Coding Conundrums and Lessons Learned Lisa Phipps, CCS, COC Manager Coding Services Norton Healthcare AHIMA Approved ICD 10 CM/PCS Trainer

Where we have been, where we are…. Where we are going!  Training and Planning for ICD 10 Train the trainer Coding education Ancillary Staff & Physician Education Software updates Multiple department integrated testing Outside payer testing Dual Coding for more than 9 months Obtained contract coding to supplement coding

 Coding Productivity  Coding accuracy audits  Revenue Cycle Reimbursement Issues Where We Are

 Implementing SVC  Supplementing with contract coding  Computer Assisted Coding (CAC)  Ongoing Education  Increasing in- house audits  Increased communication among the revenue cycle team Where We are Going

Reattachment vs Repair Transfer vs Replacement Insertions /Removals/Revisions Occlusion vs Restriction Bypass Fusion Repair NEC Conundrums in PCS Coding

Reattachment vs Repair To be “reattached” something must be detached from the body ie. avulsed kidney or ruptured tendon If it is still attached ie. Scalp flap or finger tip then the correct root operation is “repair” Also Note: In root operation “Repair” no device is allowed. If there is a device, it would be coded to “Revision” or possibly “supplement”

Transfer Vs Replacement Use the root operation of ‘transfer” when it is still connected to the blood supply. ie. Advancement flap, tendon transfer, etc. When it is disconnect from the blood supply code it with root operation of “Replacement.” ie. Free graft

Coding Note  A mastectomy with TRAM (transverse rectus abdominis myocutaneous ) flap reconstruction is coded with root operation of replacement because the TRAM is a free flap.  DIEP (Deep Inferior Epigastric Artery Perforator) is also a free flap and would be coded with root operation of replacement.  Also note, that the root operation of “replacement” includes in the description, the taking out of the body part; therefore the resection of the breast, etc is not coded separately when a TRAM is done.

Insertions, Removals, Revisions Examples would be : AICD, Pacemaker, neuro stimulators VAD, etc. Be sure to code for each component. Example: Insertion of VAD w port

Coding Note: insertion of breast implants would code to “replacement of breast where as the tissue expanders would be coded to insertion (or removal) of device. If the breast implant is being removed and a new one put in, you would code “removal” of synth. substitute from breast and then “replacement” of breast with synth. substitute

Occlusion vs. Restriction for vessel embolization procedures B3.12 If the objective of an embolization procedure is to completely close a vessel, the root operation Occlusion is coded. If the objective of an embolization procedure is to narrow the lumen of a vessel, the root operation Restriction is coded. Examples: Tumor embolization is coded to the root operation Occlusion, because the objective of the procedure is to cut off the blood supply to the vessel. Embolization of a cerebral aneurysm is coded to the root operation Restriction, because the objective of the procedure is not to close off the vessel entirely, but to narrow the lumen of the vessel at the site of the aneurysm where it is abnormally wide. Restriction vs Occlusion

Also note that in branch vessels, the coils, beads or glue are considered “intraluminal devices” Regardless of the number of coils used in the embolization you would only code one time per site.

Bypass Altering the route of passage of the content of a tubular body part. Examples of these procedures would be : Tracheostomy Colon Resections CABG AV fistula and grafts

# of sites treatedConduit used ie. LIMA, Saph vein, Radial artery Qualifier (Blood source) ie. LIMA, Aorta 2Saph. VeinAorta 1LIMA Example above: W, 02100Z9 Note: LIMA is not considered a device (no device on the 021 table ) Qualifer = blood source

AV Fistula and Grafts

Joint C3 = “Bone” body system C3- C4 = “Joint” body system Fusion

Coding Guideline B3.10c Combinations of devices and materials are often used on a vertebral joint to render the joint immobile. When combinations of devices are used on the same vertebral joint, the device value coded for the procedure is as follows: If an interbody fusion device is used to render the joint immobile (alone or containing other material like bone graft), the procedure is coded with the device value Interbody Fusion Device If bone graft is the only device used to render the joint immobile, the procedure is coded with the device value Nonautologous Tissue Substitute or Autologous Tissue Substitute If a mixture of autologous and nonautologous bone graft (with or without biological or synthetic extenders or binders) is used to render the joint immobile, code the procedure with the device value Autologous Tissue Substitute

Examples: Fusion of a vertebral joint using a cage style interbody fusion device containing morsellized bone graft is coded to the device Interbody Fusion Device. Fusion of a vertebral joint using a bone dowel interbody fusion device made of cadaver bone and packed with a mixture of local morsellized bone and demineralized bone matrix is coded to the device Interbody Fusion Device. Fusion of a vertebral joint using both autologous bone graft and bone bank bone graft is coded to the device Autologous Tissue Substitute. Source: Centers for Medicare and Medicaid Services. “ICD-10-PCS Draft Coding Guidelines.”

Coding Tip Dos and Don’ts…. Don’t’ Code BMP, it is not coded separately. Don’t code the bone marrow that is added to the donor bone graft but you do code the “aspiration” of the bone marrow.

Coding Tip Dos and Don’ts…. The removal of bone from iliac crest (harvest) is coded separately with root operation of “excision”. Local bone harvesting is not coded separately Pedicle screws and plates are not coded separately. (spinal instrumentation)

Coding Tip Dos and Don’ts…. If hardware is removed, code the “removal” (if screws and plates use joint not bone) If re-fusion is done it is coded the same as if it were an initial fusion.

Decompressive laminectomy, hemilaminectomy or laminotomy use ‘release” and the body site being released is the spinal cord (central nervous system) or nerve root (peripheral nerve)

Ever Elusive Body Parts  Body part key  Make your own Approaches PCS Codes

 Combination codes ie. GERD with reflux,  OB codes ie. “In childbirth”  DM out of control or uncontrolled  Still a lot of unspecified dx  Malignancy codes  7 th character…. initial, subsequent, sequela Diagnosis Codes

Lessons Learned Still in the “learning phase” with payers, denials, etc. Work the denials then communicate to all departments involved Example: Wound care  with ulcer level of involvement  Wound vs ulcer  DRGs  Removing the PICC line  Morbid Obesity with BMI  Adding Blood Types to the mothers chart