Understanding ICD-9-CM Coding Mary Jo Bowie MS, RHIA, RHIT Regina Schaffer AAS, RHIA, CPC

ICD-9-CM Procedural Coding PART III

CHAPTER 25 Introduction to ICD-9-CM Procedure Coding

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 4 Volume 3 of ICD-9-CM Alphabetic Index Tabular List Used by hospital Not used in outpatient setting Uniform Hospital Discharge Data Set (UHDDS) defines procedures

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 5 Procedure Code Structure and Volume Format Comprised of four digits Two digits preceding decimal point indicate body system One or two digits following decimal point indicate more specific code

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 6 Procedure Code Structure and Volume Format Alphabetic Index of Procedures –Identify main term –Comprehensive –Listed here not in the Tabular List –Eponym or acronym Identify the indentations Reference Tabular List

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 7 Medical Terminology Prefix Suffix Understanding what type of procedure was done

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 8 Terms Used to Locate Procedures Ablation—destruction with regard to function of a body part Amputation—removal of a body part Biopsy—sampling of tissue for diagnostic purposes

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 9 More Procedure Terms Destruction—eliminate completely Endoscopic—visual internal inspection Graft—transplant tissue Ligation—tie or bind off blood vessels or ducts using catgut, cotton, silk, or wire

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 10 Surgical Code Requires knowledge of intent Diagnostic procedure Procedure done for treatment Know the approach

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 11 Coding Conventions Used as they are in Volumes 1 and 2 Attention to inclusion or exclusion notes “Code also” –Additional code if referenced procedure was performed during operative session

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 12 Coding Conventions “Omit code” –“as operative approach” –Not billed separately

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 13 Canceled and Incomplete Procedures Incomplete surgery –Incision was made Code incision site –Cavity space entered Exploratory procedure –Endoscopic started but did not reach site Endoscopy only

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 14 Cancelled Procedure Patient is admitted but scheduled procedure is cancelled –Code from V64 –Persons encountering health services for specific procedures but not carried out

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 15 Scope Procedures Arthroscopy Bronchoscopy Colonoscopy Cystoscopy

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 16 Scope Procedures Cont. Esophagoscopy Laparoscopy Mediastinoscopy Thoracoscopy

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 17 Open Procedure Procedure completed via incision Endoscopic started but switched to open –Code open procedure Laparoscopic started but switched to open –V64.41, V64.42, V64.43