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Coding Ch 2

Terms in this set (48)

ICD-9-CM Volume 3: Procedures
ICD-9-CM classifies procedures in Volume 3
Includes Alphabetic Index and Tabular List
Same format as Volumes 1 and 2
ICD-9-CM procedures used for the coding of inpatient hospital procedures
Volume 3: Procedures (continued
Hospital inpatient procedures coded in range of procedure codes in categories 00-86.
Chapter 16 codes (87-99) may be used selectively for inpatient procedure coding according to hospital or facility coding policy.
Volume 3: Procedures (continued) b
Hospital outpatient departments, physicians' offices and other ambulatory care facilities use CPT-4 and HCPCS codes for procedures
Tabular List
17 chapters in Volume 3
16 chapters describe operations on specific body systems (codes 00-86)
One chapter includes miscellaneous diagnostic and therapeutic procedures (codes 87-99)
Tabular List (continued) Format
Format
Numeric codes only
3- or 4-digit codes
2 digits followed by a decimal point and one or two additional digits
3rd or 4th digits provide further information about the site, procedure, or diagnosis
Alphabetic Index
Listing of procedures, studies, tests, operations, therapies, and so on
Entries in the Alphabetic Index are more comprehensive than terms listed in the Tabular List
Trust the Alphabetic Index
Main Terms
Terms listed in boldface type
Identify the type of procedure performed with subterms indented in alphabetic order
Main terms can include
Titles of operations
Procedure names
Nouns
Verbs
Main terms for procedures indicate an action performed, not a diagnosis or reason for the procedure
Subterms
Subterms describe essential differences in the site, diagnosis, or surgical technique
Subterms may have subterms beneath
Verify all codes in the Tabular List—do not skip this step!
Connecting Words
Subterms are used to reflect an instruction or an associated procedure
Subterms may begin with the words "as," "by," or "with"
Alphabetic subterms follow the connecting terms
Eponyms
Surgical procedures may be identified by eponyms, or names for their originators
May be indexed three ways:
Under the eponym
Under the main term "operation" or "procedure"
Under a main term or subterm describing the operation in terms of the action performed
Conventions Used in ICD-9-CM Volume 3
Code also
The phrase "code also" reminds the coder that additional procedure(s) must be coded when they are performed in addition to primary procedure
May reflect individual components of an operation or procedures performed together
May describe special adjunctive procedures or equipment
Conventions Used in Volume 3 (continued)
Omit code
The phrase "omit code" is found only in volume 3 in both Alphabetic Index and Tabular List
This instruction indicates that no code is assigned, usually for exploratory part of procedure, operative approach, typical lysis of adhesions, or the closure of the procedure
Conventions Used in Volume 3 (continued)
Omit code for the operative approach
When a definitive procedure (therapeutic or diagnostic) is performed, the operative approach is considered part of the procedure and is not coded
Coder knowledge of operative techniques is essential
If only an exploratory procedure is performed, the operative approach is used to describe it
Endoscopic Procedures
"Open" = Open procedures are those that require an incision
"Endoscopic" = A less invasive procedure may be performed with a scope through tiny incisions into a cavity or joint and uses videoscopic guidance
Endoscopic Procedures (continued) b
If an endoscopic procedure is performed as the approach so that a more definitive procedure can be performed, the endoscopic portion is not coded as it is the "approach."
Endoscopic Procedures (continued) c
If an endoscopic procedure is unsuccessful, the surgeon may complete the procedure through an "open" approach.
If this is the case, only the "open" procedure is coded.
Diagnosis code V64 category explains the "conversion" from endoscopic to open.
Endoscopic Procedures (continued d
Main term "endoscopy" or the more specific term describing the procedure may be used for the Alphabetic Index
Specific procedure codes exist to describe various endoscopic procedures
Endoscopic Procedures (continued) e
If the endoscope is passed through more than one body cavity, the code for the endoscopy should identify the most distant site only
Slanted brackets [ ]
Slanted brackets found in the Alphabetic Index or in the Tabular List indicate that two codes for closely related procedures are required
This convention means both codes must be used and sequenced as listed
Aborted Surgery or Procedure
When a procedure was started but not completed, code the procedure to the extent it was performed
Coding rule = "Code as far as it goes"
Cavity entered = code exploratory procedure
Incision made = code incision only
No procedure = add V64 diagnosis code for the reason the procedure was not completed
Incomplete Procedures
When a planned procedure is started but not completed, code to the following principles:
If cavity/space entered, code to exploration of site
If endoscopic approach is used but no definitive procedure performed, code the endoscopy only
If only an incision made, code to incision of site
When the procedure does not involve an incision, no procedure code is assigned
Failed Procedures
Some procedures are considered to have failed if the procedure did not achieve the desired outcome or result
This does not influence code assigned
The procedure performed is the procedure coded
Biopsy and Surgery
If a biopsy is performed and is followed by a more extensive surgery during the same operative episode, code the surgical procedure that is the more extensive surgery first, followed by the biopsy code
An "open" biopsy requires an incision—the open biopsy code includes the incision
Closed Biopsy Procedure
A closed biopsy is performed percutaneously, endoscopically, or through the use of a needle
If a needle or percutaneous biopsy is performed via an open procedure, code both the open procedure and the needle biopsy
Endoscopic Biopsies
When ICD-9-CM provides one code to identify both the biopsy and the endoscopy, use this one code
When ICD-9-CM does not provide a code to identify both the biopsy and the endoscopy, assign two codes, listing first the endoscopy code
Bilateral Procedures
ICD-9-CM may provide a single code to identify that a bilateral procedure was performed (A bilateral procedure code is used only once)
However, when ICD-9-CM does not provide a code for a "bilateral" procedure, the code for the procedure is listed twice
Basic Steps for Procedure Coding
Identify all main terms included in the procedural statement
Locate each main term in the Alphabetic Index
Refer to any subterms indented under the main term
Basic Steps for Procedure Coding (continued)
Follow cross-reference instructions if the needed code is not located under the first main entry
Verify the code selected from the Index in the Tabular List—do not skip this step!
Basic Steps for Procedure Coding (continued) b
Read and be guided by all instructional terms
Continue coding until all procedures are identified
When the same procedure is performed bilaterally and ICD-9-CM does not identify the code as a bilateral procedure, assign the code for the procedure twice
Coding Guidelines
Each healthcare facility should specify in its coding policies what procedures will be assigned codes.
Some healthcare facilities do not assign codes to many diagnostic and nonsurgical procedures.
Introduction to ICD-10-PCS
Inpatient procedure coding replacing Volume 3 of ICD-9-CM
ICD-10-PCS is unique to United States
Developed by 3M Health Information Systems under contract with CMS
Initially released in 1998 with updates the following years
ICD-10-PCS
Designed and developed to meet healthcare needs for a procedure code system
Codes constructed from flexible code components (values) using tables; each individual number of letter is known as a value
Codes are alphanumeric
All codes are seven characters long
ICD-10-PCS, Seven Characters, Alphanumeric
1 - section of ICD-10-PCS
2 - body system
3 - root operation
4 - body part
5 - approach
6 - device
7 - qualifier
ICD-10-PCS, Seven Characters, Alphanumeric
Each of the 7 characters have a defined meaning
Character 1: Section - first character determines the broad category or section where the code is located. In the first section, Medical and Surgical, all begin with 0 or zero
Character 2: Body System - defines the body system which is the general physiological system or anatomic region involved
ICD-10-PCS, Seven Characters, Alphanumeric (cont)
Each of the 7 characters have a defined meaning
Character 3: Root Operation - the objective of the procedure being performed
Character 4: Body Part - the body part of specific anatomical site where the procedure is performed
ICD-10-PCS, Seven Characters, Alphanumeric (cont) b
Each of the 7 characters have a defined meaning
Character 5: Approach - the technique used to reach the operative site, 7 approaches defined
Character 6: Device - depending on the procedure there may or may not be a device left in place at the end of the procedure
Character 7: Qualifier - defined for a particular code, an additional attribute of the procedure
ICD-10-PCS
ICD-10-PCS is composed of 16 section, represented by numbers 0 through 9, letters B through D and F through H
16 sections contained within three main sections:
Medical and Surgical section
Medical and Surgical related section
Ancillary section
ICD-10-PCS b
First section, Medical and Surgical section, contains the majority of procedures typically performed in an inpatient setting.
All procedures begin with the section value of 0 (zero)
ICD-10-PCS c
Second section, Medical and Surgical-related section, include procedures such as
Obstetrics, Placement, Administration, Measurement and Monitoring, Extracorporeal Assistance and Performance, Extracorporeal Therapies, Osteopathic, Other procedures, and Chiropractic
All procedures begin with the section value of 1 through 9 (numbers)
ICD-10-PCS d
Third section, Ancillary section, include procedures such as
Imaging, Nuclear Medicine, Radiation Oncology, Physical Rehabilitation and Diagnostic Audiology, Mental Health and Substance Abuse
All procedures begin with the section value of B through D and F through H (letters)
ICD-10-PCS Medical-Surgical Section
First character = Medical Surgical Section (0)
Second character = Body System
31 body systems identified
Some customary body systems have multiple-body system values, for example, circulatory and musculoskeletal have multiple values
Values of 0-9, B, C, D, F, G, H, J, K, L, M, N, P, Q, R, S, T, U, V, W, X, Y, Z
Third character = Root Operations
31 root operations, each representing the specific objectives of the procedure
Nine groups of procedures
ICD-10-PCS Medical-Surgical Section b
Fourth character = Body Part
Represents the specific part of the body system on which surgery is performed; may specify laterality.
Examples, Lower extremities (body system), Left foot (body part)
Fifth character = Approach
Technique used to reach the site of the procedure.
Seven different approaches
Open; Percutaneous; Percutaneous endoscopic; Via Natural or Artificial Opening; Via Natural or Artificial Opening Endoscopic; Via Natural or Artificial Opening Endoscopic with Percutaneous Endoscopic Assistance; and External
ICD-10-PCS Medical-Surgical Section c
Sixth character = Device
Specifies the device that remains after the procedure is completed
Used with certain procedures
Four general types of devices: Biological or synthetic material that takes the place of all or a portion of a body part; Biological or synthetic material that assists or prevents a physiological function; Therapeutic material; Mechanical or electronic applicance
Seventh character = Qualifier
Used with certain procedures to define an additional attribute
Unique values for individual procedures as needed, for example, identify the destination site in a bypas
Assigning a ICD-10-PCS Code b
Index with provide first 3 or 4 values, for example, 0FT for Resection, Gallbladder
Next step is to access the 0FT code table
The remaining 4 characters are assigned based on the choices given on this table.
The values for each of the 4 characters must be from the same row of the table
Assigning a ICD-10-PCS Code c
Code for laparoscopic cholecystectomy: 0FT44ZZ
Alphabetic Index: Resection, Gallbladder gives coder first 4 characters - 0FT4
Access the code table for first 3 characters - 0FT
Find the row with the 4th character "4-gallbladder"
On that row, select value for 5th character for approach - "4" for percutaneous endoscopic (laparoscopic)
Select value for 6th character - no device (only choice)
Select value for 7th character - no device (only choice)
ICD-10-PCS Snapshot
Tabular List - Table
First Row
First three characters for procedure
Section of ICD-10-PCS, Body System, Body Part
Four column table with varying number of rows
Character 4-body part
Character 5-approach
Character 6-device
Character 7-qualified
ICD-10-PCS Snapshot b
Tabular List - Table
First Row
First three characters for procedure
Section of ICD-10-PCS, Body System, Body Part
Four column table with varying number of rows
Coder cannot make choices from multiple rows
First body part is located with the corresponding approach used for this particular procedure
Coder then must stay on that row to identify the applicable device or qualifier, characters that are not used for all codes
Character "z" is used as placeholder when device & qualified do not apply
Assigning a ICD-10-PCS Code a
Procedure code is constructed by assigning values for each of the characters of the code
Procedural term is referenced in Alphabetic Index
Main terms in the Index can be root operation phrase with subterms (Resection, gallbladder) or a common procedure term (Cholecystectomy
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