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ICD-10-CM and PCS Guidelines
Terms in this set (103)
Department of Health and Human Services (DHHS)
US Federal Governments department that hold both CMS and NCHS (National Center for Health Statistics)
who provides guidelines for coding and reporting using the International Classification of Diseases?
Both CMS and NCHS
what is ICD-10-CM?
A morbidity classification published by the United States for classifying diagnoses and reason for visits in all health care settings.
Based on ICD-10, the statistical classification of diseases published by WHO
the 4 organizations that make up the Cooperating Parties for the ICD-10-CM
the American Hospital Association (AHA)
the American Health Information Management Association (AHIMA), CMS, and NCHS.
What are the guidelines for ICD-10-CM?
A set of rules, instructions provided within the ICD-10-CM itself. The instructions and conventions of the classification take precedence over guidelines.
The guidelines are based on coding and sequencing instructions in the Tabular List and Alphabetic Index of the ICD-10-CM, BUT PROVIDE ADDITIONAL INSTRUCTION.
Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under which act?
The Health Insurance Portability and Accountability Act(HIPAA)
A joint effort between the healthcare provider and the coder is essential to achieve what?
complete and accurate documentation, code assignment, and reporting of diagnoses and procedures.
term used for all settings, including hospital admissions.
used throughout the guidelines to mean physician or any qualified health care practitioner who is legally accountable for establishing the patients diagnosis.
Section I of the ICD-10-CM: Conventions, General Coding Guidelines, and Chapter Specific Guidelines
Includes the structure and conventions of the classification and general guidelines that apply to the entire classification, and chapter-specific guidelines that correspond to the chapters as they are arranged in the classification.
All conventions, general guidelines and chapter specific guidelines are applicable to all healthcare settings unless otherwise indicated.
What do the conventions and instructions of the classification take precedence over?
Section II: Selection of Principal Diagnosis
includes guidelines for selection of principal diagnosis for non-outpatient settings.
The circumstances of inpatient admission always govern the selection of principal diagnosis.
where is the principal diagnosis defined?
in the Uniform Hospital Discharge Data Set (UHDDS), as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care"
where can the inpatient data elements and their definitions be found?
in the July 31, 1985, Federal Register (Vol. 50, No 147), pp. 31038-40.
Since that time the application of the UHDDS definitions has been expanded to include all non-outpatient settings (acute care, short term, long term care, and psychiatric hospitals; home health agencies; rehab facilities; nursing homes, ect) and all levels of hospice services
what takes precedence over the official coding guidelines of the ICD-10-CM while determining principal diagnosis, coding conventions?
the Tabular List and Alphabetic Index
the principal diagnosis
the chiefly responsible reason for the admission of the patient.
Section II, A :Codes for symptoms, signs and ill-defined conditions
Codes for symptoms, signs, and ill-
defined conditions from Chapter 18 are not to be used as principal diagnosis when a related definitive diagnosis has been established
Section II, B : Two or more interrelated conditions, each potentially meeting the definition for principal diagnosis
When there are two or more interrelated conditions (such as diseases in the same ICD-10-CM chapter or manifestations characteristically associated with a certain disease) potentially meeting the definition of principal diagnosis, either condition may be
sequenced first, unless the circumstances of the admission, the therapy provided, the
Tabular List, or the Alphabetic Index indicate otherwise
Section II, C : Two or more diagnoses that equally meet the definition for principal diagnosis
In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first.
Section II, D : Two or more comparative or contrasting conditions
In those rare instances when two or more contrasting or comparative diagnoses are
documented as "either/or" (or similar terminology), they are coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the circumstances of the admission. If no further determination can be made as to which diagnosis should be principal, either diagnosis may be sequenced first
Section II E, a symptom followed by contrasting/comparative diagnoses
Guideline has been deleted effective Oct 1, 2014
Section II F, original treatment plan not carried out
Sequence as the principal diagnosis the condition, which after study occasioned the admission to the hospital, even though treatment may not have been carried out due to unforseen circumstances.
Section II G, complications of surgery and other medical care
When the admission is for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the principal diagnosis. If the complication is classified to the T80-T88 series and the code lacks the necessary specificity in describing the complication, an additional code for the specific complication should be assigned
Section II H, uncertain Diagnosis
This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals
If the diagnosis documented at the time of discharge is qualified as "probable", "suspected", "likely", "questionable", "possible", or "still to be rule out", or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.
Section II I, admission from Observation Unit
1.Admission Following Medical Observation
When a patient is admitted to an observation unit for a medical condition, which either worsens or does not improve, and is subsequently admitted as an inpatient of the same hospital for this same medical condition, the principal diagnosis would be the medical condition which led to the hospital admission.
2.Admission Following Post-Operative Observation: When a patient is admitted to an observation unit to monitor a condition (or complication) that develops following outpatient surgery, and then is subsequently admitted as an inpatient of the same hospital, hospitals should apply the Uniform Hospital Discharge Data Set (UHDDS) definition of principal diagnosis as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.
Section II J, Admission from Outpatient Surgery
When a patient receives surgery in the hospital's outpatient surgery department and is
subsequently admitted for continuing inpatient care at the same hospital, the following
guidelines should be followed in selecting the principal diagnosis for the inpatient admission:
If the reason for the inpatient admission is a complication, assign the complication as the principal diagnosis.
If no complication, or other condition, is documented as the reason for the
inpatient admission, assign the reason for the outpatient surgery as the principal diagnosis.
If the reason for the inpatient admission is another condition unrelated to the surgery, assign the unrelated condition as the principal diagnosis.
Section II K, Admissions/Encounters for Rehabilitation
When the purpose for the admission /encounter is rehabilitation, sequence first the code for the condition for which the service is being performed. For example, for an admission/encounter for rehabilitation for right-sided dominant hemiplegia following a cerebrovascular infarction, report code I69.351, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, as the first-listed or principal diagnosis.
If the condition for which the rehabilitation service is no longer present, report the appropriate after care code as the first-listed or principal diagnosis. For example, if a patient with severe degenerative osteoarthritis of the hip, underwent hip replacement and the current encounter/admission is for rehabilitation, report code Z47.1, Aftercare following joint replacement surgery, as the first-listed or principal diagnosis.
Section III Reporting Additional Diagnoses
*in non-outpatient settings
General Rules for Other (Additional) Diagnoses
For reporting purposes the definition for "other diagnoses" is interpreted as additional conditions that affect patient care in terms of requiring:
clinical evaluation; or
therapeutic treatment; or
diagnostic procedures; or
extended length of hospital stay; or
increased nursing care and/or monitoring
he UHDDS item #11-b defines Other Diagnoses as?
"all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded."
UHDDS definitions apply to inpatients in which settings?
acute care, short-term, long term care, and psychiatric hospital setting.
Since that time the application of the UHDDS definitions has been expanded to include all non-outpatient settings (acute care, short term, long term care, and psychiatric hospitals; home health agencies; rehab facilities; nursing homes; etc.).
The guidelines are to be applied in designating "other diagnoses" when neither the Alphabetic Index nor the Tabular List in ICD-10-CM provide direction. The listing of the diagnoses in the patient record is the responsibility of the attending provider.
Section III A, Previous conditions
If the provider has included a diagnosis in the final diagnostic statement, such as the discharge summary or the face sheet, it should ordinarily be coded. Some providers include in the diagnostic statement resolved conditions or diagnoses and status-post procedures from previous admission that have no bearing on the current stay. Such condtions are not to be reported and are coded only if required by hospital policy.
*However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.
Section III B, abnormal findings
Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the provider indicates their clinical significance. If the findings are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider whether the abnormal findings should be added.
*This differs from the coding practices in the outpatient setting for coding encounters for diagnostic tests that have been interpreted by a provider.
Section III C, uncertain diagnosis
This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals
If the diagnosis documented at the time of discharge is qualified as "probable, suspected, likely, questionable, possible or still to be ruled out" or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.
Section IV- Diagnostic Coding and Reporting Guidelines for Outpatient Services
These coding guidelines for outpatient diagnoses have been approved for use by hospitals/providers in coding and reporting hospital-based outpatient services and provider-based office visits. (this means outpatient settings and physician settings.)
where can information about the use of certain abbreviations, punctuation, symbols, and other conventions used in the ICD-10-CM Tabular List (code numbers and titles) be found?
In Section IA of these guidelines, under "Conventions used in the Tabular List" Information about the correct sequence to use in finding a code is also described in Section I.
"Encounter" & "Visit"
terms can be used interchangeably in describing outpatient service contacts and, therefore, appear together in these guidelines without distinguishing one from the other.
How do coding guidelines for outpatient and provider reporting of diagnoses vary from inpatient diagnoses?
But the conventions and general guidelines apply to all settings.
-The Uniform Hospital Discharge Data Set (UHDDS) definition of principal diagnosis applies only to inpatients in acute, short-term, long-term care, and psychiatric hospitals.
-Coding guidelines for inconclusive diagnoses (probable, suspected, rule out, etc.) were developed for inpatient reporting and do not apply to outpatients.
Section IV A selection of first-listed condition
In the outpatient setting, the term first-listed diagnosis is used in lieu of principal diagnosis.
Section IV A; how to determine the first-listed diagnosis
the coding conventions of ICD-10-CM as well as the general and disease specific guidelines take precedence over the outpatient guidelines.
Diagnoses often are not established at the time of the initial encounter/visit. It may
take two or more visits before the diagnosis is confirmed.
Section IV A; whats the most critical rule involving the beginning of the search for the correct code assignment?
Use the Alphabetic Index, Never begin searching initally in the Tabular List as this will lead to coding errors.
Section IV A: 1. Outpatient Surgery
When a patient presents for outpatient surgery (same day surgery), code the reason for the surgery as the first-listed diagnosis (reason for the encounter), even if the surgery is not performed due to a contraindication.
Section IV A: 2 Observation Stay
When a patient is admitted for observation for a medical condition, assign a code
for the medical condition as the first-listed diagnosis. When a patient presents for outpatient surgery and develops complications requiring admission to observation, code the reason for the surgery as the first reported diagnosis (reason for the encounter), followed by codes for the
complications as secondary diagnoses.
Section IV B. Codes from A00.0 through T88.9, Z00-Z99
The appropriate code(s) from A00.0 through T88.9, Z00-Z99 must be used to identify diagnoses, symptoms, conditions, problems, complaints, or other reasons for the encounter/visit.
Section IV C. Accurate reporting of ICD-10-CM diagnosis codes
For accurate reporting of ICD-10-CM diagnosis codes, the documentation should describe the patients condition, using terminology which includes specific diagnoses as well as symptoms, problems, or reasons for the encounter. There are ICD-10-CM codes to describe all of these
Section IV D codes that describe symptoms and signs
Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established by the provider. Chap 18 of ICD-10-CM, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified (Codes R00-R99) contain many, but not all codes for symptoms.
Section IV E encounters for circumstances other than a disease or injury
ICD-10-CM provides codes to deal with encounters for circumstances other than a disease or injury. The Factors Influencing Health Status and Contact with Health Services codes (Z00-Z99) are provided to deal with occasions when circumstances other than a disease or injury are recorded as diagnosis or problems.
Section IV F Level of Detail in Coding
1. ICD-10-CM codes with 3, 4, 5, 6 or 7 characters
ICD-10-CM is composed of codes with 3,4,5,6,7 characters, Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of fourth, fifth, sixth or seventh characters to provide greater specificity.
Section IV F Level of Detail in Coding
2. Use of full number of characters required for a code
A three-character code is to be used only if it not further subdivided. A code is invalid if it has not been coded to the full number of characters required for that code, including the 7th character, if applicable.
Section IV G: ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit
List first the ICD-10-cm code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions. In some cases the first-listed diagnosis may be a symptom when a diagnosis has not been established by the physician.
Section IV H: Uncertain diagnosis
Do not code diagnoses documented as "probably, suspected, questionable, rule out, or working diagnosis" or other similar terms indicating uncertainty. Rather, code the conditions to the highest degree of certainty for the encounter/visit, such as symptoms, signs, abnormal test results, or other reasons for the visit.
This differs from the coding practices used by short-term, acute care, long-term care and psychiatric hospitals.
Section IV I: Chronic diseases
Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the conditions.
Section IV J: Code all documented conditions that coexist
Code all documented conditions that coexist at the time of the visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist.
However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment
Section IV K: Patients receiving diagnostic services only
For patients receiving diagnostic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses
For encounters for routine laboratory/radiology testing in the absense of any signs, symptoms, or associated diagnosis, assign Z01.89, Encounter for other specified special examinations. If routine testing is performed during the same encounter as a test to evaluate a sign, sumptom, or diagnosis, it is appropriate to assign both the z code and the code describing the reason for the non-routine test.
For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis documented in the interpretation. Do not code related signs and symptoms as additional diagnoses.
Please note: this different from coding practice in the hospital inpatient setting regarding abnormal findings on test results.
Section IV L Patients receiving therapeutic services only
For patients receiving therapeutic services only during a visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses.
The only exception to this rule is that when the primary reason for the admission/encounter is chemotherapy or radiation therapy, the appropriate Z code for the service is listed first, and the diagnosis or problem for which the service is being performed listed second.
Section IV M Patients receiving preoperative evaluations only
For patients receiving preoperative evaluations only, sequence first a code from subcategory Z01.81, Encounter for pre-procedural examinations, to describe the pre-op consultations. Assign a code for the condition to describe the reason for the surgery as an additional diagnosis. Code any findings related to the pre-op evaluation.
Section IV N Ambulatory surgery
For ambulatory sergery, code the diagnosis for which the surgery was performed. If the postoperative diagnosis is known to be different from the preoperative diagnosis at the time the diagnosis is confirmed, select the postoperative diagnosis for coding, since it is the most definitive.
Section IV O Routine outpatient prenatal visits
see section I.C.15. Routine outpatient prenatal visits
Section IV P Encounters for general medical examinations with abnormal findings
the subcategories for encounters for general medical examinations, Z00.0-, provide codes for with and without abnormal findings. Should a general medical examination result in an abnormal finding, the code for general medical examination with abnormal findings should be assigned as the first-listed diagnosis.
An examination with abnormal findings refers to a condition/diagnosis that is newly identified or a change in severity of a chronic condition (such as uncontrolled hypertension, or an acute exacerbation of chronic obstructive pulmonary disease) during a routine physical examination. A secondary code for the abnormal finding should also be coded.
Section IV Q encounters for routine health screenings
See section I.C.21. Facotirs influencing health status and contact with health services, Screening
Appendix I: Present on Admission Reporting Guidelines
These guidelines are to be used as a supplement to the ICD-10-CM Official Guidelines for Coding and Reporting to facilitate the assignment of the Present on Admission (POA) indicator for each diagnosis and external cause of injury code reported on claim forms (UB-04 and 837 Institutional)
Subsequent to the assignment of the ICD-10-CM codes, the POA indicator should then be assigned to those conditions that have been coded.
. Medical record documentation from any provider involved in the care and treatment of the patient may be used to support the determination of whether a condition was present on admission or not
these guidelines are not to be substituted for the providers clinical judgment as to the determination of whether a condition was/was not present on admission
The provider should be queried regarding issues related to the linking of signs/symptoms, timing of test results, and the timing of findings.
CDC website for the detailed list of ICD-10-CM codes that do not require the use of a POA indicator
The conditions on this exempt list represent categories and/or codes for circumstances regarding the healthcare encounter or factors influencing health status that do not represent a current disease or injury or are always present on admission.
General Reporting Requirements
All claims involving inpatient admissions to general acute care hospitals or other facilities that are subject to a law or regulation mandating collection of present on admission information.
Present on admission is defined as?
Present at the time the order of inpatient admission occurs -- conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission.
POA indicator is assigned to what diagnoses?
Principal and secondary diagnoses (as defined in Section II of the official Guidelines for Coding and Reporting) and the external cause of injury codes
Issues related to inconsistent, missing, conflicting or unclear documentation must be resolved by whom?
If a condition would not be coded and reported based on UHDDS definitions and current official coding guidelines, what happens?
Then the POA indicator would not be reported.
Unreported/Not used - (exempt from POA reporting)
Y= present at the time of inpatient admission
N= not present at the time of inpatient admission
U= documentation is insufficient to determine if condition is present on admission
W= provider is unable to clinically determine whether condition was present on admission or not
Timeframe for POA Identification and Documentation
There is no required timeframe a provider must identify or document a condition to be present on admission. In some situations it may not be possible for a provider to make a definitive diagnosis, or a condition may not be recognized or reported by the patient for a period of time after admission. This does not mean that the condition was not present on admission. Determination of whether the condition was present or not will be based on the applicable POA guideline, or on the providers best clinical judgment.
It is appropriate to query the provider for clarification if at the time of code assignment the doc is unclear as to whether a condition was POA or not.
Condition is on the "Exempt from Reporting" list
Leave the "present on admission" field blank if the condition is on the list of ICD-10-CM codes for which this field is not applicable. This is the only circumstance in which the field may be left blank.
POA Explicitly Documented
Assign Y for any condition the provider explicitly documents as being present on admission.
Assign N for any condition the provider explicitly documents as not present at the time of admission.
Conditions diagnosed prior to inpatient admission
Assign Y for conditions that were diagnosed prior to admission (example: hypertension, diabetes mellitus, asthma)
Conditions diagnosed during the admission but clearly present before admission
Assign Y for conditions diagnosed during the admission that were clearly present but not diagnosed until after admission occurred.
Diagnoses subsequently confirmed after admission are considered present on admission if at the time of admission they are documented as suspected, possible, rule out, differential diagnosis, or constitute an underlying cause of a symptom that is present at the time of admission.
Conditions develops during outpatient encounter prior to inpatient admission
Assign Y for any condition that develops during an outpatient encounter prior to a written order for inpatient admission.
Documentation does not indicate whether condition was present on admission
Assign U when the medical record documentation is unclear as to whether the condition was present on admission. U, should not be routinely assigned and used only in very limited circumstances. Coders are encouraged to query the providers when the documentation is unclear.
Documentation states that is cannot be determined whether the condition was or was not present on admission
Assign W when the medical record documentation indicates that it cannot be clinically determined whether or not the condition was present on admission.
Chronic condition with acute exacerbation during admission
If a single code identifies both the chronic condition and the acute exacerbation, see POA guidelines pertaining to codes that contain multiple clinical concepts.
If a single code only identifies the chronic condition and not the acute exacerbation (e.g., acute exacerbation of chronic leukemia), assign Y.
Conditions documented as possible, probable, suspected, or rule out at the time of discharge
If the final diagnosis contains a possible, probably, suspected, or rule out diagnosis, and this diagnosis was based on signs, symptoms or clinical findings suspected at the time of inpatient admission, assign Y.
If the final diagnosis contains a possible, probably, suspected, or rule out diagnosis, and this diagnosis was based on signs, symptoms or clinical findings that were NOT present on admission, assign N
conditions documented as impending or threatened at the time of discharge
If the final diagnosis contains an impending or threatened diagnosis, and this diagnosis is based on symptoms or clinical findings that were present on admission, assign Y
If the final diagnosis contains an impending or threatened diagnosis, and this diagnosis is based on symptoms or clinical findings that were NOT present on admission, assign N
Acute and Chronic Conditions
Assign Y for acute conditions that are present at time of admission and N for acute conditions that are not present at time of admission
Assign Y for chronic conditions, even though the condition may not be diagnosed until after admission
If a single code identifies both an acute and chronic condition, see the POA guidelines for codes that contain multiple clinical concepts
Codes that Contain Multiple Clinical Concepts
Assign N if at least one of the clinical concepts included in the code was not present on admission (e.g., COPD with acute exacerbation and the exacerbation was not present on admission; gastric ulcer that does not start bleeding until after admission; asthma patient develops status asthmaticus after admission)
Assign Y if all of the clinical concepts included in the code were present on admission (e.g., duodenal ulcer that perforates prior to admission)
For infection codes that include the casual organism, assign Y if the infection (or signs of the infection) were present on admission, even though the culture results may not be known until after admission (e.g., patient is admitted with pneumonia and the provider documents Pseudomonas as the casual organism a few days later)
Same Diagnosis Code for Two or More Conditions
When the same ICD-10-CM diagnosis code applies to two or more conditions during the same encounter (e.g., two separate conditions classified to the same ICD-10-CM diagnosis code): Assign Y if all conditions represented by the single ICD-10-CM code were present on admission (e.g., bilateral unspecified age-related cataracts)
Assign N if any of the conditions represented by the single ICD-10-CM code was not present on admission (e.g., traumatic secondary and recurrent hemorrhage and seroma is assigned to a single code T79.2, but only one of the conditions was present on admission.)
Whether or not the patient delivers during the current hospitalization does not affect assignment of the POA indicator. The determining factor for POA assignment is whether the pregnancy complication or obstetrical condition described by the code was present at the time of admission or not.
If the pregnancy complication or obstetrical condition was present on admission (e.g., patient admitted in preterm labor), assign Y
If the pregnancy complication or obstetrical condition was not present on admission (e.g., 2nd degree laceration during delivery, postpartum hemorrhage that occured during current hospitalization, fetal distress develops after admission). assign N
If the obstetrical code includes more than one diagnosis and any of the diagnoses identified by the code were not present on admission assign N (e.g., Category O11, Pre-existing hypertention with pre-eclampsia)
Newborns are not considered to be admitted until after birth. Therefore, any condition present at birth or that developed in utero is considered present at admission and should be assigned Y. This includes conditions that occur during delivery (injury during delivery, meconium aspiration, exposure to streptococcus B in the vaginal canal)
Congenital conditions and anomalies
Assign Y for congenital conditions and anomalies except for categories Q00-Q99, Congenital anomalies, which are on the exempt list. Congenital conditions are always considered present on admission.
External cause of injury codes
Assign Y for any external cause code representing an external cause of morbidity that occurred prior to inpatient admission (patient fell out of bed at home, patient fell out of bed in emergency room prior to admission)
Assign N for any external cause code representing an external cause of morbidity that occurred during inpatient hospitalization (patient fell out of hospital bed during hospital stay, patient experienced an adverse reaction to a medication administered after inpatient admission)
who provides the guidelines for coding and reporting using ICD-10-PCS ?
The Centers for Medicare & Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), two departments within the U.S. Federal Government's Department of Health and Human Services (DHHS)
who are the 4 organizations that make uo the Cooperating Parties for the ICD-10-PCS?
the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS.
Adherence to the guidelines when assigning ICD-10-PCS procedure codes is required under which act?
The Health Insurance Portability and Accountability Act (HIPAA)
Under which settings were the procedure codes under HIPAA adopted?
for hospital inpatient healthcare settings.
The parts of the ICD-10-PCS Guidelines are listed:
Medical and Surgical Section Guidelines
2. Body System
3. Root Operation
4. Body Part
Obstetrics Section Guidelines
ICD-10-PCS codes are composed of how many characters? A1
seven characters. Each character is an axis of classification that specifies information about the procedure performed. Within a defined code range, a character specifies the same type of information in that axis of classification
One of 34 possible values can be assigned to each axis of classificationin the seven-character code: they are the numbers 0 through 9 and the alphabet (except I and O
because they are easily confused with the numbers 1 and 0).The number of unique values used in an axis of classification differs as needed
Where the fifth axis of classification specifies the approach, seven different approach values are currently used to specify the approach
The valid values for an axis of classification
can be added to as needed.
If a significantly distinct type of device is used in a new procedure, a new device value can be added to the system.
As with words in their context, the meaning of any single value is a combination of its axis of classification and any preceding values on which it may be dependent
The meaning of a body part value in the Medical and Surgical section is always dependent on the body system value. The body part value 0 in the Central Nervous body system specifies Brain and the body part value 0 in the Peripheral Nervous body system
specifies Cervical Plexus
As the system is expanded to become increasingly detailed, over time more values will depend on preceding values for their meaning.
Example: In the Lower Joints body system, the device value 3 in the root operation Insertion specifies Infusion Device and the device value 3 in the root operation Replacement specifies Ceramic Synthetic Substitute
The purpose of the alphabetic index is to locate the appropriate table that contains all
information necessary to construct a procedure code. The PCS Tables should always be consulted to find the most appropriate valid code.
It is not required to consult the index first before proceeding to the tables to complete the code. A valid code may be chosen directly from the tables.
All seven characters must be specified to be a valid code. If the documentation is incomplete for coding purposes, the physician should be queried for the necessary information.
Within a PCS table, valid codes include all combinations of choices in characters 4 through 7 contained in the same row of the table. In the example below, 0JHT3VZ is a valid code, and 0JHW3VZ is not a valid code.
"And", when used to code description, means "and/or." Example: Lower Arm and Wrist Muscle means lower arm and/or wrist muscle.
Many of the terms used to construct PCS codes are defined within the system. It is the coder's responsibility to determine what the documentation in the medical record equates to in the PCS definitions. The physician is not expected to use the terms used in PCS code descriptions, nor is the coder required to query the physician when the correlation between the documentation and the defined PCS terms is clear.
example: when the physician documents "partial resection" the coder can independently correlate "partial resection" to the root operation Excision without querying the physician for clarification
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