Presentation is loading. Please wait.

Presentation is loading. Please wait.

Presented by: Karen Kvarfordt, RHIA, CCS-P, CCDS President, DiagnosisPlus, Inc. 2014.

Similar presentations


Presentation on theme: "Presented by: Karen Kvarfordt, RHIA, CCS-P, CCDS President, DiagnosisPlus, Inc. 2014."— Presentation transcript:

1 Presented by: Karen Kvarfordt, RHIA, CCS-P, CCDS President, DiagnosisPlus, Inc. 2014

2

3  Things will never be the same once we switch to ICD-10-PCS!  Complete overhaul of the procedure classification system as we know it today. Appendix F: Character Meanings  Tip! Refer to Appendix F: Character Meanings – this will save you!  But don’t panic, it can be easily mastered! 3

4  ICD-10-PCS codes include one digit for the root operation that the physician performs.  Root operation is always the 3 rd character in the seven character code.  Start by reviewing the definitions of the various root operations. If you learn the root operations early, you’ll have a head start on learning how to code in ICD-10- PCS. 4

5  Always look first in the Alphabetic Index (will give you the first 3 or 4 characters) and then finish building the procedure code in the Tables. across  Key! You can’t jump around in the tables. Need to go across to get your procedure code! 5

6  CMS awarded the contract to 3M Health Information Systems to develop a new procedure coding system for ICD-10. inpatient  New system is intended to replace ICD- 9-CM Volume 3 for reporting hospital inpatient procedures.  But what about the outpatient side? 6

7  Diagnosticnot  Diagnostic information is not included in the code description.  A ‘not elsewhere classified’ option is allowed for new devices and substances.  All substantially different procedures are defined. 7

8 general  A general body part, approach, or root operation can be used when the level of specificity is not available in the record or cannot otherwise be obtained.  Should you query? 8

9  Body Part  Body Part: ◦ Example: “Liver” is used when the specific liver lobe is not identified.  Approach  Approach: ◦ “Open”, “Percutaneous” and “Via Natural or Artificial Opening” are used when a more specific type of approach is not documented and cannot otherwise be determined.  Root Operation  Root Operation: ◦ “Repair” is used when the procedure documentation does NOT support a specific root operation and the information cannot otherwise be obtained. 9

10  ICD-9-CM (Volume 3) Procedures (Procedures) ◦ Min. characters: 3 ◦ Max. characters: 4 ◦ Numeric format (+ V code) ◦ Decimal point ◦ 3,000 ◦ 3,000 procedure codes  ICD-10-PCS Procedures (Procedures) ◦ Min. characters: 7 ◦ Max. characters: 7 ◦ Alphanumeric format ◦ No decimal point ◦ 71,918 ◦ 71,918 procedure codes 10

11 SectionCodes Medical and Surgical**61,896 Obstetrics300 Placement861 Administration1,384 Measurement and Monitoring339 Extracorporeal Assistance and Performance 41 Extracorporeal Therapies42 Osteopathic100 Other Procedures60 Chiropractic90 Imaging2,934 Nuclear Medicine463 Radiation Oncology1,939 Rehabilitation and Diagnostic Audiology1,380 Mental Health30 Substance Abuse Treatment59 Total71,918 11

12  Seven Character Alphanumeric Code ◦ All ◦ All procedure codes will be seven characters long IO ◦ “I” and “O” (letters) are never used  Why not?  34 possible values for each character ◦ Digits 0 – 9 ◦ Letters A-H, J-N, P-Z 12

13 Medical and SurgicalOther Procedures ObstetricsChiropractic PlacementImaging AdministrationNuclear Medicine Measurement and Monitoring Radiation Oncology Extracorporeal Assistance and Performance Physical Rehabilitation and Diagnostic Audiology Extracorporeal TherapiesMental Health OsteopathicSubstance Abuse Treatment 13

14  Each table contains four columns and varying numbers of rows.  Column: Specifies the allowable values for characters 4-7  Row: Specifies the valid combinations of values  Building block concept! 14

15 15

16 Section Section: Identifies general type of procedure Body System Body System: Identifies general body system Root Operation Root Operation: Specifies objective of procedure Body Part Body Part: Identifies specific part of body system on which procedure is being performed Approach Approach: Technique used to reach the site of the procedure Device Device: Identifies devices that remain after procedure is completed Qualifier Qualifier: Provides additional information about a procedure, if necessary 16

17  Provides the first three or four characters of the procedure code.  The tables must always be used to obtain the remaining digits for the complete code.  No eponyms are included.  Tables are used to construct a complete and valid code.  Only characters appearing on the table may be used. 17

18 Medical and Surgical Section 18

19 Root Section Operation Approach Qualifier Body Body Device System Part

20 S  1 st character = Section B  2 nd character = Body System R  3 rd character = Root Operation B  4 th character = Body Part A  5 th character = Approach D  6 th character = Device Q  7 th character = Qualifier 20

21 objective or intent not  The root operation is based on the “objective or intent” of the procedure not by the procedure name.  If multiple procedures as defined by distinct objectives are performed, then multiple ICD-10-PCS procedure codes are assigned. 21

22  16 sections within ICD-10-PCS, the largest being the Medical & Surgical section.  Defines the general ‘type’ of procedure, i.e., Med/Surg, OB, etc.  Medical and Surgical Section the first character is always the number “0”. 22

23  Identifies the body system, which is the general physiological system or anatomical region where the procedure is performed. 31  Total of 31 body systems in ICD-10-PCS.  Some traditional categories are subdivided into several body systems, for example: Cardiovascular is subdivided into 5 body systems:  Heart and Great Vessels  Upper Arteries  Lower Arteries  Upper Veins  Lower Veins 23

24  Refer to the ICD-10-PCS code book for a complete listing of the body systems (pg. 5). 24

25  Defines the “objective” or “intent” of doing the procedure.  33  33 different root operation values  Each root operation identifies a precise and distinct objective. ◦ This is the most difficult part of procedural coding as the root operations may sound familiar, but may mean different things. ◦ Most time will be spent here! 25

26  The root operations ‘excision’ and ‘resection’ will be the most difficult to distinguish. ◦ Excisionportion ◦ Excision: Cutting out or off, without replacement a portion of a body part ◦ Resectionall ◦ Resection: Cutting out or off, without replacement, all of a body part portionall  These definitions look very similar, but are very different as they involve a portion versus all of a body part. 26

27 AlterationFragmentationRestriction BypassExcisionRelease ChangeExtirpationRemoval ControlExtractionRepair CreationFragmentationReplacement DestructionFusionReposition DetachmentInsertionResection DilationInspectionRestriction DivisionMapRevision DrainageOcclusionSupplement ReattachmentTransfer Transplantation 27

28  In ICD-10-PCS, every procedure falls into one of 33 root operations, which define the ‘objective’ of the procedure.  Some root operations seem self-explanatory, i.e., transplantation or reattachment, others are not so easy. PCS definitions ◦ Procedure documentation may often include the term “removal”, but according to PCS definitions the physician actually performed an extraction or even an extirpation, Do not code directly what the physician lists as the procedure; rather, you should always read the OP report to determine what the physician actually did and which definition the procedure meets. 28

29 Nonexcisional debridement extraction Procedure: Nonexcisional debridement of skin and back. There is no term in ICD-10-PCS for “debridement”, so based on definitions, the coder must review the body of the OP report to see what the physician actually performed. In this case, code the debridement as an extraction because it fits the definition (i.e., being pulled off a portion of the body part by use of force). In this case, skin is the body part. 29

30  The root operation is coded according to the objective of the procedure actually performed.  Discontinued or modified procedures coded to procedure actually performed.  Composite terms (i.e., colonoscopy, sigmoidectomy) are not root operations.  Combination procedures are coded separately ◦ Each procedure with a distinct objective during an operative episode is coded separately. 30

31  The complete or partial redo of a procedure is coded to the root operation performed rather than “revision”. ◦ Revision is confined to correcting a malfunctioning or displaced device  New for ICD-10 31

32  Procedures that take out or eliminate all or a portion of a body part  Procedures that involve putting in or on, putting back, or moving body parts  Procedures that take out or eliminate solid matter, fluids, or gases from a body part  Procedures that only involve examination of body parts and regions  Procedures that can be performed only on tubular body parts  Procedures that always involve devices  Procedures involving cutting or separation only  Procedures involving other repairs  Procedures with other objectives 32

33  Procedures that take out or eliminate all or a portion of a body part  Excision  Resection  Extraction  Destruction  Detachment 33

34  Definition portion  Definition: Cutting out or off, without replacement, a portion of a body part  Explanation  Explanation: The qualifier Diagnostic is used to identify excision procedures that are biopsies  Examples  Examples:  Partial nephrectomy  Liver Biopsy 34

35  Definition all  Definition: Cutting out or off, without replacement, all of a body part  Examples  Examples:  Total nephrectomy  Total lobectomy of lung 35

36  Definition  Definition: Pulling or stripping out or off all or a portion of a body part by the use of force  Explanation  Explanation: The qualifier Diagnostic is used to identify extraction procedures that are biopsies  Examples  Examples:  Dilatation and curettage  Vein stripping 36

37  Definition  Definition: Physical eradication of all or a portion of a body part by the direct use of energy, force or a destructive agent  Explanation  Explanation: None of the body part is physically taken out  Examples  Examples:  Fulguration of rectal polyp  Cautery of skin lesion 37

38  Definition  Definition: Cutting off all or part of the upper or lower extremities  Explanation  Explanation: The body part value is the site of the detachment, with a qualifier if applicable, to further specify the level where the extremity was detached  Examples  Examples:  Below knee amputation  Disarticulation of shoulder 38

39  Procedures that involve putting in or on, putting back, or moving living body parts  Transplantation  Reattachment  Reposition  Transfer 39

40  Definition  Definition: 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  Explanation  Explanation: The native body part may or may not be taken out, and the transplanted body part may take over all or a portion of its function  Examples  Examples:  Kidney transplant  Heart transplant 40

41  Definition  Definition: Putting back in or on all or a portion of a separated body part to its normal location or other suitable location  Explanation  Explanation: Vascular circulation and nervous pathways may or may not be reestablished  Examples  Examples:  Reattachment of hand  Reattachment of avulsed kidney 41

42  Definition  Definition: Moving to its normal location or other suitable location all or a portion of a body part  Explanation  Explanation: The body part is moved to a new location from an abnormal location, or from a 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 location  Examples  Examples:  Reposition of undescended testicles  Fracture reduction 42

43  Definition  Definition: 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 part  Explanation  Explanation: The body part transferred remains connected to its vascular and nervous supply  Examples  Examples:  Tendon transfer  Skin pedicle flap transfer 43

44  Procedures that take out or eliminate solid matter, fluids or gases from a body part  Drainage new  Extirpation (new term in ICD-10)  Fragmentation 44

45  Definition  Definition: Taking or letting out fluids and/or gases from a body part  Explanation  Explanation: The qualifier Diagnostic is used to identify drainage procedures that are biopsies  Examples  Examples:  Thoracentesis  Incision and drainage (I&D) 45

46  Definition  Definition: Taking or cutting out solid matter from a body part  Explanation  Explanation: The solid matter may be an abnormal byproduct of a biological function or a foreign body. The solid matter is imbedded in a body part, or is in the lumen of a tubular body part. The solid matter may or may not have been previously broken into pieces. No appreciable amount of the body part is taken out  Examples  Examples:  Thrombectomy  Choledocholithotomy 46

47  Definition  Definition: Breaking solid matter in a body part into pieces  Explanation  Explanation: The solid matter may be an abnormal byproduct of a biological function or a foreign body. Physical force, i.e. manual, ultrasonic, applied directly or indirectly through intervening body parts is used to break the solid matter into pieces. The pieces of solid matter are not taken out, but are eliminated or absorbed through normal biological functions  Example  Example: Extracorporeal shockwave lithotripsy 47

48 examination  Procedures that only involve examination of body parts and regions  Inspection  Map 48

49  Definition  Definition: Visually and/or manually exploring a body part  Explanation  Explanation: Visual exploration may be performed with or without optical instrumentation. Manual exploration may be performed directly or through intervening body layers  Examples  Examples:  Diagnostic arthroscopy  Exploratory laparotomy 49

50  Definition  Definition: Locating the route of passage of electrical impulses and/or locating functional areas in a body part  Explanation  Explanation: Applicable only to the cardiac conduction mechanism and the central nervous system  Examples  Examples:  Cardiac mapping  Cortical mapping 50

51 tubular  Procedures that can be performed only on tubular body parts  Bypass  Dilation  Occlusion  Restriction 51

52  Definition  Definition: Altering the route of passage of the contents of a tubular body part  Explanation  Explanation: Rerouting contents around an area of a body part to another distal (downstream) area in the normal route; rerouting the contents to another different but similar route and body part; or to an abnormal route and another dissimilar body part. It includes one or more concurrent anastomoses with or without the use of a device such as autografts, tissue substitutes and synthetic substitutes  Examples  Examples: ◦ Coronary artery bypass ◦ Colostomy formation 52

53  Definition  Definition: Expanding an orifice or the lumen of a tubular body part  Explanation  Explanation: The orifice can be a natural orifice or an artificially created orifice. Accomplished by stretching a tubular body part using intraluminal pressure or by cutting part of the orifice or wall of the tubular body part  Examples  Examples:  Percutaneous transluminal angioplasty  Pyloromyotomy 53

54  Definition  Definition: Completely closing the orifice or lumen of a tubular body part  Explanation  Explanation: The orifice can be a natural orifice or an artificially created orifice  Examples  Examples:  Fallopian tube ligation  Ligation of inferior vena cava 54

55  Definition  Definition: Partially closing the orifice or lumen of a tubular body part  Explanation  Explanation: The orifice can be a natural orifice or an artificially created orifice  Example  Example:  Esophagogastric fundoplication 55

56  Procedures that always involve devices  Insertion  Replacement  Supplement  Removal  Change Revision 56

57  Definition  Definition: Putting in a nonbiological appliance that monitors, assists, performs or prevents a physiological function but does not physically take the place of a body part  Examples  Examples:  Insertion of radioactive implant  Insertion of central venous catheter 57

58  Definition  Definition: Putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part  Explanation Removal  Explanation: The biological material is non-living, or the biological material is living and from the same individual. The body part may have been previously taken out, previously replaces, or may be taken out concomitantly with the replacement procedure. If the body part has been previously replaced, a separate Removal procedure is coded for taking out the device used in the previous replacement  Example  Example: Total knee/hip replacement 58

59 Right Knee Joint Replacement ICD-9-CM: (Total Knee Replacement) 590SRD0JZ Section (Medical/Surgical) Body System (Lower Joints) Root Operation (Replacement) Body Part (Knee Joint, Right) Approach (Open) Device (Synthetic Substitute) Qualifier (No Qualifier)

60  Definition  Definition: Putting in or on biological or synthetic material that physically reinforces or augments the function of a body part  Explanation Supplement  Explanation: The biological material in non-living, or the material is living and from the same individual. The body part may have been previously replaced. If the body part has been previously replaced, the Supplement procedure is performed to physically reinforce and/or augment the function of the replaced body part  Examples  Examples:  Herniorrhaphy using mesh  New acetabular liner in a previous hip replacement 60

61  Definitiondevice  Definition: Taking out or off a device from a body part  Explanation Change Removal  Explanation: If the device is taken out and a similar device is put in without cutting or puncturing the skin or mucous membrane, the procedure is coded to the root operation Change. Otherwise, the procedure for taking out the device is coded to the root operation Removal and the procedure for putting in the new device is coded to the root operation as performed  Examples  Examples: Drainage tube removal Cardiac pacemaker removal 61

62  Definition  Definition: Taking out or off a device from a body part and putting back an identical or similar device in or on the same body part without cutting or puncturing the skin or a mucous membrane  ExplanationChange External  Explanation: All Change procedures are coded using the approach External  Examples  Examples:  Urinary catheter change  Gastrostomy tube change 62

63  Definition  Definition: Correcting, to the extent possible, a malfunctioning or displaced device  Explanation  Explanation: Revision can include correcting a malfunctioning or displaced device by taking out or putting in components of the device such as a screw  Examples  Examples:  Adjustment of pacemaker lead  Adjustment of hip prosthesis 63

64  Procedures involving cutting or separation only  Division  Release 64

65  Definition  Definition: Cutting into a body part without draining fluids and/or gases from the body part in order to separate or transect a body part  Explanation two or more  Explanation: All or a portion of the body part is separated into two or more portions  Examples  Examples:  Spinal cordotomy  Osteotomy 65

66  Definition  Definition: Freeing a body part from an abnormal physical constraint by cutting or by use of force  Explanation  Explanation: Some of the restraining tissue may be taken out but none of the body part is taken out  Examples  Examples:  Adhesiolysis  Carpal tunnel release 66

67  Procedures involving other repairs  Control  Repair 67

68  Definition post-procedure bleeding  Definition: Stopping, or attempting to stop, post-procedure bleeding  Explanation  Explanation: The site of the bleeding is coded as an anatomical region and not to a specific body part  Examples  Examples:  Control of post-prostatectomy hemorrhage  Control of post-tonsillectomy hemorrhage 68

69  Definition  Definition: Restoring, to the extent possible, a body part to its normal anatomic structure and function  Explanation default  Explanation: Used only when the method to accomplish the repair is not one of the other root operation (used as ‘default’)  Examples  Examples:  Herniorrhaphy  Suture of laceration 69

70  Procedures with other objectives  Alteration  Creation  Fusion 70

71  Definition  Definition: Modifying the anatomical structure of a body part without affecting the function of the body part  Explanation  Explanation: Principal purpose is to improve appearance  Examples  Examples:  Face lift  Breast augmentation 71

72  Definition  Definition: Making a new genital structure that does not take over the function of a body part  Explanation  Explanation: Used only for sex change operations  Examples  Examples:  Creation of vagina in a male  Creation of penis in a female 72

73  Definition  Definition: Joining together portions of an articular body part rendering the articular body part immobile  Explanation  Explanation: The body part is joined together by fixation device, bone graft, or other means  Examples  Examples:  Spinal fusion  Ankle arthrodesis 73

74  Identifies the body part or specific anatomical site where the physician performed a procedure  34  34 possible body part values in each body systemHepatobiliary Liver Liver, Right Lobe Liver, Left Lobe Gallbladder Hepatic Duct, Right Hepatic Duct, Left 74

75 technique  Indicates the technique the physician used to reach the site of the procedure.  Approaches may be through the skin or mucous membranes, through an orifice, or external. 7  ICD-10-PCS will have 7 different approach values. 75

76  Approaches through the skin or mucous membrane  Open (Abdominal hysterectomy)  Percutaneous (Needle biopsy of liver)  Percutaneous Endoscopic (Arthroscopy ) 76

77  Approaches through an orifice  Via Natural or Artificial Opening (Endotracheal intubation)  Via Natural or Artificial Opening Endoscopic (Sigmoidoscopy)  Via Natural or Artificial Opening Endoscopic with Percutaneous Endoscopic Assistance (Lap-assisted vaginal hysterectomy) 77

78 Procedures performed directly on the skin or mucous membrane and procedures performed indirectly by the application of ‘external’ force through the skin or mucous membrane  Example: Closed fracture reduction 78

79 remain after the procedure is completed.  The term “device” includes only those devices that remain after the procedure is completed.  Instruments that describe how a procedure is performed are not specified in the device character.  Instruments for visualization are specified in the approach character, i.e., scope, etc.  Materials that are incidental to a procedure (i.e., clips, sutures) are not considered devices and would use device character “Z” to indicate “no device” in the ICD-10-PCS code. 79

80  Four (4) Categories Of Devices: ◦ Grafts and Prostheses ◦ Implants ◦ Simple or Mechanical Appliances ◦ Electronic Appliance  Some of the devices used in musculoskeletal system procedures are internal and external fixation devices, bone growth stimulators, and drainage devices. 80

81  Biological or synthetic material that takes the place of all or a portion of a body part (i.e., skin graft, joint prosthesis).  Biological or synthetic material that assists or prevents a physiological function (i.e. urinary catheter, IUD).  Therapeutic material that is not absorbed by, eliminated by, or incorporated into a body part (i.e. radioactive implant, orthopedic pins). Therapeutic materials that are considered devices can be removed. 81

82  Mechanical or electronic appliances used to assist, monitor, take the place of, or prevent a physiological function (i.e., diaphragmatic pacemaker, hearing device). 82

83  Drainage Device  Radioactive Element  Autologous Tissue Substitute  Extraluminal Device  Intraluminal Device  Synthetic Substitute  Nonautologous Tissue Substitute 83

84  Defines an additional attribute of the procedure performed, if applicable.  May have a narrow application, to a specific root operation, body system, or body part.  Examples of Qualifiers ◦ Type of transplant ◦ Second site for a bypass ◦ Diagnostic excision (biopsy) 84

85 CHIEF COMPLAINT CHIEF COMPLAINT: Foreign body in nose. HISTORY OF PRESENT ILLNESS HISTORY OF PRESENT ILLNESS: The patient is a 3-year-old child who comes in today after having put a raisin in her left nostril while playing at home. Grandmother was unable to remove it. EMERGENCY DEPARTMENT COURSE EMERGENCY DEPARTMENT COURSE: The raisin was grasped by bayonet forceps and removed atraumatically. Examination of the nostril fails to reveal any further foreign body or problems. DIAGNOSIS DIAGNOSIS: Foreign body in nostril with removal. 85

86  ICD-9-CM  ICD-9-CM: 932 (Foreign body in nose)  ICD-10-CM anatomic siteencounter  ICD-10-CM: 2 options which contain more specific information about anatomic site and encounter.  T170xxA  T170xxA = Foreign body in nasal sinus, initial encounter  T171xxA  T171xxA = Foreign body in nostril, initial encounter 86

87  ICD-9-CM  ICD-9-CM: (Removal of intraluminal foreign body from nose without incision)  ICD-10-PCS  ICD-10-PCS: Only 1 translation and/or coding option ◦ 09CKXZZ ◦ 09CKXZZ = Extirpation of matter from nose, external approach 87

88 That’s ICD-10-PCS! 88

89 Let’s Practice What We Have Learned! 89

90

91 THANKS A TON! Day Egusquiza, President Karen Kvarfordt, RHIA, CCS-P, CCDS AHIMA Certified ICD-10 Trainer President, DiagnosisPlus, Inc. 91


Download ppt "Presented by: Karen Kvarfordt, RHIA, CCS-P, CCDS President, DiagnosisPlus, Inc. 2014."

Similar presentations


Ads by Google