExamplesSpinal fusion, Arthrodesis of R ankle, openIntercarpal fusion of L hand w/ bone bank bone graft, openRadiocarpal fusion of R hand with internal fixation, open
78Insertion (H)Putting in a non-biological device that monitors, assists, performs or prevents a physiological function but does not physically take the place of a body partExplanation - N/AExamplesInsertion of radioactive implantPercutaneous insertion of bone growth stimulator electrode, L femoral shaftTissue expander for skin graft
79Inspection (J) Visually and/or manually exploring a body part ExplanationVisual exploration may be performed w/ or w/o optical instrumentation. Manual exploration may be performed directly or through intervening body layersExamplesDiagnostic arthroscopy, exploratory laparotomy
81Reattachment (M)Putting back in or on all or a portion of a separated body part to its normal location or other suitable locationExplanationVascular circulation and nervous pathways may or may not be reestablishedExamplesReattachment of hand, reattachment of avulsed kidney
82Release (N)Freeing a body part from an abnormal physical constraint by cutting or by use of forceExplanationSome of the restraining tissue may be taken out but none of the body part is taken outExamplesManual rupture of L shoulder joint adhesions under general anesthesiaCarpal tunnel release
83Removal (R ) Taking out or off a device from a body part Explanation When device taken out & similar device put in w/out cutting or puncturing skin or mucous membrane, code to root operation CHANGE.Otherwise, procedure for taking out device is coded to root operation REMOVAL & procedure for putting in new device is coded to root operation performedExamplesIncision w/ removal of K-wire fixation, L 2nd metacarpal
84Repair (Q)Restoring, to extent possible, a body part to its normal anatomic structure and functionExplanationUsed ONLY when method to accomplish repair is NOT one of the other root operationsExamplesHerniorrhaphy, suture of laceration
85Repair Root Operation In Medical/Surgical Section is a NEC option Default when procedure is NOT any other specific root operationExample: Suture R biceps tendon laceration
86Replacement (R)Putting in/on biological/synthetic material that physically takes place and/or function of all or portion of body partExplanationBiological material is non-living, or living & from same individual. The body part may have been previously taken out, previously replaced, or may be taken out concomitantly with Replacement procedure.ExamplesTotal hip replacement, bone graft, free skin graft
87Replacement, Cont.If body part has been previously replaced, separate Removal procedure is coded for taking out device used in previous replacementExamplesTotal hip replacement, bone graft, free skin graftR hip hemiarthroplasty, openOpen tenonectomy w/ graft to L ankle using cadaver graft
88Reposition (S)Moving to its normal location or other suitable location all or a portion of a body partExplanationBody part is moved to new location from abnormal location, or from normal location where it is not functioning correctly. The body part may or may not be cut out or off to be moved to the new locationExamplesFracture reduction, Reposition of undescended testicle
89Other Reposition Procedures ORIF, L tibia and ulnaOpen fx, displaced fx of R distal humerusClosed reduction w/ percutaneous internal fixation of L femoral neck fxR knee arthroscopy w/ reposition of patellar ligament
90Fracture Reduction Reposition – Root Operation S Moving to its normal location or other suitable location all or a portion of a body partReposition procedures include movingBody part to its normal locationBody part to new location to enhance its ability to functionReflects DISPLACED Fracture
91Fracture TreatmentTreatment of non-displaced fracture is coded to procedure performedEx: Putting pin in non-displaced fx =Insertion Root OperationEx: Casting non-displaced fx =Immobilization Root OperationIn Placement Section, NOT Med/Surg
92Resection vs ExcisionExcision – cutting out or off, w/o replacement, a portion of a body partBiopsy, with Diagnostic QualifierResection - cutting out or off, w/o replacement, all of a body partTotal Mastectomy, Complete Excision of nipple, Complete excision of nail
93Supplement (U)Putting in/on biologic/synthetic material that physically reinforces and/or augments function of a portion of body part ExplanationBiological material is non-living, or living and from the same individual. Body part may have been previously replaced. If body part previously replaced, Supplement procedure performed to physically reinforce and/or augment function of replaced body part
94Supplement, Cont. Examples New acetabular liner in a previous hip replacementOpen tendon graft using autograftOpen resurfacing procedure on left acetabular surface
95Transfer (X)Moving, without taking out, all or a portion of a body part to another location to take over the function of all or a portion of a body partExplanationBody part transferred remains connected to its vascular and nervous supplyExamplesR wrist palmaris longus tendon transfer, openTransfer R index finger to right thumb position, openSkin pedicle flap
96ICD-10-PCS Coding Process Codes are constructed1. ID Root Operation based on documentationThen, Using Index (But NOT required)2. ID Body System, Body Part3. After finding the 1st 3-4 values, go to Table4. Using documentation, ID last 3-4 valuesOnce 4th Character selected, MUST stay in Row
97Selection Process0JHW3VZ is NOT valid code - Why?
98Coding Process Example Intramedullary rod insertion, L femoral shaft for non-displaced fx1. Insertion =2. Index Main TermBy Body system – Lower Bones 0QHBy Device – Intramedullary Fixation Device 0QHBy Body part - not under this Main Term
993. Use Table 0 Q H Insertion: Putting in nonbiological appliance that monitors, assists, performs or prevents physiological function, but does not physically take place of body part0QH906ZBody PartCharacter 4ApproachCharacter 5DeviceCharacter 6QualifierCharacter 76 Upper Femur, R7 Upper Femur, L8 Femoral Shaft, R9 Femoral Shaft,LB Lower Femur, RC Lower Femur, LG Tibia, RH Tibia, LJ Fibula, RK Fibula, L0 Open3 Percutaneous4 Percutaneous Endoscopic4 Internal Fixation Device6 Intramedullary Fixation DeviceZ No QualifierThis is one of four rows in this TableValues for characters 4 thru 7MUST come from same row in Table
100Case Accidental amputation of right ring finger, initial encounter Degloving injury; Ring caught onHandrail screw while leaving SubwayProcedureAmputation atMetacarpophalangeal joint
101Coding Process Index Entry Amputate – see Detachment Amputation – see DetachmentDetachmentby Body SystemAnatomical Regions, Upper Extremities 0X6by Body PartRing Finger 0X6
102Tables (HO)0X6Find correct rowStay in row to find rest of values
103Code is 0X6S0Z0 From Table X 6 S Z Section Body System Operation Body PartApproachDeviceQualifierX6SZMedical/ SurgicalAnatomical Regions, Upper ExtremitiesDetachment: Cutting off all or a portion of the upper or lower extremitiesRing Finger, RightOpenNo DeviceCompleteAmputation at the metacarpo-phalangeal/ metatarsal-phalangeal joint
104Case 1Preoperative Diagnosis: Extensive laceration, distal left index finger with partial severance of distal phalanxPostoperative Diagnosis: SameOperation: Open reduction internal fixation distal phalanx L index finger with Kirschner wire stabilization; nonexcisional debridement of laceration of L index finger; repair laceration L middle fingerProcedure: Pt prepped & draped in the usual manner after axillary block administered. Pt had a Miter saw go into his index finger, lacerating the dorsal radial aspect of index finger at distal phalangeal phalanx level.Saw went into base of nail.
105Case 1, Cont.We used C-arm fluoroscopy to thoroughly evaluate area & then inflated tourniquet to 280 mm of Mercury after arm exsanguinated. Wound thoroughly irrigated w/saline solution to which antibiotics were added & subcutaneous tissue debrided of all devitalized tissue, trash, & foreign bodies present in tissue. Then used Kirschner wire of inches in dia. & drilled across fracture site in joint to totally stabilize area. Once this in place, then very carefully closed skin w/ interrupted running 5-0 Ethibond suture. Area of laceration on middle finger just distal to insertion of extensor tendon. Looked like bulk of nail bed would be viable, some damage to base of nail bed. Laceration of left middle finger, which extended into subcutaneous tissue, then repaired w/ 4-0 Vicryl sutures. Large compression dressing applied.
106Case 1 ANSWER 0PSV04Z Reposition, Phalanx, Finger, Left (0PSV) In IndexReduction, Fracture, see Reposition0JDK0ZZ Extraction, Subcutaneous Tissue and Fascia, Hand, Left (0JDK)Debridement, Non-Excisional, see Extraction0JQK0ZZ Repair, Subcutaneous Tissue and Fascia, Hand, Left (0JQK)Suture, Laceration repair, see RepairB4.1a
108OPS Table (One Row of 8) V = Value in 2 rows, so then must use Approach to determine row
109Case 2 Preoperative Diagnosis: Left upper eyelid laceration & chin lacerationPostoperative Diagnosis: SameOperation: Repair of L upper eyelid & chin lacerationsProcedure: After patient suitably prepared under general anesthesia, left upper eyelid & chin were dressed & draped with Betadine. Left upper eyelid laceration (3 cm) inspected. It did appear to go through left upper eyelid canaliculus. Distal end could be seen, proximal end could not. It was elected not to try to repair canaliculus.
110Case 2One interrupted 6-0 silk suture placed through lid margin & then 3 interrupted 5-0 Vicryl sutures placed through deep tissue. Running 6-0 silk suture then placed through skin. 2.0 cm chin laceration of skin closed w/three interrupted 6-0 silk sutures. Gentamicin ointment applied to lacerations and dressing placed over left eye. Patient tolerated procedure well & left OR in stable condition.
111Case 2 ANSWER 08QPXZZ Repair, Eyelid, Upper, Left (08QP) Suture, Laceration repair, see Repair0HQ1XZZ Repair, Skin, Face (0HQ1XZZ)
113Case 2 Explanation One of 2 Rows in 0HQ Table; Only Row with Body Part Value of 1
114Case 3Preoperative Diagnosis: Localized area of extensive fibrocystic mastitis, upper outer quadrant, right breastPostoperative Diagnosis: SameOperation: Partial mastectomy (quadrectomy), upper outer quadrant, right breastProcedure: Pt prepped & draped in usual manner after general anesthesia. Local anesthesia w/Xylocaine & Marcaine, Adrenalin added, infiltrated around breast to lessen postop pain. Localized area of extensive fibrocystic mastitis in upper outer quadrant of right breast, persistently tender.
115Case 3We made infra-areolar incision around upper outer quadrant of R breast & undermined skin to upper outer quadrant. Then carried out wedge excision of right breast, removing full thickness of breast in traditional quadrectomy & partial mastectomy type. Specimen sent to lab for histological frozen section. Revealed benign fibrocystic mastitis w/o any evidence of malignancy. Hemostasis secured w/ electro-coagulation, & breast parenchyma secured with electrocoagulation. Breast parenchyma reconstructed with 2-0 Dexon suture, followed by 4-0 chromic, & finally 4-0 subcuticular Prolene. Large compression dressing & Jobst mammary support applied.
116Case 3 Answer 0HBT0ZZ Excision, Breast, Right (0HBT) Mastectomy, see, Excision, Skin and Breast (0HB)Quadrant resection of breast, see Excision, Skin and Breast (0HB)
117Case 3 ExplanationOne of two Rows in 0HB Table; Only Row with T Body Part
118Case 4 Preoperative Diagnosis: Breast cancer Postoperative Diagnosis: SameOperation: Port-a-cath placement for chemotherapy infusionProcedure: Patient taken to OR & placed in supine position. Right chest & neck prepped & draped in usual manner, and 20 cc of 1 percent Lidocaine injected. Right subclavian vein punctured, & wire passed percutaneously into superior vena cava. Introducer kit was introduced into subclavian vein, & port-a-cath placed through introducer and, by fluoroscopy, placed down to superior vena cava.
119Case 4Next incision made in chest region over right pectoralis major muscle superior to breast & pocket created in subcutaneous tissue. Port-a-cath reservoir placed into this pocket & tacked down. Catheter then tunneled through to reservoir. Hemostasis achieved, and subcutaneous tissue closed with #2-0 Dexon. Skin closed with #3-0nylon. Port-a-cath flushed with saline.
120Case 4 ANSWER02HV33Z Insertion of device in, Vena Cava, Superior (02HV)0JH60WZ Insertion of device in, Subcutaneous Tissue and Fascia, Chest (0JH6)
122Case 4 Explanation One of 6 Rows in 0JH Table; 2 Rows have W Device; Other Row is for Extremities
123Case 5 Preoperative Diagnosis: Full thickness burn to right foot Postoperative Diagnosis: SameOperation: Split thickness skin graft from right thigh to right footIndications: The patient is a 33-year-old male who suffered a full thickness burn to his right foot. The patient has a history of cardiac disease and hypertension. Pt is 40-pack-a-year smoker who quit 10 yrs ago. Pt presents for elective debridement of wound and split thickness skin graft.
124Case 5Operative Description: Pt taken to OR & placed supine on operating table. After adequate IV sedation provided, right lower extremity prepped & draped in standard sterile fashion. Sharp debridement of ulcer carried out. Ulcer approx. 4 × 5 cm in area, lateral dorsum of R foot. Debridement carried down to viable tissue. 4 × 5 cm split thickness skin graft harvested from upper aspect of R thigh. Graft then meshed & applied to R foot wound. Graft secured w/running locked #3-0 chromic suture. Two centrally located chromic sutures placed for further attention. Attention placed to donor site; dressed w/Xeroform & 4 × 4 gauze. R lower extremity wrapped in Kerlix dressing. Sponge & instrument counts correct at end of case. Pt tolerated procedure well and transported to recovery room.
125Case 5 Answer 0HRMX74 Replacement, Skin, Foot, Right (0HRM) Graft, see Replacement0HBHXZZ Excision, Skin, Upper Leg, Right (0HBHXZ)Coding Guideline B 3.9. Excision for GraftIf an autograft is obtained from a different body part in order to complete the objective of the procedure, a separate procedure is coded.
126Case 5 Explanation One of 6 Rows in 0HR Table; Only Row with Body Part Value for Right Foot;Body Part 1-7 Values deleted from this Row
127Case 5 Explanation One of two Rows in 0HB Table; Only Row with H Body Part
128Case 6 Preoperative Diagnosis: Carpal tunnel syndrome, left Postoperative Diagnosis: Carpal tunnel syndrome, leftOperation: Release, left carpal tunnelProcedure: After successful axillary block placed, patient’s left arm prepared & draped in usual sterile fashion. Tourniquet inflated. Curvilinear hypothenar incision made and palmaris retracted radially. Carpal tunnel & transverse carpal ligament were then opened & completely freed in proximal directions. It was noted to be severely tight in palm w/flattening & swelling of median nerve. Carpal tunnel opened distally in hand& noted to be clear. Wound then closed w/4-0 Dexon in subcuticular tissues. Sterile bulky dressing applied, & patient awakened & taken to recovery room in satisfactory condition.
129Case 6 ANSWER01N50ZZ Release, Nerve, Median Nerve (01N5)
131Case 7 Preoperative Diagnosis: Displaced comminuted fracture of shaft of right humerusPostoperative Diagnosis: SameProcedure: Open reduction,internal fixation of fracture ofHistory: Pt is 4th-grader whose class wason field trip at local bowling alley. Pt tripped over object on alley & fell sustaining fracture of right humerus.Description: P anesthetized & prepped w/ Betadine, sterile drapes applied, and pneumatic tourniquet inflated around arm.
132Case 7Incision made in area of lateral epicondyle through Steri-drape, and carried through subcutaneous tissue, & fracture site easily exposed. Inspection revealed fragment to be rotated in two planes about 90 degrees. It was possible to manually reduce this quite easily, and judicious manipulation resulted in almost anatomic reduction. Fixed w/ two pins across humerus. Pins cut off below skin level. Wound closed w/ some plain catgut subcutaneously & 5-0 nylon in skin. Dressings applied to pt and tourniquet released.
133Case 7 ANSWER 0PSF04Z Reduction, Fracture see Reposition Reposition, Humeral Shaft, Right (0PSF)Coding Guideline B3.15. Reposition for Fracture TreatmentReduction of a displaced fracture is coded to the root operation Reposition, and the application of a cast or splint in conjunction with the Reposition procedure is not coded separately. Treatment of a nondisplaced fracture is coded to the procedure performed.
134Case 7 Explanation One of 8 Rows in 0PS Table; Two Rows have F Body Part Value and same Approach Values;Have to go to DEVICE column to determine correct row
135Case 8Case Summary: Pt is 22-year-old male, admitted thru ED after motorcycle he was driving collided with elk while driving in mountains. Pt was driving in mountains & not on road when accident occurred. Pt not wearing helmet & sustained skull fracture over L temporal & orbital roof areas w/ depressed zygomatic arch on L side. Pt unconscious at scene & upon examination in ED, w/ Glasgow coma scale (GCS) score of 3: Eyes, never open; No verbal response; No motor response. Left pupil was blown (fixed and dilated), indicating intracranial injury. Hypoxemia, hypotension, and cerebral edema were noted.
136Case 8Pt admitted to ICU w/ continuous monitoring of intracranial pressure (percutaneous). Pt experienced increasing periods of apnea & placed on ventilator following endotracheal intubation. Pt’s family (in another state) notified & arrived 2 days later. No improvement in pt’s status over following five days.Pt continued to be monitored & was unconscious. Attempts to wean from ventilation unsuccessful. Brain wave measurement showed no brain wave electrical activity. Family decided to discontinue life support and life-sustaining efforts were discontinued.
137Case 8 ANSWER 0BH17EZ Insertion of device in, Trachea (0BH1) Intubation, Airway, see Insertion of device in, Trachea (0BH1)5A1955Z Performance, Respiratory, Greater than 96 Consecutive Hours, Ventilation (5A1955Z)4A103BD Monitoring, Central Nervous, Pressure, Intracranial (4A10)4A00X4Z Measurement, Central Nervous, Electrical Activity (4A00)
142Case 9 Preoperative Diagnosis: Bucket-handle tear left medial meniscus Postoperative Diagnosis:Procedure: Arthroscopic partial medial meniscectomyIndications: Pt is 16-year-old male who torn his L medial meniscus while playing football at local high school football field. Pt is wide receiver for football team & was tackled resulting in torn medial meniscus. I saw & treated pt initially in ED three weeks ago for this injury.
143Case 9Technique: After induction w/ general anesthesia, standard three-portal approach of knee was evaluated. Mild synovitic changes were noted in suprapatellar pouch. No chondromalacia changes were noted.Anterior portion of medial meniscus had flap tear, which was removed. After all instruments withdrawn, 4-0 nylon horizontal mattress stitches used to close wound, & pressure dressings applied. Pt awakened and taken to recovery room in good condition.
144Case 9 ANSWER 0SBD4ZZ Excision, Joint, Knee, Left (0SBD) Meniscectomy, see Excision, Lower Joints (0SB)Root operation = Excision - only portion (anterior) ofmedial meniscus removed.Approach = Percutaneous Endoscopic becauseprocedure was arthroscopic
147Case 10 Preoperative Diagnosis: Chronic right calf skin ulcer with necrosisof bone; E. coli sepsis with acute respiratoryfailure & disseminated intravascular coagulation (DIC)Postoperative Diagnosis: SameProcedure: Right below-the-knee amputationDescription of Procedure: Pt brought to OR & placed supine on OR table. Pt placed under general endotracheal anesthesia. Tourniquet placed on R proximal thigh & R lower extremity prepped & draped in standard sterile fashion. Below-the-knee amputation carried out directly below tibial tubercle w/ posteriorly based flap.
148Case 10Skin & soft tissue cut sharply to bone along line of skin incision. Once soft tissue incised, tibia & fibula provisionally cut w/oscillating saw & remainder of R lower extremity removed & sent to path. Next, tibia & fibula dissected out subperiosteally proximal to anterior portion of skin incision & re-cut w/oscillating saw. Anterior portion of tibia beveled again w/oscillating saw & smoothed w/rasp. Fibular cut beveled in lateral to medial direction while extending posteriorly. Nerves & blood vessels then addressed. Anterior tibial & posterior tibial arteries, as well as peroneal artery & attendant veins suture ligated with #1 Vicryl suture. Anterior & posterior tibial nerves & peroneal nerve also identified, pulled out of wound, cut short, & allowed to retract back into soft tissue.
149Case 10In addition, large veins identified & ligated. Tourniquet then released for total tourniquet time of 32 minutes & minimal bleeding encountered. Several smaller bleeders ligated. Some clotting observed, which was important as blood clotting of significant concern preceding this operation. Wound closed over medium Hemovac drain with 2 limbs, w/posterior flap brought anteriorly. Fascia closed using interrupted 1 Vicryl suture, & subcutaneous tissue closed using interrupted 3-0 Monocryl suture in simple buried fashion. Staples placed at level of skin in interest of time. After a sterile compressive dressing placed & Hemovac drain extension & reservoir attached & activated, patient awoken from anesthesia & sent to ICU in unchanged condition.
150Case 10 ANSWER 0Y6H0Z1 Detachment, Leg, Lower, Right (0Y6H0Z) Amputation see Detachment
154ICD-10-PCS ResourcesAdvanced Anatomy and Physiology for ICD-10-CM/PCS; An essential resource for diagnostic and procedural coding Salt Lake City: Contexo.Barta, Ann. "ICD-10-PCS Root Operation Groups, Part 2." Journal of AHIMA 81, no.4 (April 2010):Dimick, Chris. "Top Documentation Issues for ICD-10." (AHIMA Blog Post, AHIMA Journal web site).
155ICD-10-PCSDimick, Chris. "Presenters Discuss ICD-10 Documentation Needs."ICD-TEN: Top Emerging News (July 2011).Endicott, M. A. ICD-10-CM/PCS codes for musculoskeletal system include greater level of specificity. 8/30/11HIMSS. ICD-10 PlaybookICD-10-PCS Coder Training Manual, 2012 Instructor’s Edition. Professional Practice Resources Team, AHIMA.ICD-10-PCS Reference Manual ed. Zip file.
156ICD-10-PCS ResourcesSimmons, C. R. Understanding the Differences within ICD-10-PCS. ICD-TEN: Top Emerging News (September 2010).https://newsletters.ahima.org/newsletters/ICDTen/2010/September/Difference.htmlZeisset, Ann. "ICD-10-PCS Root Operation Groups, Part 4: Root Operations That Always Involve a Device, Involve Examination Only, or Define Other Objectives." Journal of AHIMA 81, no.10 (October 2010):
157ICD-10-PCS ResourcesZeisset, Ann. "ICD-10-PCS Root Operation Groups: Root Operations that Take Out Some or All of a Body Part." Journal of AHIMA 81, no.3 (March 2010):Zeisset, Ann. "Rooting Out ICD-10 Procedure Codes, Part 6." ICD-TEN: Top Emerging News (August 2010).Zeisset, Ann. "Rooting Out ICD-10 Procedure Codes, Part 7." ICD-TEN: Top Emerging News (September 2010).2012 ICD-10-PCS and GEMsCode Tables and IndexOfficial GuidelinesReference Manual