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ICD-10-CM & ICD-10-PCS CODING

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ICD-10-CM: Diagnosis Coding

Chapter 19

• Injury, poisoning and certain other consequences of external causes

– Includes codes beginning with S00 through codes beginning with T88

– Examples of codes in Chapter 19 include:

• Fractures

• Nerve, blood vessel, superficial, muscle, or tendon injuries

• Open wounds

Chapter 19 Guidelines

Most categories in chapter 19 have a 7th character requirement for each applicable code. This requirement will describe the type of encounter. • A: Initial Encounter

– Used while the patient is receiving active treatment for the condition.

– Examples of “active treatment”: surgical treatment, emergency department encounter, and evaluation & treatment by a new physician.

• D: Subsequent Encounter • S: Sequela

**Categories for traumatic fractures have a separate set of 7th character values.

Injuries

• When coding injuries, assign separate codes for each injury unless a combination code is provided, in which case the combination code is assigned. – Traumatic injury codes (S00-T14.9) are

not to be used for normal, healing surgical wounds or to identify complications of surgical wounds.

• The code for the most serious injury, as determined by the provider and the focus of treatment, is sequenced first.

Superficial Injuries

• Superficial injuries such as abrasions or contusions are not coded when associated with more severe injuries of the same site.

Nerves & Blood Vessels

• When a primary injury results in minor damage to peripheral nerves or blood vessels, the primary injury is sequenced first with additional code(s) for injuries to nerves and spinal cord (such as category S04), and/or injury to blood vessels (such as category S15).

• When the primary injury is to the blood vessels or nerves, that injury should be sequenced first.

Traumatic Fractures

• Displaced and nondisplaced are new terms that have been added in ICD-10.

– A fracture not indicated whether displaced or not displaced should be coded to displaced.

• A fracture not indicated as open or closed should be coded to closed.

• Be on the lookout for new classifications and types of fractures in ICD-10 codes:

– Gustilo Classification

– Salter-Harris Type

– Barton’s, Colle’s, Smith, etc.

Fracture: Encounter Type

• Initial Encounter for Fracture (Receiving active treatment) – Examples of active treatment: surgical treatment,

emergency department encounter, and evaluation and treatment by a new physician.

– The appropriate 7th character for initial encounter should also be assigned for a patient who delayed seeking treatment for the fracture or nonunion.

• Subsequent Encounter for Fracture (Routine care during recovery)

– With Routine Healing

– With Delayed Healing

– With Nonunion

– With Malunion

• Sequela (Indicates a late effect of the fracture)

Multiple Fractures

• Multiple fractures are sequenced in accordance with the severity of the fracture.

LET’S PRACTICE Diagnosis Coding!

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Scenario #4 SEE PRINTOUT AND

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Scenario #6 SEE PRINTOUT AND

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Scenario #7 SEE PRINTOUT AND

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Scenario #8 SEE PRINTOUT AND

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ICD-10-CM: Question and

Answer Session

ICD-10-PCD: Procedure Coding

Procedure Sections

• Medical and Surgical – Drainage, Repair

• Placement – Packing, Immobilization, Compression,

Dressing

• Administration – Transfusion, Irrigation

• Extracorporeal Assistance and Performance – Restoration

Medical and Surgical Section

• Includes 31 root operations

– Be sure to keep the definitions of these root operations handy. Look for them at the front of your ICD-10-PCS codebook.

• Procedure codes from this section will always have a first character of…

… 0

Medical and Surgical Section

• Drainage

– Taking or letting out fluids and/or gases from a body part.

– Example: Percutaneous chest tube placement for right pneumothorax

• 0W9930Z

Medical and Surgical Section

• Repair

– Restoring, to the extent possible, a body part to its normal anatomic structure and function.

– Example: Bilateral Inguinal Open Herniorrhaphy

• 0YQA0ZZ

• Remember that if MESH is used during a hernia repair it will be considered a different root operation

Placement Section

• Includes 7 root operations.

– The root operations represent procedures for putting a device in or on a body region for the purpose of protection, immobilization, stretching, compression, or packing.

• Procedure codes from this section will always have a first character of…

… 2

Placement Section

• Packing

– Putting material in a body region or orifice.

– Example: Packing of abdominal wall wound

• 2W43X5Z

Placement Section

• Immobilization

– Limiting or preventing motion of an external body region

– Example: Application of cast to right wrist

• 2W3CX2Z

Placement Section

• Compression

– Putting pressure on a body region

– Example: Placement of intermittent pneumatic compression device, covering right lower leg

• 2W1LX7Z

Placement Section

• Dressing

– Putting material on a body region for protection

– Example: Sterile dressing placement to wound of the chest wall

• 2W24X4Z

Administration Section

• Includes 3 root operations.

– The root operations represent procedures for putting in or on a therapeutic, prophylactic, protective, diagnostic, nutritional, or physiological substance.

• Procedure codes from this section will always have a first character of…

… 3

Administration Section

• Transfusion

– Putting in blood or blood products

– Example: Bone marrow transplant using donor marrow from identical twin, central vein infusion

• 30243G1

Administration Section

• Irrigation

– Putting in or on a cleansing substance

– Example: Peritoneal dialysis via indwelling catheter

• 3E1M392

Extracorporeal Assistance and Performance Section

• Includes 3 root operations – The root operations represent

procedures that use equipment outside the body to assist or perform a physiological function.

– Example: Mechanical ventilation for greater than 96 consecutive hours. • 5A1955Z

• Remember that there are now three time classifications for mechanical ventilation (<24 hours, 24-96 hours, >96 hours)

Extracorporeal Assistance and Performance Section

• Restoration

– Returning, or attempting to return, a physiological function to its natural state by extracorporeal means

– *This root operation includes only one procedure code.

LET’S PRACTICE Procedure Coding!

Scenario #1 SEE PRINTOUT AND

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Scenario #2 SEE PRINTOUT AND

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Scenario #3 SEE PRINTOUT AND

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Scenario #4 SEE PRINTOUT AND

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Scenario #5 SEE PRINTOUT AND

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Scenario #6 SEE PRINTOUT AND

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Scenario #7 SEE PRINTOUT AND

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Scenario #8 SEE PRINTOUT AND

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Scenario #9 SEE PRINTOUT AND

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ICD-10-PCS: Question and

Answer Session