UHDDS / Coding Guidelines for Operations & Procedures

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Other DX

Other Diagnoses(cc's)

"All conditions (recorded to the highest documented level of specificity) that coexist at the time of admission, develop subsequently, or affect the treatment received and/or length of stay"

Diagnoses that have no impact on care

Dx's that have no impact on patient care during the hospital stay are not reported even when they are present.

UHDDS" Other diagnosis" (5)

1. Clinical evaluation
2. Therapeutic treatment
3. Further evaluation by diagnostic studies, procedures or consultation
4. Extended length of hospital stay
5. Increased nursing care and or other monitoring

Admission following medical observation

Principal dx reported would be the medical condition that led to the hospital admission.

Admission following postoperative observation

That condition established after study to be chiefly responsible
What ever condition that develops postoperative

Admission from outpatient surgery

1. If the reason for the Inpt. adm. is a complication assign the complication as the Principle dx.
2.If no complication or other cond is doc, assign the reason for the outpatient surgery.
3. If the reason for the inpatient adm. is another condition unrelated to the surgery assign the it as the principle Dx.

Two or more diagnoses that equally meet the definition for principal diagnosis(PD)

1. Either diagnosis may be sequenced first when the Alpha nor Tabular list directs otherwise.
2. PD is determined by the circumstance of the admission and the diagnistic workup.
3. If only one cond would req inpt. care, or treatment was directed towards on cond.

a symptom followed by contrasting/ comparative diagnosis

The symptom code is sequenced first.

Other diagnoses that should be studied: 1
"Previous conditions stated as diagnoses"

History codes v10-v19 may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.

Other diagnoses that should be studied:2
"Other diagnosis with no documentation supporting reporatability"

Query the Physician

Other diagnoses that should be studied:3
"Chronic conditions that are not the thrust of treatment"

If they take up any resources it is and additional Dx.

UHDDS- Reporting Procedures
Significant procedures

SIGNIFICANT PROCEDURES
1. Is surgical in nature
2. Carries an anesthetic risk
3. Carries a procedural risk
4. Requires specialized training

Surgery includes:

1. Incision, 2. Excision, 3. destruction, 4. amputation
5. introduction, 6. insertion, 7. endoscopy, 8. repair
9. suturing, 10. manipulation

Principle Procedure UHDDS defines

Procedure - performed for definitive treatment ( rather than for diagnostic or exploratory purposes) or one that is necessary to care for a complication

Removal of an organ is listed where?

Under the main term Excision or Resection
you may also look under the sub-term/lesion

Coding Operative Approaches and Closures

1. No code is assigned when a definitive procedure is carried out, except for the rare instants when the code dose not imply the approach.
2. Codes are not assigned foe closure or anesthesia
3. The operative approach (ie: laparotomy) is coded only when an opening into a body cavity is followed only by a diagnostic procedure.( ie: Biopsy) so, laparotomy is coded first, then the biopsy

When conversing from a Laparoscopic, Thoracoscopic and Arthroscipic approaches to an open approache you would code what?

Only the open prodcedure is coded, no code is assigned for the other approaches. You would use V64.41 Laparoscopic, V64.42Thoracoscopic and V 64.43 Arthroscipic

Other Endoscopic approaches

Endoscopy, when it's performed and passed through more than one body cavity, the code foe theendoscopy identifies the most distant site. ie: Esophagogastroduodenoscopy- 45.13, other endoscopy if the small intestine

Biopsy

Biopsy code is not assigned when a lesion removed for therapeutic purpose.

There are two basic types of biopsies: open and closed

Open Biopsy- performed by incision. the incision and the approached is implicit.
When the biopsy is incidental to the removal of other tissue during a procedure, both the procedure and the biopsy are coded. The code for the definitive procedure is sequenced first, with an additional code for the needle biopsy.

Coding Incomplete procedures 1.
V64.X procedure code is not carried out.

1. If incision only, code to incision of site

Coding Incomplete procedures 2.
V64.X procedure code is not carried out.

2. If endoscopic approach is unable to reach site, code endoscopy only.
ie: Pt. was admitted foe transurethral removal of ureteral stone. Scope was passed as far as the bladder, but the surgeon was unable to pass to into the ureter. Code the cystoscopy only.

Coding Incomplete procedures 3.
V64.X procedure code is not carried out.

3.If cavity or space was entered, code to exploration of site.
54.11 Exploratory laparotomy.
Because, that was the extent that the procedure actual performed.

There are two basic types of biopsies: closed and open

Closed Biopsy- are performed percutaneously by needle, brush aspiration or by endoscopy.

Watch out for Biopsy of the urethra (58.23) , which dose not the distinction, If it is done by endoscopy, code both the endoscopic approach and the biopsy. The endoscopy is first then the biopsy. (The Endoscopy is the more significant procedure, it poses the highest risk)

Coding Shunt Procedures 1.( Drains Fluids)

1.Codes are assigned on the basis of the therapeutic intent and the procedure involved. Not the name of the shunt

Coding Shunt Procedures 2.

2. Main terms: Creation, Formation or Shunt

Revision=

Replacement

Insert=

Incision

Coding Stent Insertions 1. ( Restore Blood flow)
Drug Eluting stent , Type 2

1. Sirolimus, taxol or pacitaxel
2. Drug coated stent 36.07 Insertion of drug- eluting coronary artery stent(s)
3. insertion of drug eluting peripheral vessel stent
To code: Angioplasty 1st, additional code for the stent insertion

Coding Stent Insertions 2.
Conventional stents, Type 1

1. 39.90 Insertion of non- drug eluting peripheral vessel stents(s)
2.stents codes to 36.06 Insertion of non drug eluting coronary artery stent(s)

Coding Stent Insertions 3. Vessels treated

1. additional codes are used for the number of vessels treated (00.40-00.43) AND The number of stents inserted(00.45/00.48), if multiple stents are inserted.
So, you must code the Procedure on the stent, Insertion(#) of stents( this may be one or more), and the type (1 or 2) stent.
Therefore, you must code at least 3 items for the stent, and of course, the ICD-9 code that after study
2. If a vessel bifurcation was done you may list this once
00.44 Procedure on vessel bifurcation along with the codes listed above.

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