ICD-10-CM/PCS: AN OVERVIEW - AVHIMAavhima.org/2011/CM_PCS_SEMINAR_PRESENTATION_Pam_6_11.pdf ·...

6/12/2011

1

Prepared by First Class Solutions, Inc. (c) 2011

ICD-10-CM/PCS: AN OVERVIEW

Prepared by: Pam Scott, RHIT, CCS, AHIMA ICD-10 Certified TrainerFirst Class Solutions Inc © 2011First Class Solutions, Inc. © 2011

1


CODING CONVENTIONS

2

6/12/2011

2

CONVENTIONS THAT REMAIN THE SAME

NECNOS

SEE/SEE ALSOCODE FIRST


NOS [BRACKETS] AND/OR OTHER UNSPECIFIED

CODE FIRST USE ADDITIONAL CODE CODE ALSO DEFAULT CODES SYNDROMES

INCLUDES WITH

IN DISEASES CLASSIFIED ELSEWHERE

3

CONVENTIONS THAT WILL CHANGE

EXCLUDES EXCLUDES 1


EXCLUDES 1 EXCLUDES 2

PLACEHOLDERS 7TH CHARACTER REQUIREMENT

4

6/12/2011

3

EXCLUDES NOTE 2 EXERCISE

EXERCISE 1 Di h di


Discharge diagnoses:1. Moderate persistent asthma with status asthmaticus2. Acute exacerbation of COPD.

Code(s)( )____________________________________

5

PLACEHOLDER AND 7TH CHARACTER EXERCISE

EXERCISE 2:The ICD 10 External Cause code for a dog bite is W54 0


The ICD-10 External Cause code for a dog bite is W54.0 and requires a seventh character to identify the encounter. Which of the following is the correct code for the initial encounter to treat the dog bite?

C d ( )Code(s)________________________________

6

6/12/2011

4


GENERAL GUIDELINES

7

CODING GUIDELINES THAT REMAIN THE SAME

SIGNS AND SYMPTOMSINTREGRAL CONDITIONS


INTREGRAL CONDITIONS NON-INTEGRAL CONDITIONS ACUTE AND CHRONIC CONDITIONS

SUBACUTE

COMBINATION CODES LATE EFFECTS BMI AND PRESSURE ULCERS

8

6/12/2011

5

CODING GUIDELINES THAT WILL CHANGE

LATE EFFECTS: 1. Coding of late effects generally requires two codes


g g y qsequenced in the following order: The condition or nature of the late effect is sequenced first. The late effect code is sequenced second.

2. An exception to the above guidelines are those instances where the code for late effect is followed by a manifestation code identified in the Tabular List and title, or the late effect code has been expanded p(at the fourth, fifth or sixth character levels) to include the manifestation(s).

3. The code for the acute phase of an illness or injury that led to the late effect is never used with a code for the late effect.

9

CODING GUIDELINES THAT WILL CHANGE

LATERALITY


REPORTING CODES MORE THAN ONCE EXCEPTbilateral conditions when there are no

distinct codes identifying laterality or two different conditions classified to the same ICD-10-CM diagnosis code.

10

6/12/2011

6

EXAMPLE

Old CVA with aphasia (manifestation included in the code)


in the code) Choices are

I69.920 I69.320 I69.120

69 220 I69.220 I69.820 I69.020

11


CHAPTER SPECIFIC CODING GUIDELINE CHANGES

12

6/12/2011

7

CHAPTER 1: CERTAIN INFECTIOUS AND PARASITIC DISEASES.

CODE RANGE: A00-B99 GUIDELINE CHANGES:


GUIDELINE CHANGES:

1. Sepsis-Urosepsis is a nonspecific term and DOES NOT HAVE A DEFAULT CODE IN ICD-10. Cannot assume it is sepsis, so a query will be required. If severe sepsis is not documented, you cannot code it, UNLESS septic shock or acute organ dysfunction documented as associated with acute organ dysfunction documented as associated with the sepsis is documented. Then the code for severe sepsis with septic shock would be coded. All other guidelines for sepsis remain the same as ICD-9.

13

CHAPTER 2: NEOPLASMS

CODE RANGE: C00-D49

GUIDELINE CHANGES:


GUIDELINE CHANGES:

1. Anemia associated with a malignancy-When admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis followed by code D63.0, Anemia in neoplastic disease).

14

6/12/2011

8

CHAPTER 2: NEOPLASMS

EXERCISE 3: Patient was admitted for anemia due to


EXERCISE 3: Patient was admitted for anemia due to lung cancer. Blood was transfused and the patient was discharged.

Code(s)_______________________________

15

CHAPTER 3: BLOOD AND BLOOD FORMING ORGANS

CODE RANGE: D50-D89


No guidelines have been established to date.

16

6/12/2011

9

CHAPTER 4: ENDOCRINE, NUTRITION AND METABOLIC

CODE RANGE: E00-E89GUIDELINE CHANGES:


GUIDELINE CHANGES:

1. Diabetes: There is no “controlled/uncontrolled”.

2. There are four diabetes categories. A. Type I (Code book states this includes “brittle”, “idiopathic” and

“J il ”)“Juvenile onset”)B. Type II…includes unspecifiedC. Secondary…drug induced or underlying conditionD. Other specified types…genetic disorders

17

CHAPTER 5: MENTAL AND BEHAVIORAL DISORDERS

CODE RANGE: F01-F99


No guideline changes to date

18

6/12/2011

10

CHAPTER 6: NERVOUS SYSTEM AND SENSE ORGANS

CODE RANGE: G00-G99GUIDELINE CHANGE


GUIDELINE CHANGE

1. Dominant/non dominant side: Should this information not be available in the record, and the classification system does not indicate a default, the default should be dominant. For ambidextrous patients, the default should also be dominant.

2. Pain guidelines are included in this section

19

CHAPTER 7: DISEASES OF EYE

CODE RANGE: H00-H59


No guidelines have been established to date

20

6/12/2011

11

CHAPTER 8: DISEASES OF EAR

CODE RANGE: H60-H95



21

CHAPTER 9: DISEASES OF CIRCULATORY SYSTEM

CODE RANGE: I00-I99 GUIDELINE CHANGES:


GUIDELINE CHANGES:

1. Hypertension: There is NO hypertension table. There is no distinction made for “malignant/accelerated” hypertension. Both controlled and uncontrolled in any form is I10.

2. Angina: The CAD codes will include the type of angina. No need to code an additional code for the angina.

22

6/12/2011

12

CHAPTER 9: DISEASES OF CIRCULATORY SYSTEM

CODE RANGE: I00-I99GUIDELINE CHANGES


GUIDELINE CHANGES

3. Post-procedural CVA: A. There are separate codes for a CVA occurring

“intra-operatively” or “postoperatively”. B There are separate codes for CVA’s occurring during B. There are separate codes for CVA s occurring during

cardiac surgery or other surgery.C. There are separate codes that distinguish between

a hemorrhage vs. an infarct.

23

CHAPTER 9: CONTINUED

4. MI: The time frame for a subsequent MI is 4 weeks If the patient has an MI and presents with


weeks. If the patient has an MI and presents with another MI within the 4 weeks timeframe, both MI’s would be coded.

24

6/12/2011

13

CHAPTER 10: DISEASE OF RESPIRATORY SYSTEM

CODE RANGE: J00-J99


GUIDELINE CHANGES

AVIAN/H1N1 FLU: Code only confirmed cases of avian influenza (code J09.0-, Influenza due to identified avian influenza virus) or novel H1N1 or swine flu, code J09.1-. This is an exception to the hospital inpatient guideline Section II, H. an exception to the hospital inpatient guideline Section II, H. (Uncertain Diagnosis).

25

CHAPTER 10: DISEASE OF RESPIRATORY SYSTEM

CODE RANGE: J00-J99 GUIDELINE CHANGES:


GUIDELINE CHANGES:

In this context, “confirmation” does not require documentation of positive laboratory testing specific for avian or novel H1N1 (H1N1 or swine flu) influenza. However, coding should be based on the provider’s diagnostic statement that the patient has avian influenza.

If the provider records “suspected or possible or probable avian influenza ” the appropriate influenza code from category J10 influenza,” the appropriate influenza code from category J10, Influenza due to other influenza virus, should be assigned. A code from category J09, Influenza due to certain identified influenza viruses, should not be assigned.

26

6/12/2011

14

CHAPTER 11: DISEASE OF DIGESTIVE SYSTEM

CODE RANGE: K00-K94



27

CHAPTER 11: DISEASES OF SKIN AND SUBCUTANEOUS TISSUE

CODE RANGE: L00-L99


No guidelines changes have been established to date.

28

6/12/2011

15

CHAPTER 12: DISEASE OF MUSCULOSKELETAL SYSTEM

CODE RANGE: M00-M99GUIDELINES CHANGES:


GUIDELINES CHANGES:

1. Site and laterality: For certain conditions, the bone may be affected at the upper or lower end, (e.g., avascular necrosis of bone, M87, Osteoporosis, M80, M81). Though the portion of the bone affected may be at the joint, the site designation gwill be the bone, not the joint.

29

CHAPTER 12: DISEASE OF MUSCULOSKELETAL SYSTEM

CODE RANGE: M00-M99 GUIDELINES CHANGES:


GUIDELINES CHANGES:

2. Osteoporosis and Pathological fractures: The appropriate 7th character is to be added to each code from category M80:

A initial encounter for fracture D b t t f f t ith ti h li g D subsequent encounter for fracture with routine healing G subsequent encounter for fracture with delayed healing K subsequent encounter for fracture with nonunion P subsequent encounter for fracture with malunion S sequela

30

6/12/2011

16


3. Osteoporosis with current pathological fracture


Category M80, Osteoporosis with current pathological fracture, is for patients who have a current pathologic fracture at the time of an encounter. The codes under M80 identify the site of the fracture.

31


3. Osteoporosis with current pathological fracture


A code from category M80, not a traumatic fracture code, should be used for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal healthy trauma would not usually break a normal, healthy bone.

32

6/12/2011

17


EXERCISE 4:


70 year old female with senile osteoporosis complains of severe right shoulder pain. She has reported no trauma to the area. Radiological studies show evidence of a fracture of the right humerusfracture of the right humerus.

Code(s)_____________________________

33

CHAPTER 14: DISEASES OF GENITOURINARY SYSTEM

CODE RANGE: N00-N99 GUIDELINE CHANGES:


1. Chronic kidney disease and kidney transplant status Patients who have undergone kidney transplant may still have some form of chronic kidney disease (CKD) because the kidney transplant may not fully restore kidney function. Therefore, the presence of CKD alone does not constitute a transplant complication.

Assign the appropriate N18 code for the patient’s stage of CKD and code Z94.0, Kidney transplant status. If a transplant complication such as failure or rejection or other transplant complication is documented, see section I.C.19.g for information on coding complications of a kidney transplant. If the documentation is unclear as to whether the patient has a complication of the transplant, query the provider.

34

6/12/2011

18

CHAPTER 15: PREGNANCY, CHILDBIRTH AND THE PUERPERIUM

CODE RANGE: O00-09AGUIDELINE CHANGES


GUIDELINE CHANGES

1. There is no “delivered/undelivered” except preterm delivery2. Coding for pregnancy is defined in “trimesters”.

Trimesters are counted from the first day of the last menstrual period. They

are defined as follows: 1st trimester- less than 14 weeks 0 days 2nd trimester- 14 weeks 0 days to less than 28 weeks 0 days 3rd trimester- 28 weeks 0 days until delivery

35


Trimesters are based on the CURRENT encounter, even if the condition began in a different trimester. The exception to this


rule is: Selection of trimester for inpatient admissions that encompass

more than one trimesters: In instances when a patient is admitted to a hospital for complications of pregnancy during one trimester and remains in the hospital into a subsequent trimester, the trimester character for the antepartum complication code should be assigned on the basis of the p gtrimester when the complication developed, not the trimester of the discharge. If the condition developed prior to the current admission/encounter or represents a pre-existing condition, the trimester character for the trimester at the time of the admission/encounter should be assigned.

36

6/12/2011

19


The peripartum period is defined as the last month of pregnancy to five months postpartum.


3. Multiple gestations: One of the following 7th characters is to be assigned to each code under category O31. 7th character 0 is for single gestations and multiple

gestations where the fetus is unspecified. g p 7th characters 1 through 9 are for cases of multiple

gestations to identify the fetus for which the code applies. The appropriate code from category O30, Multiple gestation,

must also be assigned when assigning a code from category O31 that has a 7th character of 1 through 9.

37


3 Multiple gestations:


3. Multiple gestations:0 not applicable or unspecified 1 fetus 1 2 fetus 2 3 fetus 3 4 fetus 4 5 fetus 5 9 other fetus

38

6/12/2011

20

CHAPTER 16: NEWBORN/PERINATAL

CODE RANGE: P00-P96GUIDELINE CHANGES:


GUIDELINE CHANGES:

1. Perinatal coding: Birth process or community acquired conditions . If a newborn has a condition that may be either due to the birth process or community acquired and the documentation does not indicate which it is, the default is due to the birth process and the code from Chapter 16 should be used. If the condition is community-acquired, a code from Chapter 16 should not be assigned.

39


N b id li f ddi i l di C d


2. Newborn guideline for additional diagnoses: Codes should be assigned for conditions that have been specified by the provider as having implications for future health care needs. This guideline is NOT to be used for adult patients.

40

6/12/2011

21

CHAPTER 17: CONGENITAL MALFORMATIONS

CODE RANGE: Q00-Q99


No new guidelines have been established to date.

41

CHAPTER 18: SYMPTOMS, SIGNS AND ABNORMAL FINDINGS

CODE RANGE: R00-R99 GUDELINE CHANGES:


GUDELINE CHANGES:

1. Glasgow coma scale: The Glasgow coma scale codes (R40.2-) can be used in conjunction with traumatic brain injury codes or sequelae of cerebrovascular accident codes.

These codes are primarily for use by trauma registries, but they may be used in any setting where this information is collected. The coma scale codes should be sequenced after the diagnosis code(s).

42Source of Glasgow Coma Score: www.TheEMTspot.com 6/12/11

6/12/2011

22

CHAPTER 18: SYMPTOMS, SIGNS AND ABNORMAL FINDINGS

CODE RANGE: R00-R99 GUDELINE CHANGES:


GUDELINE CHANGES:

1. Glasgow coma scale: These codes, ONE FROM EACH CATEGORY, are needed to

complete the scale. The 7th character indicates when the scale was recorded. The 7th character should match for all three codes. At i i t th i iti l d t d At a minimum, report the initial score documented on presentation at your facility. This may be a score from the emergency medicine technician (EMT) or in the emergency department. If desired, a facility may choose to capture multiple Glasgow coma scale scores.

43

EXAMPLE

Glascow coma score requires 3 codes to be valid:1 Eyes open


1. Eyes open2. Best verbal response3. Best motor response

44

6/12/2011

23


2. Functional quadriplegia: Functional quadriplegia (code R53.2) is the lack of ability to use one’s limbs or to ambulate due to


yextreme debility.

It is not associated with neurologic deficit or injury, and code R53.2 should not be used for cases of neurologic quadriplegia. It should only be assigned if functional quadriplegia is specifically documented in the medical record. specifically documented in the medical record.

45

CHAPTER 19: INJURY, POISONING AND OTHER CONSEQUENCES OF EXTERNAL CAUSES.

CODE RANGE: S00-T99


GUIDELINE CHANGES:

1. Code Extensions: A: Initial EncounterD: Subsequent EncounterS: Sequela

2 Fractures: 2. Fractures: A fracture not indicated as open or closed should be

coded to closed.A fracture not indicated whether displaced or not

displaced should be coded to displaced.

46

6/12/2011

24


Gustilo classification of “open” fractures:Open fractures are coded according to the “Gustilo”


Open fractures are coded according to the “Gustilo” classification for open fractures.

47Source: www.EatonHand.com 6/12/11


3. Underdosing: Underdosing refers to taking less of a medication than is prescribed by a provider or a manufacturer’s


instruction. Normally, a code from categories T36-T65 is sequenced first, followed by the code(s) that specify the nature of the adverse effect, poisoning, or toxic effect. Note: This sequencing instruction does not apply to underdosing codes.Codes for underdosing should never be assigned as principal or first-listed codes If a patient has a relapse or exacerbation of first listed codes. If a patient has a relapse or exacerbation of the medical condition for which the drug is prescribed because of the reduction in dose, then the medical condition itself should be coded.

48

6/12/2011

25

CHAPTER 20: EXTERNAL CAUSES

CODE RANGE: V01-Y99GUIDELINE CHANGES:


GUIDELINE CHANGES:

1. External causes: A. Unknown or Undetermined Intent Guideline: If the intent

(accident, self-harm, assault) of the cause of an injury or other condition is unknown or unspecified, code the intent other condition is unknown or unspecified, code the intent as accidental intent. All transport accident categories assume accidental intent.

49

CHAPTER 20: EXTERNAL CAUSES

CODE RANGE: V01-Y99GUIDELINE CHANGES:


GUIDELINE CHANGES:1. External causes:

B. Use of undetermined intent: External cause codes for events of undetermined intent are only for use if the documentation in the record specifies that the i t t t b d t i dintent cannot be determined.

50

6/12/2011

26


2. Hierarchy of sequencing of External Causes: The first-listed external cause code should correspond to


first-listed external cause code should correspond to the cause of the most serious diagnosis due to an assault, accident, or self-harm, following the order of hierarchy listed below:1. Child and adult abuse2. Terrorism (Only Federal Government Confirmed)( y )

Suspected cases should be classified as assault. 3. Cataclysmic events4. Transport accidents

51


3 Activity codes: An activity code is used only once at


3. Activity codes: An activity code is used only once, at the initial encounter for treatment. Only one code from Y93 should be recorded on a medical record. An activity code should be used in conjunction with a place of occurrence code, Y92.

52

6/12/2011

27



4. The external cause status codes are not applicable to poisonings, adverse effects, misadventures or late effects.

53

CHAPTER 21: OTHER FACTORS INFLUENCING HEALTH STATUS

CODE RANGE: Z00-Z99 GUIDELINE CHANGES:


GUIDELINE CHANGES:

1. Z28.3 Under immunization status

2. Contact/Exposure: Category Z20 indicates contact with, and suspected exposure to, communicable diseases. These codes are for patients who do not show any sign or symptom of a are for patients who do not show any sign or symptom of a disease but are suspected to have been exposed to it by close personal contact with an infected individual or are in an area where a disease is epidemic

54

6/12/2011

28


3. Transplanted organ removal status:


Use Z98.85 to indicate that a transplanted organ has been previously removed.

This code should not be assigned for the encounter in which the transplanted organ is removed.

The complication necessitating removal of the p gtransplant organ should be assigned for that encounter.

55


ICD-10-PCS (PROCEDURAL CODING SYSTEM).

56

6/12/2011

29

WHAT MAKES UP A CODE?

ICD-10 PCS codes are seven characters and can be alpha numeric using numbers 0 9 and


can be alpha-numeric using numbers 0-9 and letters A-H, J-N and P-Z. In order to avoid confusion with 1 and 0, I and O are not used. Each character contains 34 possible values.

Each code is “built” from the procedure description rather than a fixed number per procedure.

57

CHARACTERS

Character # 1 defines the “section” that identifies the general type of procedure such


identifies the general type of procedure such as, Medical and Surgical, Obstetrics or Imaging.

There are 16 sections: 0. Medical and Surgical 1 Obstetrics 1. Obstetrics 2. Placement 3. Administration

58

6/12/2011

30

CHARACTERS (CONTINUED)

4. Measurement and Monitoring


5. Extracorporeal Assistance and Performance 6. Extracorporeal Therapies 7. Osteopathic 8. Other procedures 9. Chiropractic B. Imaging

59

CHARACTERS (CONTINUED)

C. Nuclear Medicine


D. Radiation Oncology F. Physical Rehab and Diagnostic Audiology G. Mental Health H. Substance Abuse Treatment

60

6/12/2011

31

SECTION 0-MEDICAL AND SURGICAL

Each section has it’s own meaning for the code characters. The Medical and Surgical section characters have the


The Medical and Surgical section characters have the following meanings:

Character #1=Section Character #2=Body System Character #3=Root operation Character #4=Body partCharacter #4 Body part Character #5=Approach Character #6=Device Character #7=Qualifier

61

SECTION 0-MEDICAL AND SURGICAL (CONT)

Character # 2=Body system has 31 categories.


They are: 0. Central Nervous System 1. Peripheral Nervous System 2. Heart and Great Vessels 3. Upper Arteries (Above the diaphragm) 4. Lower Arteries (Below the diaphragm) 5. Upper veins

62

6/12/2011

32


6. Lower veins


7. Lymphatic and Hemic Systems 8. Eye 9. Ear, Nose, Sinus B. Respiratory System C. Mouth and Throat D. Gastrointestinal System

63


F. Hepatobiliary System and Pancreas


G. Endocrine System H. Skin and Breast J. Subcutaneous Tissue and Fascia K. Muscles L. Tendons M. Bursae and Ligaments

64

6/12/2011

33


N. Head and Facial Bones


P. Upper Bones Q. Lower Bones R. Upper Joints S. Lower Joints T. Urinary System U. Female Reproductive System

65


V. Male Reproductive System


W. Anatomical regions, Upper Extremities Y. Anatomical regions, Lower Extremities

66

6/12/2011

34


Character #3 of the Medical Surgical Section is the Root Operation


the Root Operation. There are 31 different Root Operations The Root Operations defines the OBJECTIVE of

the procedure Root operations have specific definitions Root operations have specific definitions

67

ROOT OPERATIONS

The procedure may be documented as a resection however if the ENTIRE organ was not


resection, however, if the ENTIRE organ was not removed, then this would be an EXCISION based on the definitions of root operations.

68

6/12/2011

35

ROOT OPERATION DEFINITIONS

Alteration: Modifying the natural anatomic structure of a body part without affecting the


structure of a body part without affecting the function of a body part. Intended to improve appearance such as a face lift.

Bypass: Altering the route of passage of the Bypass: Altering the route of passage of the contents of a tubular body part. An example is a gastro-jejunal bypass.

69


Change: Taking out or off a device from a body part or putting back an identical or similar


part or putting back an identical or similar device in or on the same body part without cutting or puncturing the skin or a mucous membrane. An example is changing a urinary catheter.

70

6/12/2011

36


Control: Stopping, or attempting to stop, post-procedural bleeding If a “control” procedure is


procedural bleeding. If a “control” procedure is unsuccessful and a more definitive procedure is required to stop the bleeding, code only the definitive procedure. For example, if removal of part of an organ is required to stop the bleeding then the root operation would become “excision” rather than “control”.

71


Creation: Making a new genital structure that does not physically take the place of a body


does not physically take the place of a body part. This is used for sex change operations.

Destruction: Physical eradication of all or a portion of a body part by the direct use of portion of a body part by the direct use of energy, force, or destructive agent. Examples are cauterization or fulguration of a lesion.

72

6/12/2011

37


Detachment: Cutting off all or a portion of the upper or lower extremities An example would


upper or lower extremities. An example would be an amputation of an extremity.

Dilation: Expanding an orifice of the lumen of a tubular body part An example would be tubular body part. An example would be percutaneous transluminal angioplasty.

73


Division: Cutting into a body part without draining fluids and/or gases from the body part


draining fluids and/or gases from the body part in order to separate or transect a body part. An example is an osteotomy.

Drainage: Taking or letting out fluids and/or Drainage: Taking or letting out fluids and/or gases from a body part. Examples are a paracentesis or incision and drainage.

74

6/12/2011

38


Excision: Cutting out or off, without replacement a portion of a body part An


replacement, a portion of a body part. An example is a biopsy.

Extirpation: Taking or cutting out solid matter from a body part An example is a from a body part. An example is a thrombectomy.

75


Extraction: Pulling or stripping out or off all of a body part by the use of force Examples are


body part by the use of force. Examples are dilation and curettage and vein stripping.

Fragmentation: Breaking solid matter in a body part into pieces An example is extracorporeal part into pieces. An example is extracorporeal shockwave lithotripsy.

76

6/12/2011

39


Fusion: Joining together portions of an articular body part rendering the articular part


articular body part rendering the articular part immoble. An example is spinal fusion.

Insertion: Putting on a non-biological appliance that monitors assists performs or prevents a that monitors, assists, performs or prevents a physiological function but does not physically take the place of a body part. An example is insertion of a central venous catheter.

77


Inspection: Visually and/or manually exploring a body part An example is a diagnostic


a body part. An example is a diagnostic laparotomy.

Map: Locating the route of passage of electrical impulses and/or locating functional electrical impulses and/or locating functional areas in a body part. An example is cardiac mapping.

78

6/12/2011

40


Occlusion: Completely closing an orifice or lumen of a tubular body part An example is


lumen of a tubular body part. An example is fallopian tube ligation.

Reattachment: Putting back in or on all or a portion of a separated body part to its normal portion of a separated body part to its normal location or other suitable location. An example is reattaching a traumatic amputation of an extremity.

79


Release: Freeing a body part from an abnormal physical constraint by cutting or by use of force


physical constraint by cutting or by use of force. An example is lysis of adhesions.

Removal: Taking out or off a device from a body part An example is removal of a body part. An example is removal of a pacemaker without reinsertion.

80

6/12/2011

41


Repair: Restoring, to the extent possible, a body part to its normal anatomic structure and


body part to its normal anatomic structure and function. An example is suturing a laceration.

Replacement: putting in or on biological or synthetic material that physically takes the synthetic material that physically takes the place and/or function of all or a portion of a body part. An example is a hip replacement.

81


Reposition: Moving to it normal location or other suitable location all or part of a body part


other suitable location all or part of a body part. An example is fracture reduction.

Resection: Cutting out or off, without replacement all of a body part An example is replacement, all of a body part. An example is a cholecystectomy.

82

6/12/2011

42


Restriction: Partially closing an orifice or lumen of a tubular body part An example is cervical


of a tubular body part. An example is cervical cerclage.

Revision: Correcting, to the extent possible, a malfunctioning or displaced device An malfunctioning or displaced device. An example is revision of a pacemaker lead.

83


Supplement: Putting in or on biologic or synthetic material that physically reinforces


synthetic material that physically reinforces and/or augments the function of all or a portion of a body part. An example is a repair of a hernia with mesh.

84

6/12/2011

43


Transfer: Moving, without taking out, all or a portion of a body part to another location to


portion of a body part to another location to take over the function of a body part. An example is a tendon transfer.

85


Transplantation: Putting in or on all or a portion of a living body part taken from another


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. An example is a kidney transplant.

86

6/12/2011

44


Character #4=Body part. Tubular body parts are defined as hollow body parts that provide a


are defined as hollow body parts that provide a route of passage for solids, liquids and gases. This includes, cardiovascular, biliary, gastrointestinal, urinary and respiratory tracts.

87


Character # 4=Approach.


There are 7 approaches defined. Open: Cutting through the skin or mucous

membrane and any other body layers necessary to expose the site of the procedure. An example is an open abdominal An example is an open abdominal hysterectomy.

88

6/12/2011

45

APPROACH

Percutaneous: Entry, by puncture or a minor incision of instrumentation through the skin or


incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach the site of the procedure. An example is liposuction.

89

APPROACH

Percutaneous Endoscopic: Entry, by puncture or a minor incision of instrumentation through


or a minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach and visualize the site of a procedure. An example is an arthroscopy.

90

6/12/2011

46

APPROACH

Via natural or artificial opening: Entry of instrumentation through a natural or artificial


instrumentation through a natural or artificial external opening to reach the site of the procedure. An example is a urinary catheter placement.

91

APPROACH

Via natural or artificial opening endoscopic: Entry of instrumentation through a natural or


Entry of instrumentation through a natural or artificial external opening to reach and visualize the site of the procedure. An example is an EGD.

92

6/12/2011

47

APPROACH

Via natural or artificial opening with Percutaneous endoscopic Assistance: Entry of


Percutaneous endoscopic Assistance: Entry of instrumentation through a natural or artificial external opening and entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to aid in the performance of the procedure. An example is a laparoscopic appendectomy.

93

APPROACH

External: Procedures performed directly on the skin or mucous membrane and procedures


skin or mucous membrane and procedures performed indirectly by the application of external force through the skin or mucous membrane. An example is Closed reduction of a fracture.

94

6/12/2011

48


Character #6=Device


The definition of a device in this case is, any device that remains after the procedure is complete.

There are four general types of devices There are four general types of devices.

95

DEVICES

Biological or synthetic material that takes the place of all or a portion of a body part An


place of all or a portion of a body part. An example is a joint prosthesis.

Biological or synthetic material that assists or prevents a physiological function An example prevents a physiological function. An example is a urinary catheter.

96

6/12/2011

49

DEVICES

Therapeutic material that is not absorbed by, eliminated by or incorporated into a body part


eliminated by, or incorporated into a body part. Am example is an internal fixation device.

Mechanical or electronic appliances used to assist monitor take the place of or prevent a assist, monitor, take the place of, or prevent a physiological function. An example is a pacemaker.

97


Character # 7=Qualifier


The qualifier contains unique values for individual procedures. It is specific to a body part, body system or root operation.

98

6/12/2011

50

CONVENTIONS

All seven characters are required to be a valid code


code.

The normal components of opening and closing are included in the procedure.

“AND” means and/or.

99

CONVENTIONS

The coder is responsible for determining the correct root operation based on the definitions


correct root operation based on the definitions of root operations and the description of the procedure based on the physician’s documentation of the operation. The physician is not expected to know the definitions of root operations or use the correct terminology.

100

6/12/2011

51

GUIDELINES FOR MEDICAL AND SURGICAL

Body systems with description of “upper or lower” body parts indicate “above or below” the


lower” body parts indicate “above or below” the diaphragm.

Procedural steps required to reach the operative site and close the operative site are operative site and close the operative site are not coded separately. An example is a laparotomy to perform a more definitive procedure.

101


Multiple procedures:


1. The same root operation is performed on different body parts. An example is a biopsy of the liver and the skin.

2 The same root operation is repeated at 2. The same root operation is repeated at different parts of a body site. An example is a biopsy of 2 different muscles of the upper arm.

102

6/12/2011

52


3. Multiple root operations with distinct objectives performed on the same body part


objectives performed on the same body part. An example is destruction of a lesion and then bypass of the same area due to the presence of an unresectable obstructive lesion.

103


4. The intended root operation was attempted using one approach but required conversion to


using one approach, but required conversion to another approach to complete. An example is a laparoscopic appendectomy that was converted to an open approach.

104

6/12/2011

53


Discontinued procedures. If a procedure is discontinued code to the root operation that


discontinued, code to the root operation that was performed. If it is discontinued before a definitive root operation was performed, then code to “inspection”.

Biopsy followed by a definitive treatment. Code both the biopsy and the definitive procedure.

105


Overlapping body layers. If root operations Excision Repair or Inspection are performed on


Excision, Repair or Inspection are performed on overlapping layers of the musculoskeletal system, code to the deepest layer. An example is repair of skin, subcutaneous tissue and muscle. Code the repair of muscle.

106

6/12/2011

54


Bypass procedures. Bypass procedures are identified by the body part bypassed “from” to


identified by the body part bypassed “from” to the body part bypassed “to”. The 4th character of the code identifies the body part bypassed “from”. The 7th character (the qualifier) of the code identifies the body part bypassed “to”.

107


An exception to this guideline is coronary artery bypass grafts These are classified by the


bypass grafts. These are classified by the number of distinct sites treated instead of the number of arteries or the name of the artery. The 4th character of the code identifies the number of sites bypassed and the 7th character (the qualifier) identifies the vessel bypass “from”, (aorta, internal mammary, etc.).

108

6/12/2011

55


If multiple coronary arteries are bypassed, a separate procedure is coded for every coronary


separate procedure is coded for every coronary artery site that uses a different device and/or qualifier. An example is a coronary artery bypass to the aorta and a coronary artery bypass from the right internal mammary would be coded separately.

109


Control of post-procedural bleeding. If control of post procedural bleeding is unsuccessful


of post-procedural bleeding is unsuccessful and requires a more definitive procedure to control the bleeding, code the more definitive procedure, rather than the “control” root operation.

110

6/12/2011

56


Anatomical subdivisions. Some organs have anatomical subdivisions such as lobes of liver


anatomical subdivisions such as lobes of liver and lung and specific regions of the intestine. The root operation “excision” is removal of a portion of an organ while “resection” is removal of the entire organ. In the cases where there are subdivisions, removal a “lobe” or “specific region” is classified as “resection”, removal of the entire organ.

111


Excision for graft. If an autograft is obtained from a different body part to complete the


from a different body part to complete the objective of the procedure, a separate procedure is coded. An example is an Iliac crest bone excision for spinal fusion. Excision of the iliac bone would be coded separately from the fusion.

112

6/12/2011

57



If multiple tubular body parts are inspected, code to the most distal body part. An example is and EGD. Code inspection of the upper intestinal tract (location of the duodenum).

113


If multiple non-tubular body parts in a particular region are inspected code the body


particular region are inspected, code the body part that specifies the entire region. An example is an exploratory laparotomy which would be coded to the body part, “peritoneal cavity”.

114

6/12/2011

58


Occlusion for vessel embolization refers to the complete closure of the vessel such as to stop


complete closure of the vessel such as to stop blood flow to a tumor. Restriction, on the other hand, is a partial occlusive embolization or narrowing of a vessel for treatment of an aneurysm.

115


Fracture treatment. Reduction of a displaced fracture codes to root operation “Reposition”


fracture codes to root operation “Reposition” and includes casting. If casting only is done for a non-displaced fracture it codes to the root operation “Immobilization”. Placing a pin for fracture treatment codes to the root operation “insertion”.

116

6/12/2011

59


Transplant refers to putting in a functioning living body part taken from another individual


living body part taken from another individual or animal.

Administration refers to putting in autologous or non-autologous CELLS For example a Bone or non autologous CELLS. For example a Bone Marrow Transplant would be classified in the “Administration” section

117

GUIDELINES FOR BODY PARTS

If a procedure is performed on a body part that does not have a specified body part value code


does not have a specified body part value, code to the whole body part value. An example is an alveolar process of the mandible would code to the mandible.

The prefix “peri” is included in the main body part. An example is peri-rectal would code to rectum.

118

6/12/2011

60


Branches of body parts. When a specific branch of a body part does not have its own body part


of a body part does not have its own body part value, the body part is coded to the most PROXIMAL branch that has a specific body part value. An example is the mandibular branch of the trigeminal nerve does not have its own body

l d h i i l i h part value, and the trigeminal nerve is the most proximal nerve to the mandibular nerve, therefore, this codes to the trigeminal nerve.

119


Certain body parts have “bilateral” body part values An example is bypass of the ureters


values. An example is bypass of the ureters. This would be coded once since it has a bilateral body part value. A joint replacement however, would be coded twice as a right and a left since there is no bilateral value option.

120

6/12/2011

61


Tendons, ligaments, bursae and fascia NEAR a joint These structures are coded to the


joint. These structures are coded to the respective body system that is the focus of the procedure. If the procedure is of the joint itself, then code to the body part in the joint body system.

121


Skin, subcutaneous tissue and fascia OVERLYING a joint Procedures on these


OVERLYING a joint. Procedures on these structures are coded to these body parts:

Shoulder=Upper Arm Elbow and Wrist=Lower Arm Hip=Upper Leg Hip=Upper Leg Knee=Lower Leg Ankle=Foot

122

6/12/2011

62


Fingers and toes. If fingers and toes do not have a specific body part value they code to


have a specific body part value, they code to hand and foot respectively.

123

EXERCISES 5-6

A patient undergoes an open right lobectomy of the liver The correct code for this procedure is:


the liver. The correct code for this procedure is: Code(s)____________________________

A patient has a percutaneous biopsy of the left liver lobe The correct code for this procedure liver lobe. The correct code for this procedure is:Code(s)____________________________

124

6/12/2011

63

EXERCISE 7

A patient has an open reduction with internal fixation of the right femoral shaft fracture The


fixation of the right femoral shaft fracture. The correct procedure code is:

Code(s)______________________________

125

EXERCISE 8

A patient developed post op bleeding following a colonoscopy and returned to the OR for control


colonoscopy and returned to the OR for control of the hemorrhaging. The physician was unable to control the hemorrhaging and proceeded to do an excision of the transverse colon for definitive treatment. The correct code for this procedure is:Code(s)_____________________________

126

6/12/2011

64

OBSTETRICS

The meaning of the characters for Obstetrics is the same as the Medical and Surgical section


the same as the Medical and Surgical section. Character #1=Section Character #2=Body System Character #3=Root operation Character #4=Body party p Character #5=Approach Character #6=Device Character #7=Qualifier

127

SECTION 1-OBSTETRICS

This section includes procedures on the “products of conception” (POC) only


“products of conception” (POC) only. Procedures on a pregnant female are coded in the Medical and Surgical section 0.

The definition of “products of conception can The definition of products of conception can include fetus, amnion, umbilical cord and placenta. Terms included may be zygote, and embryo.

128

6/12/2011

65


Character #1=ObstetricsCh #2 B d S i “ ”


Character #2=Body Section “pregnancy” Character #3=Root Operation”. 2 new root

operations are valid in this section. Abortion: Artificially terminating a pregnancy Delivery: Assisting the passage of the POC from Delivery: Assisting the passage of the POC from

the genital canal

129


Character #4=Body Part. The only body parts valid in this section are:


valid in this section are:Products of conception (POC).Products of conception, retainedProducts of conception, ectopic

Character #5=Approach

130

6/12/2011

66


Character #6=Devices (i.e. Fetal monitoring)


Character #7=Qualifiers that are specific to the root operation. An example is types of forceps used or type of cesarean section.

131

OBSTETRIC EXERCISE 9

A patient presented with a missed abortion and required a D&C for retained Products of


required a D&C for retained Products of Conception. The correct codes for this procedure is:

Code(s)Code(s)______________________________

132

6/12/2011

67

SECTION 2-PLACEMENT

The meaning of the characters for the Placementsection is slightly different than sections 0 & 1


section is slightly different than sections 0 & 1. Character #1=Section Character #2=Anatomical region Character #3=Root operation Character #4=Body region/Orifice Character #5=Approach Character #6=Device Character #7=Qualifier

133

SECTION 2-PLACEMENT


Character #1 is always 2 for “Section 2” Character #2 only contains 2 values.

Anatomical regionsAnatomical orifices

134

6/12/2011

68

SECTION 2-PLACEMENT

Character #3 uses the already established root operations “change” and “removal” 5 additional


operations change and removal . 5 additional root operations are also valid values in the section.

Compression: Putting pressure on a body region Dressing: Putting material on a body region for protection. Immobilization: Limiting or preventing motion of an external

body region.body region. Packing: Putting material in a body region or orifice Traction: Exerting a pulling force on a body region in a distal

direction.

135

SECTION 2-PLACEMENT

Character #4 is either “body region” such as “upper arm” or natural orifice such as “mouth”


“upper arm” or natural orifice such as “mouth”. Character #5 is the approach. It is always

“external” in this section. Character #6 is the device. Most of the devices

referred to in this section are “off the shelf” referred to in this section are off the shelf and do not require and fabricating or fitting. (Those devices are to be coded in the “Rehabilitation” section.

136

6/12/2011

69

SECTION 2-PLACEMENT

Character #7 is the qualifier and in this section, it is always “no qualifier”


it is always “no qualifier”.

137

PLACEMENT EXERCISE 10


A patient presents for a application of a dressing to his left upper leg. The correct code for this procedure is:

Code(s)Code(s)_________________________________

138

6/12/2011

70

SECTION 3-ADMINISTRATION

The meaning of the characters for this section:Ch #1 S i


Character #1=Section Character #2=Physiological System and Anatomical

Region Character #3=Root operation Character #4=Body System/Region Character #5=Approach Character #6=Substance Character #7=Qualifier

139



Character #1 is always 3. Character #2 contains only 3 values

Indwelling Devices Physiological Systems and Anatomical Regions Circulatory System (used for transfusion Circulatory System (used for transfusion

procedures)

140

6/12/2011

71


Character #3 is the root operation. There are only 3 valid root operations for this section:


only 3 valid root operations for this section: Introduction: putting in all or on a therapeutic,

diagnostic, nutritional, physiological, or prophylactic substance except blood or blood products

Irrigation: Putting in or on a cleaning substance Transfusion: Putting in blood or blood products

141


Character #4 Body System/Region. This identifies the site of administration not the site


identifies the site of administration, not the site where the substance takes effect.

Arteries and veins are classified as “peripheral” and “central” A substance administered through a peripheral vessel in usually a g p p y“systemically acting” substance, such as chemotherapy.

142

6/12/2011

72


A substance administered through a central vessel is usually “locally acting” such as


vessel is usually “locally acting” such as attempting to break up a clot with a thrombolytic agent directly through a catheter.

Character #5 is the approach. New terms for this section are “intradermal, subcutaneous ,and intramuscular. They are considered a “percutaneous” approach.

143


Character #6 is the substance being introduced Examples are anesthetic contrast


introduced. Examples are anesthetic, contrast, and specific blood products.

Character #7 is the qualifier. It may be “autologous” or “non-autologous”, or further specify the substance.p y

144

6/12/2011

73

EXERCISE 11

A patient presents for a unit of packed red blood cells which will be transfused through a


cells which will be transfused through a peripheral artery. The correct code for this procedure is:

Code(s)Code(s)______________________________

145

SECTION 4-MEASUREMENT AND MONITORING

The meaning of the characters for this section are:


are: Character #1=Section Character #2=Physiological System Character #3=Root Operation Character #4=Body System’y y Character #5=Approach Character #6=Function/Device Character #7=Qualifier

146

6/12/2011

74

SECTION 4-MEASUREMENTS AND MONITORING

Character #1 is always 4 for Section 4Ch t #2 h l 2 ti


Character #2 has only 2 options A=Physiological System B=Physiological Device

Character #3 has only 2 root operations

Measurement: Determining the level of a Measurement: Determining the level of a physiological function at a point in time.Monitoring: Determining the level of a physiological or physical function repeatedly over time.

147

SECTION 4-MEASUREMENTS AND MONITORING

Character #4 specifies the body systemCh t #5 i th h S M di l


Character #5 is the approach. Same as Medical and Surgical Section 0)

Character #6 specifies what is being measured or monitored. Examples of function may include, temperature, pulse, volume, conductivity, etc. If a d i i i t d d l ft i t d t th device is inserted and left in to conduct the monitoring then a code from the Medical and Surgical Section may be coded as a separate procedure.

148

6/12/2011

75

SECTION 5-EXTRACORPOREAL ASSISTANCE AND PERFORMANCE The meaning of the characters for Section 5 is:


Character #1=Section Character #2=Physiological System Character #3=Root Operation Character #4=Body System Character #5=Duration Character #6=Function Character #7=Qualifier

149

SECTION 5- 5-EXTRACORPOREAL ASSISTANCE AND PERFORMANCE Character #1 is always 5 for Section 5 Character #2 is always Physiological Systems


Character #2 is always Physiological Systems Character #3 has 3 root operations:

Assistance: Taking over a portion of a physiological function by extracorporeal means.

Performance: Completely taking over a physiological function by extracorporeal meansfunction by extracorporeal means.

Restoration: Returning, or attempting to return, a physiological function to its natural state by extracorporeal means.

150

6/12/2011

76

SECTION 5- 5-EXTRACORPOREAL ASSISTANCE AND PERFORMANCE

Character #4 is the body system to which the


extracorporeal assistance is being applied Character #5 identifies the duration of the

procedure Single

I t itt t Intermittent Continuous

151

SECTION 5- 5-EXTRACORPOREAL ASSISTANCE AND PERFORMANCE For respiratory ventilation assistance the

duration is specified in hours


duration is specified in hours Less than 24 consecutive hours 24-96 consecutive hours More than 96 consecutive hoursCharacter #6 identifies the physiological function p y g

assisted during the procedure. (i.e. oxygenation, ventilation)

Character #7 identifies the type of equipment used.

152

6/12/2011

77

SECTION 6-EXTRACORPORAL THERAPIES

The meaning if the characters for this section:


Character #1=Section Character #2=Physiological Systems Character #3=Root Operation Character #4=Body System Character #5=Duration Character #6=Qualifier Character #7=Qualifier

153

SECTION 6-EXTRACORPOREAL THERAPIES

Character #1 is always 6 for Section 6


Character #2 is always Physiological Systems Character #3 is the root operation. There are

10 root operations valid for Section 6 Atmospheric Control: Extracorporeal control of

atmospheric pressure and composition.atmospheric pressure and composition. Decompression: Extracorporeal elimination of un-

dissolved gas from body fluids. This is only used for decompression sickness in a hyperbaric chamber.

154

6/12/2011

78


Electromagnetic Therapy: Extracorporeal treatment by electromagnetic rays


treatment by electromagnetic rays. Hyperthermia: Extracorporeal raising of body

temperature. Hypothermia: Extracorporeal lowering of body

temperaturetemperature. Pheresis: Extracorporeal separation of blood

products

155


Phototherapy: Extracorporeal treatment by light rays


light rays. Shock Wave Therapy: Extracorporeal treatment

by shock waves. Ultrasound therapy: Extracorporeal treatment

by ultrasoundby ultrasound. Ultraviolet Light Therapy: Extracorporeal

treatment by ultraviolet light.

156

6/12/2011

79


Character #4 is the body system on which the therapy is performed


therapy is performed. Character #5 identifies the duration such as

single or intermittent. Character #6 is not specified as a value and is

always “no qualifier”always no qualifier . Character #7 is only used for “pheresis” and

“Ultrasound”, otherwise it is “no qualifier”.

157

SECTION 7-OSTEOPATHIC

The meaning of the character for this section:


Character #1=Section Character #2=Anatomical Region Character #3=Root Operation Character #4=Body Region Character #5=Approach Character #6=Method Character #7=Qualifier

158

6/12/2011

80

SECTION 7=OSTEOPATHIC

Character #1 is always 7 for Section 7


Character #2 is always Anatomical Region Character #3 is the Root Operation and there is

only 1 Root Operation valid for this Section Treatment: Manual treatment to eliminate or

alleviate somatic dysfunction and related disorders.alleviate somatic dysfunction and related disorders.

Character #4 the body region on which the osteopathic treatment is being performed

159

SECTION 7=OSTEOPATHIC

Character #5 is the approach and it is always “external”


“external”. Character #6 identifies the method of

treatment being utilized. Character #7 is the qualifier and always has a

value of “none”value of none .

160

6/12/2011

81

SECTION 8-OTHER PROCEDURES

The meaning of the characters in this section:


Character #1=Section Character #2=Body System Character #3=Root Operation Character #4=Body region Character #5=Approach Character #6=Method Character #7=Qualifier

161

SECTION 8=OTHER PROCEDURES

Character #1 is 8 for Section 8


Character #2 is the body system which includes Physiological Systems Anatomical Regions

Character #3 is the Root Operation and there is only 1 Root Operation valid for this sectionis only 1 Root Operation valid for this sectionOther Procedures: Methodologies that attempt to remediate or cure a disorder or disease

162

6/12/2011

82

SECTION 8-OTHER PROCEDURES

Character #4 contains specific body region values and a body region value of “none” for


values and a body region value of “none” for extracorporeal procedures.

Character #5 is the approach and is the same as in the Medical Surgical Section 0.

Character #6 specifies the method of Character #6 specifies the method of treatment.

Character #7 contains qualifiers as needed.

163

SECTION 9-CHIROPRACTIC

The meaning of the characters in this section


Character #1=Section Character #2=Anatomical Region Character #3=Root Operation Character #4=Body Region Character #5=Approach Character #6=Method Character #7=Qualifier

164

6/12/2011

83


Character #1 is always 9 for Section 9.


Character #2 is always Anatomical Region Character #3 is the Root Operation and there is

only 1 Root Operation in this section Manipulation: Manual procedure that involves a

directed thrust to move a joint past the directed thrust to move a joint past the physiological range of motion, without exceeding the anatomical limit.

165


Character #4 is the body region


Character #5 is the approach of manipulation and is always “external”

Character #6 is the method of manipulation. Character #7 is the Qualifier which is always a

value of “none” for this sectionvalue of none for this section.

166

6/12/2011

84

SECTION B-IMAGING

The meanings of the characters for this section


Character #1=Section Character #2=Body System Character #3=Root Type Character #4=Body Part Character #5=Contrast Character #6=Qualifier Character #7=Qualifier

167

SECTION B-IMAGING

Character #1 is always B for Section BCharacter #2 defines the body system


Character #2 defines the body system Character #3 defines the type of imaging performed.

Options are: Computerized Tomography (CT) Fluoroscopy Magnetic Resonance Imaging (MRI) Plain Radiography Ultrasonography

168

6/12/2011

85

SECTION B-IMAGING

Character #4 defines the body part within the body system from character #2


body system from character #2. Character #5 defines if contrast was used and if

so it defines the type such as High or Low Osmolar.

Character #6 is a qualifier specific to a procedure. Character #7 specifies whether the procedure was

performed intra-operatively or using desitometry.

169

SECTION C-NUCLEAR MEDICINE

The meanings of the characters for this section


Character #1=Section Character #2=Body System Character #3=Root Type Character #4=Body Part Character #5=Radionuclide Character #6=Qualifier Character #7=Qualifier

170

6/12/2011

86


Character #1 is always C for Section C


Character #2 specifies the body system on which the procedure is performed

Character #3 identifies the type of procedure. These are:

N i gi g t k Non-imaging uptake Non-imaging Probe Non-imaging Assay

171


Planar Imaging Positron Emission Tomography (PET)


Positron Emission Tomography (PET) Systemic Therapy Tomographic (TOMO) ImagingCharacter #4 is the body part studied. Character #5 identifies the radiation source. Character #6 is a qualifier and it is always “none”.Character #7 is a qualifier and it is always “none”.

172

6/12/2011

87

SECTION D-RADIATION ONCOLOGY

The meaning of the characters in this section


Character #1=Section Character #2=Body System Character #3=Root Type Character #4=Treatment Site Character #5=Modality Qualifier Character #6=Isotope Character #7=Qualifier

173


Character #1 is always D for Section D


Character #2 specifies the body system being irradiated

Character #3 specifies the general modality used

Character #4 specifies the body part that is the Character #4 specifies the body part that is the focus of radiation therapy

174

6/12/2011

88


Character #5 further specifies the radiation modality used


modality used. Character #6 specifies the isotopes introduced

in the body, if applicable. Character #7 is the qualifier and may indicate if

the procedure was performed intra-operativelythe procedure was performed intra operatively

175

SECTION F-PHYSICAL REHABILITATION ND DIAGNOSTIC AUDIOLOGY The meaning of the characters in this section


Character #1=Section Character #2=Section Qualifier Character #3=Root Type Character #4=Body System and Region Character #5=Type Qualifier Character #6=Equipment Character #7=Qualifier

176

6/12/2011

89

SECTION F-PHYSICAL REHABILITATION ND DIAGNOSTIC AUDIOLOGY Character #1 is always F for Section F

Ch t #2 id tifi h th it i


Character #2 identifies whether it is “Rehabilitation” or “Diagnostic Audiology”

Character #3 has 14 different root types which can be classified into these 4 basic groups: Assessment Caregiver Training Fitting(s) Treatment

177

SECTION F-PHYSICAL REHABILITATION ND DIAGNOSTIC AUDIOLOGY Character #4 is the body region or system on

which the procedure was performed


which the procedure was performed Character #5 further specifies the procedure

performed Character #6 specifies any equipment used. Character #7 is the qualifier and it is always Character #7 is the qualifier and it is always

“none” in this section

178

6/12/2011

90

SECTION G-MENTAL HEALTH

The meanings for the characters in this section


Character #1=Section Character #2=Body System Character #3=Root Type Character #4=Type Qualifier Character #5=Qualifier Character #6=Qualifier Character #7=Qualifier

179


Character #1 is always G for Section G


Character #2 is always “none”Character #3 indicates the type of procedure. There are 12 types of procedures in the Mental Health Section. They are:1 Psychological Tests1. Psychological Tests2. Crisis Intervention3. Medication Management

180

6/12/2011

91


4. Individual Psychotherapy


5. Counseling 6. Family Psychotherapy 7. Electroconvulsive Therapy 8. Biofeedback 9. Hypnosis 10. Narcosythesis

181


11. Group Psychotherapy


12. Light Therapy Character #4 is a qualifier specific to a

procedure Character #5, 6, & 7 are always a value of

“none”none

182

6/12/2011

92

SECTION H-SUBSTANCE ABUSE TREATMENT

The meanings of the characters in this section


Character #1=is always H for Section H Character #2=Is the Body system and is always

a value of “none Character #3=is the type of procedure. There

are 7 root types in this section They are:are 7 root types in this section. They are: 1. Detoxification Services 2. Individual Counseling

183


3. Group Counseling


4. Individual Psychotherapy 5. Family Counseling 6. Medication management 7. Pharmacotherapy Character #4 is a qualifier specific to a root

type.

184

6/12/2011

93


Characters #5, 6, & 7 are always qualifiers of “none”


“none”

185

GEMS

GEMs are “General Equivalence Mappings”. This is a mapping system to map current ICD 9


This is a mapping system to map current ICD-9 codes to equivalent ICD-10 codes. It is more complex than just a simple Cross-walk which is a one-to-one connection. There may be multiple ICD-10 codes for a single ICD-9 code. The mapping can be performed both from ICD-9 to ICD-10 and from ICD-10 to ICD-9.

186

6/12/2011

94

First Class Solutions 2011 187

GEM EXCERPT 1-1

2229 D299

ICD-9 ICD-10

2229 D299 2230 D3000 2231 D3010 2232 D3020 2233 D303 22381 D304 22389 D307 2239 D309

2240 D3140

ICD-9 to ICD-10Excerpt

2240 D3140 2241 D3160 2242 D3150 2243 D3100

http://www.cms.hhs.gov/ICD10/


GEMS 1 TO MANY

24950 E0931124950 E09349

24951 E0934124951 E09351

ICD-9 ICD-10 ICD-9 ICD-10

24950 E09349 24950 E0939 24950 E0936 24950 E09359 24950 E09351 24950 E09341 24950 E09339 24950 E09331

24951 E09351 24951 E0939 24951 E09359 24951 E09349 24951 E09331 24951 E09329 24951 E09311 24951 E0932124950 E09331

24950 E09329 24950 E09319 24950 E09321

24951 E09321 24951 E0936 24951 E09319 24951 E09339

http://www.cms.hhs.gov/ICD10/ ICD-9 to ICD-10 ExcerptSome of the I-10 codes that

map to a single I-9 code

6/12/2011

95


GEM EXCERPT

J869 5109

ICD-10 ICD-9

J869 5109J90 5119J90 51189J910 51181 J918 5119

ICD-10 to ICD-9

Same I-10 code ties to 2different I-9 codes;

Same I-9 code ties to 2J918 5119 J920 5110http://www.cms.hhs.gov/ICD10/

Same I 9 code ties to 2 different I-10 codes

ABOUT THE SPEAKER: PAM SCOTT, RHIT, CCS

Pam is a Senior Compliance and Classification Consultant for First Class Solutions, Inc. She routinely leads and participates in Coding Compliance Reviews


Compliance Reviews. In the past, she has served as a Financial Data Manager, participated

in Quality and Performance Improvement programs, and has expertise in all types of inpatient and outpatient coding activities.

Pam also is experienced in Tumor, Myocardial Infarction, and Head and Spinal Cord Injury Registries.

Ms. Scott has experience with alternative care facilities such as dialysis centers and long term hospitals, has provided on-site and off-site one-on-one training/oversight for new coders, and assists clients with inpatient and outpatient coding support.

Pam is an AHIMA Certified ICD-10 Trainer. Ms. Scott obtained her RHIT in 1990, has coursework in business, accounting,

management training and nursing. She is a member of AHIMA, MoHIMA, and EMoHIMA. She has spoken on a variety of coding related topics.

Pam has three children and 1 dog.

190

ICD-10-CM/PCS: AN OVERVIEW - AVHIMAavhima.org/2011/CM_PCS_SEMINAR_PRESENTATION_Pam_6_11.pdf ·...

Documents

Transcript of ICD-10-CM/PCS: AN OVERVIEW - AVHIMAavhima.org/2011/CM_PCS_SEMINAR_PRESENTATION_Pam_6_11.pdf ·...