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Copyright Health Information Associates, Inc. 1 COMMON ICD10 CODING ERRORS POST IMPLEMENTATION Virginia Health Information Management Association Annual Meeting April, 2016 ICD 10 Education Series 1 TIME SENSITIVE INFORMATION This information contained in this presentation is valid as of the time of this presentation, April 2016. The creator of this presentation is not responsible for the viewer’s lack of research for updated advice following this presentation. Be sure to check subsequent official guidance in these areas following the presentation. Official coding advice can change rapidly. 2 © Health Information Associates, Inc OBJECTIVES Review common ICD10 errors made by coders ICD10CM ICD10PCS Discussion of official guidance regarding problem areas Utilization of documentation examples What to do while you await official advice 3 © Health Information Associates, Inc

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    COMMONICD10CODINGERRORS POSTIMPLEMENTATION

    VirginiaHealthInformationManagementAssociationAnnualMeeting

    April,2016ICD10EducationSeries

    1

    TIMESENSITIVEINFORMATION

    Thisinformationcontainedinthispresentationisvalidasofthetimeofthispresentation,April2016.Thecreatorofthispresentationisnotresponsiblefortheviewerslackofresearchforupdatedadvicefollowingthispresentation.Besuretochecksubsequentofficialguidanceintheseareasfollowingthepresentation.Officialcodingadvicecanchangerapidly.

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    OBJECTIVES

    ReviewcommonICD10errorsmadebycodersICD10CMICD10PCS

    DiscussionofofficialguidanceregardingproblemareasUtilizationofdocumentationexamplesWhattodowhileyouawaitofficialadvice

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    ICD10CM

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    Excludes1Notes

    IftwoICD10CMdiagnosesarenotrelatedtoeachother,buttheyexistatthesametime,theymaybothbereportedtogetherdespiteanExcludes1noteaccordingtotheCDC.http://www.cdc.gov/nchs/data/icd/Interim_advice_updated_final.pdfOriginalexcludes1advicestatedthatthetwocodescouldNEVERbereportedtogetherI25.10forCADofnativevesselswithoutanginaI25.810forCADofbypassgraftswithoutangina

    HasExcludes1noteforI25.10CADofnativecoronaryarteryw/oanginaHIAreceivedAHACCletterthatstatestocodebothifpresent

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    Excludes1Notes

    Patientadmittedwithpartialbowelobstructionalsohasahiatalhernia.Thereisanexcludes1noteatK56thatstatesintestinalobstructionwithhernia(K40K46)isnotcodedtoK56.60,smallbowelobstructionWhatiftheintestinalobstructionisunrelatedtothehiatalhernia?

    Assignacodeforbothcodesandsequencethereasonforadmissionasprincipal.

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    COPDExacerbationwithPneumonia

    TheissuehereisthatthereisacodeJ44.0whichisassignedforCOPDwithacutelowerrespiratoryinfection.HIAwrotetoAHAtoaskifpneumoniawasconsideredanacutelowerrespiratoryinfectionforcodingpurposesandtheystatedyes.Nosequencingadvicewasgiven.ManyvendorsarestatingthatcodeJ44.0MUSTbesequencedfirstwhenthepneumoniaisdocumentedinthesamerecord.TheyarebasingthisontheindexentryofDisease,Lung,Obstructive,with,acute,lowerrespiratoryinfectionandtheuseadditionalcodetoidentifytheinfectionnoteatJ44.0.HIAhassentthisbackforsequencingadvice.SenttoAHAforadvice.2/9/16Ref.#50013139.1215senttoEABforadvice.Awaitingdecisionregardingpropersequencing.

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    COPDExacerbationwithPneumonia

    Recommendcodingasprincipaldiagnosis,theconditionfound,afterstudy,tobethechiefreasonforadmissiontothehospital.ExampleA:PatientadmittedwithCOPDandpneumonia.PlacedonIVLevaquinforpneumonia.ContinuewithbronchodilatorsandinhaledsteroidsforCOPD.Whatisyourprincipal?

    ExampleB:PatientadmittedwithCOPDandpneumonia.PlacedonIVSoluMedrolaspatientwasnotrespondingtobronchodilators.Patientalsoplacedonoxygen.IVLevaquinwasprescribedforthepneumonia.Whatisyourprincipal?

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    COPDExacerbationwithPneumonia

    J18.9,PneumoniaasPDXJ44.0,COPDwithacuteupperrespiratoryinfection

    DRG194,SimplepneumoniaandpleurisywithCCRelativeWeight:0.9695

    J44.0,COPDwithacuteupperrespiratoryinfectionasPDXJ18.9,Pneumonia(MCC)

    DRG190,COPDwithMCCRelativeWeight:1.1578

    WhatifJ44.1,acuteexacerbationofCOPDisdocumented?

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    PeriprostheticFractures

    Theprimaryissuehereiswhatisconsideredaperiprostheticfracture?Consideracasewhereapatientfallsandfracturestheleftshaftofthefemurintheareaaroundtheprosthesis.Doesthecoderassign:

    T84.041AperiprostheticfxMSDRG4821.62ORS72.302AforthetraumaticfxMSDRG4821.62ORT84.041AandS72.302AMSDRG4802.99 ORS72.302AandT84.041AMSDRG4811.97

    Clientsarguethatatraumaticfx,eveninapatientwithaprosthesis,isnotacomplicationunlesstheMDstatesit.SenttoAHAforadvice.

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    PeriprostheticFractures

    VALID?MechanicalcomplicationofprostheticjointsCodingClinic,FourthQuarter2005Page:91to93Effectivewithdischarges:October1,2005 CAUTION:OLD

    Statesthatalthoughthecodesareinthecomplicationsectiontheydonotindicatepoormedicalcareorfaultydevices.Afractureofaprostheticjointduetotraumashouldbecodedtoatraumaticfracturecodewithanappropriatestatuscodeforjointreplacedstatus.Fracturesaroundjointreplacementprosthesesarecalled periprosthetic fractures.Thesefracturescanoccurwithminimaltrauma(especiallywithapreviouslylooseprosthesisorosteoporoticbone).Eventually,wearingofthearticularbearingsurfacescanoccur.Thisproblemmayleadto periprosthetic inflammationgranulomaformation,boneresorption,andimplantloosening.

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    PeriprostheticFractures

    IsentasimilarquestiontoAHAexactlyoneyearago.Ireceivedaletter3/2013lettingmeknowitwasbeingreferredtotheEditorialAdvisoryBoard.Ifinallyreceivedmyresponsethisweek.Inmyexample,thepatientfellandtheoperativereportsaidshehadaperiprostheticfemurfracturewithloosefemoralcomponent. AHAsaidtheadvicepublishedinCC4thQtr.2005pgs.9193isnotvalid.Ishouldcode996.44(periprostheticfx),996.41(mechanicallooseningofprostheticjoint),and820821(traumatichipfracture).

    TheywentontosayCC2ndQtr.2013pg.5,statesthatanadditionalcodeshouldbeassignedwithcategories996999toidentifythespecificcomplication, whenitprovidesinformationaboutthenatureofthecomplication. TheNCHShasagreedtoconsiderapossibleICD10CMCoordinationandMaintenancecommitteeproposaltomodifytheICD10CMsothataperiprostheticfractureisnotclassifiedasacomplication.

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    RehabilitationUnitPrincipalDiagnosis

    NoequivalenttooldICD9CMV57codesAssignthereasonforadmissiontorehabasPDXMSDRGassignmentsoutofDRGS985/986withsomedenials86yearoldwithmobilityandselfcaredysfunctionafterhospitalizationforCHFexacerbation.Thepatienthasahistoryofmultiplespinalfusionandlaminectomyprocedures.Thepatientcontinuestorequireinpatientrehabilitationforfunctionalupgradereturntocommunityliving.HerequiresPTandOTforatleast3hoursdaily5daysaweektoaddresshisdebility,focusingonimprovingmobilityambulationandADLs.Patientsfunctionalgoalsaretogethisstrengthbackafterhislastfewmonthsofsurgeriesandillnessesandreturnhome.WhatisthePDXfortheUB04?Debility?CHF?

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    RehabilitationUnitPrincipalDiagnosis

    CodingClinic4Q2013page129PatienttransferredtorehabunitforOTandPTfollowingprolongedstayataLTCHwherepatientwasweanedfrommechanicalvent.Patientreceivedrehabduetodeconditionanddebility.Theproviderdocumentedtatthepatientpresentedwithcomplexmedicalproblemsthatincludedchronichypoxicrespiratoryfailure,COPD,diabeticneuropathyandobesity.AssignJ96.11,ChronicrespiratoryfailurewithhypoxiaasPDX.Thisistheunderlyingreasonforanddeconditioningandtheunderlyingreasoniscodedastheprincipaldiagnosis.

    CodingClinic4Q2012pages9098WhenapatientisadmittedtoLTCnursinghomefordeconditioninghowisthiscoded?Answeriscodethesymptomsofdeconditioningsuchasgaitdisturbance,weakness,etc.ThisseemstoconflictwithCodingClinic4Q2013page129above.

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    RehabilitationUnitPrincipalDiagnosis

    WhenaninjuryisreasonforrehabilitationCoding Clinic4Q2013pages9098and128129IfapatientistransferredtoLTC(orrehab)followinghospitalstayfortreatmentoffractureorinjurysuchaspelvicandclavicularfracture,assigntheS32.9XXD with7th characterofD,subsequentencounter.

    ReviewCodingClinic3Q2015page36DiscussesIRFPAIvsUB04coding

    ReviewCodingClinic1Q2015page21Rehabilitationservicesarenotconsideredactivetreatmentandtheencountershouldbereportedwiththeappropriate7thcharacterforsubsequentencounter.

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    RehabilitationUnitPrincipalDiagnosis

    OCGIIPDXK.Admissions/EncountersforRehabilitationWhenthepurposefortheadmission/encounterisrehabilitation,sequencefirstthecodefortheconditionforwhichtheserviceisbeingperformed.Forexample,foranadmission/encounterforrehabilitationforrightsideddominanthemiplegiafollowingacerebrovascularinfarction,reportcodeI69.351,Hemiplegiaandhemiparesisfollowingcerebralinfarctionaffectingrightdominantside,asthefirstlistedorprincipaldiagnosis.Iftheconditionforwhichtherehabilitationserviceisnolongerpresent,reporttheappropriateaftercarecodeasthefirstlistedorprincipaldiagnosis.Forexample,ifapatientwithseveredegenerativeosteoarthritisofthehip,underwenthipreplacementandthecurrentencounter/admissionisforrehabilitation,reportcodeZ47.1,Aftercarefollowingjointreplacementsurgery,asthefirstlistedorprincipaldiagnosis.SeeSectionI.C.21.c.7,Factorsinfluencinghealthstatesandcontactwithhealthservices,Aftercare. 16

    RehabilitationUnitProcedures

    InsomecasesaddingtherehabilitationICD10PCScodewhenpairedwithadiagnosiscodethatisincludedwithinMDC23willchangeyourDRGto945/946ManydiagnosiscodesassignedforrehabpatientsdonotendupinMDC23.Example,patientadmittedtorehabwithS02119D,Unspecifiedfractureofocciput,subsequentencounterforfracturewithroutinehealing,isincludedinMDC8.AddingaprocedurecodesuchasF0706GZ(TherapeuticExerciseTreatmentofNeurologicalSystem HeadandNeckusingaerobicenduranceandconditioningequipment)wouldnotleadtoDRG945/946.However,assigningZ51.89,EncounterforotherspecifiedaftercareorZ44.9,EncounterforfittingandadjustmentofotherexternalprostheticdeviceswiththisprocedurewillleadtoDRG945/946assignment.

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    RehabilitationProcedureExamples

    F07Z9ZZF PhysicalRehab0Rehabilitation7 MotorTreatment0 NeurologicalSystem HeadandNeck

    6 TherapeuticExerciseG AerobicEnduranceandConditioning

    Z NoQualifier

    F07L0ZZF PhysicalRehab0Rehabilitation7 MotorTreatmentL MusculoskeletalLowerBack/LowerExtremity

    0 ROM&JointMobilityZ NoEquipmentZ NoQualifier

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    SIRSduetoInfectionvs.Sepsis

    Noindexentryforsystemicinflammatoryresponsesyndrome(SIRS)duetoinfection.Sothisdoesnotautomaticallytranslatetosepsis.CodersmustnotassumeSIRSduetoinfectioniscodedtosepsiswithoutquery.

    Clinicalindicatorsmustbemettoquery.Increasedamountsofqueries

    Severesepsisandsepticshockmustbedocumentedinordertoassigncodes.

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    NewSepsisCriteria!

    Newcriteriaisoutforsepsis;TheThirdInternationalConsensusDefinitionsforSepsisandSepticShock(sepsis3)http://www.esicm.org/newsarticle/ARTICLEREVIEWsepsis3DePascale articleswillbepublishedtodayhttp://jama.jamanetwork.com/article.aspx?articleid=2492881 publishedFebruary22,2016http://www.hcpro.com/acdis/details.cfm?content_id=325920NotethatthisisCLINICALcriteria.Nodirectivesforcodinghavebeenreleasedbythecooperatingparties.Lookformoreinformationto

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    NewSepsisCriteria!

    Sepsisisdefinedaslifethreateningorgandysfunctioncausedbyadysregulatedhostresponsetoinfection.Inlayterms,sepsisisalifethreateningconditionthatariseswhenthebodysresponsetoaninfectioninjuresitsowntissuesandorgans.PatientswithsuspectedinfectionwhoarelikelytohaveaprolongedICUstayortodieinthehospitalcanbepromptlyidentifiedatthebedsidewithsignsincludingalterationinmentalstatus,systolicbloodpressure100mmHg,orrespiratoryrate22/min.

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    NewSepsisCriteria!

    Septicshockisasubsetofsepsisinwhichunderlyingcirculatoryandcellular/metabolicabnormalitiesareprofoundenoughtosubstantiallyincreasemortality.Patientswithsepticshockcanbeidentifiedwithaclinicalconstructofsepsiswithpersistinghypotensionrequiringvasopressorsandhavingahighserumlactateleveldespiteadequatevolumeresuscitation.Withthesecriteria,hospitalmortalityisinexcessof40%.HoweverSOFAcriteria(SequentialOrganFailureAssessment)isclinical,andCMScriteriaisqualityoriented.ASOFAscore2reflectsanoverallmortalityriskofapproximately10%inageneralhospitalpopulationwithsuspectedinfection. 22

    NewSepsisCriteriaSOFA

    23

    ObstetricalPrincipalDiagnosis

    Somecodesthatonewouldthinkwouldbeacceptableprincipaldiagnoses,arenot.ExampleSupervisionofPregnancycodes

    O09.523,Supervisionofelderlymultigravida,thirdtrimesterisnotavalidprincipaldiagnosis.DRG998,PDXInvalid.

    InICD9CMthiswascode659.53andassignedtoDRG782,Otherantepartumdiagnoses.Howcanclientsovercomethis?

    Z38.1fornewborndeliveredoutsidehospitalisinCMSeditsasanunacceptableprincipaldiagnosis.

    MayhavetouseZ38.2untilitisfixed

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    ObstetricalPrincipalDiagnosis

    CodersstruggledwithchoosingtheobstetricalPDX.Codersmisinterpretedtheguidelinethatstateswhenadeliveryoccurs,theprincipaldiagnosisshouldcorrespondtothemaincircumstancesorcomplicationofthedelivery.Codersliterallythoughtthecodethatwasrelatedtothedelivery,suchasa2nd degreeperineallacerationMUSTbePDX,eveniftheobstetricspatientwasadmittedwithanotherobstetricalconditionsuchasgestationalhypertension.1Q2016page36clarifiesthatthereasonforadmissionshouldbelistedasPDX,notthediagnosisrelatedtodelivery,unlessthereisnootherconditionresponsibleforadmission. 25 Health Information Associates, Inc.

    ICD10PCS

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    (0)MedicalandSurgicalProcedures

    Thesevencharactersformedicalandsurgicalproceduressectionhavethefollowingmeanings:

    1 2 3 4 5 6 7

    |

    |

    |

    |

    |

    |

    |Section |

    |Root

    Operation||

    Approach ||

    Qualifier

    Body System

    Body Part Device

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    (B)ImagingProcedures

    Thesevencharactersforimaging proceduressectionhavethefollowingmeanings:

    1 2 3 4 5 6 7

    |

    |

    |

    |

    |

    |

    |Section |

    |Root Type |

    |Contrast |

    |Qualifier

    Body System

    Body Part Contrast/ Qualifier

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    BiopsyDiagnosticQualifierX:

    PROBLEM:

    Codersarenotapplyingthe7TH characterXDiagnosticcorrectly

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    BiopsyDiagnosticQualifierX:B3.4a

    BiopsyproceduresarecodedusingtherootoperationsExcision,Extraction,orDrainageandhequalifierDiagnostic.ThequalifierDiagnosticisusedonlyforbiopsies.ColonoscopywithbiopsyoftransversecoloniscodedtorootoperationExcisionandqualifierDiagnostic.

    Ifacolonoscopyisdonetoremoveapolyp,andthepolypissenttopathology,doNOTusequalifierX diagnostic.

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    BiopsywithDefinitiveTreatment:B3.4b

    IfadiagnosticExcision,Extraction,orDrainageprocedure(biopsy)isfollowedbyamoredefinitiveprocedure,suchasDestruction,ExcisionorResectionatthesameproceduresite,boththebiopsyandthemoredefinitivetreatmentarecoded.Biopsyoflesionoftheleftparotidgland,followedbyresectionofentireleftparotidgland.CodesareassignedforboththediagnosticExcisionandResectionofleftparotidgland.

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    Example:ExcisionofRULofLungDuetoCancer

    ApatienthasundergonepreviousCTofthelungwithidentificationofarightupperlobemass,andpatientwasscheduledforsurgerytoremovethemass.Patientisadmittedinpatientandundergoesopenrightupperloberemovalwhichincludesthemass.Thespecimenissenttopathologywhereadenocarcinomaofthelungisdiagnosed.Thelungtissuemarginsareclear.Wouldthecoderassignthe7th characterofXDiagnostictotheresectioncode?

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    Example:VideoAssistedThoracoscopicWedgeResection

    H&P Mr.XXXisheretodaytodiscussoptionsfordiagnosinghisprogressivediffusingcapacitydysfunction,nowdownto59%predicted. Hehassignificantexposurehistoryincludingsmoking.PreviousFOB/BALshowedeosinophiliaandwasthoughttoberelatedtomedicationsthathassincebeenstopped. Heisheretodiscusstissuediagnosis...Mr.XXXhaswhatappearstobeprogressiveanddiffusepulmonaryinterstitialdisease. Thereisvolumelossintherighthemithorax. Nosignificantmediastinallymphadenopathy. Wouldagreewithtissuesamplingtomakeadefinitivediagnosisofthecauseofthefibrosis...

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    Example:VideoAssistedThoracoscopicWedgeResection

    Opnote: ..Rightsidedvideoassistedthoracoscopicexplorationwithwedgeresectionofthemiddlelobeandtheupperlobe....Indicationfortheprocedure: ..anunfortunate68yearoldgentlemenwhopresentswithworseningSOBanddyspneaonexertion. Hehasundergonebronchoscopyinthepastwithbiopsies,brushingandculturesandthesehavebeendiagnostic. Hisdiseasehasprogressed andhewastherefore,referredforpossibletissuebiopsy.Procedure...Ipalpatedthelung,andalongwiththetactilestimulus,aswellasCTscanfindings, theareaswerechosenintheupperlobe,aswellasthemiddlelobeforbiopsy.

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    Example:VideoAssistedThoracoscopicWedgeResection

    Opnote: ...Ipalpatedthelung,andalongwiththetactilestimulus,aswellasCTscanfindings, theareaswerechosenintheupperlobe,aswellasthemiddlelobe forbiopsy. AnEndoGIAstaplerwasusedtodividethesesmallportionsoflungfromtheremainderofthelung. ThesebothwereplacedinanEndoCatchpouchAsmallportionofeachspecimenwassentformicrobiologyandgramstain,cultureandsensitivity. Theremainingmajorityofthespecimenwassentforpermanentanalysis...Pathology: Lung,Rightmiddlelobe,wedgebiopsy: Advancedinterstitialpneumoniawithausualinterstitialpneumoniapattern..

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    Example:VideoAssistedThoracoscopicWedgeResection

    0BBC4ZX0 Medical/SurgicalBRespiratoryB ExcisionC UpperLungLobe,Right

    4 PercutaneousEndoscopic

    Z NoDeviceX Diagnostic

    0BBD4ZX0 Medical/SurgicalBRespiratoryB ExcisionD MiddleLungLobe,Right

    4 PercutaneousEndoscopic

    Z NoDeviceX Diagnostic

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    Example:Paracentesis

    Patientwithalcoholiccirrhosisoftheliverandascites(K70.31)hereforparacentesis.Ascitesfluidissenttopathologyforanalysis.Doyouassign7th characterXDiagnosticorZNoQualifier?InsomecasesifXDiagnosticisassignedtheDRGvarieswidelysuchasDRG186vsDRG987.XDiagnosticassignsthecasetoasurgicalDRG.ManyfacilitiesareassigningZNoQualifieruntilCMSfixestheproblemhowevercontactyourMACandcompliancedepartment.

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    Example:Paracentesis

    0W9G3ZZ0 Medical/SurgicalW AnatomicRegions9 DrainageG PeritonealCavity3 PercutaneousZ NoDeviceZ NoQualifier

    0W9G3ZX0 Medical/SurgicalWAnatomicRegions9 DrainageG PeritonealCavity3 PercutaneousZ NoDeviceX Diagnostic

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    DRG 434, Cirrhosis and AlcoholicHepatitis without CC/MCC 0.6235

    DRG 422, Hepatobiliary DiagnosticProcedures without CC/MCC 1.2941

    VascularAccessDevices

    PROBLEM:

    ThereareseveraltypesofvascularaccessdevicesthatarecodeddifferentlyinICD10.Officialadvicehasbeenconflictingandincompleteinhowtocodeeachtype.

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    VascularAccessDevices

    CodingClinic4Q2015pages3032DifferenttypesofVADsrequiredifferenttypesofICD10PCScodes.PICC,CVC,implantedport,etc.Codetotheendpointofthecatheter,nottheentrypointofthecatheterforcentrallines.CodefluoroandU/Sifutilizedorguidance(B51).ConfusingadviceregardingapproachesinthisCodingClinicforinsertionofportdevices.TheystatedpercutaneousiscorrecthoweverlaterinthearticlestateOpenapproachbeusedfortotallyimplantedport.CodingClinic4Q2013pages116117supportthatopenbeusedfortotallyimplantableports.

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    VascularAccessDevicetotheSVC

    VADthrurightsubclaviantoSVCsuturedatinsertionsitebyrightsubclavianvein.

    02HV33Z

    0MedicalandSurgical2 HeartandGreatVesselsHInsertionVSuperiorVenaCava3Percutaneousapproach3InfusionDeviceZNoQualifier

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    CavoatrialJunction

    CodingClinic4Q2015pages3032alsoaddressedcavoatrialjunctionVADinsertioniscodedtobodypartSVCandnotrightatrium.CAUTION:CodinginsertionofVADtoanopenapproachandtorightatriumcode02H603ZwillchangeyourMSDRGassignmenttoasurgicalMSDRG.

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    TunneledHemodialysisCatheter

    Twocodesorone?Notatotallyimplantedport.Cathetertunneledunderskinhoweverthetwoportsareoutsideofthebody,accessedforhemodialysis,etc.thencappedwhennotinuse.SenttoAHACodingClinicforofficialadvice.CodingClinic4Q2015pages2632alsoaddressedthisbutitisveryconfusing.AHACodingClinic2Q1996statedthatthesewerenotconsideredtotallyimplantableVADsandwerecodedto38.93or38.95.

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    TunneledHemodialysisCatheter

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    TunneledVADfromjugulartochest,VADinSVC

    02HV33Z0 Medical/Surgical2 HeartandGreatVessels

    H InsertionV SuperiorVenaCava3 PercutaneousZ NoDeviceZ NoQualifier

    ???0JH60XZ???0 Medical/SurgicalJ SubcutaneousTissueandFascia

    H Insertion6 Subcutissue,chest0 OpenapproachXVascularAccess

    DeviceZ NoQualifier

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    TotallyImplantablePortwithVAD

    Twocodesastherearetwopartdevices.Portistotallyimplantedpluscodeforcentralveincatheterinsertion.Needleaccessthroughskintoreachport.AresometimescalledMediport;PortaCath;Groshongport.Useopenapproachforimplantedportandcodetolocationwithinsubcutaneousandfasciabodyarea.Forcentralvenouscath,codepercutaneousandtobodyareaofwherethetipendsup(i.e.rightatrium,SVC)CodingClinic4Q2015pages2732alsoaddressedthisbutitisveryconfusing.

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    TotallyImplantablePortwithVAD

    Totally Implantable Vascular Access Device

    Totally Implantable VAD, Reservoir and

    Pump

    Code: Insertion, SubQ if chest, VAD port 0JH60XZ

    PLUScatheter to SVC 02HV33Z

    Code: Insertion, SubQ if chest, Pump 0JH60VZ and Reservoir

    0JH60WZ PLUSInfusion device, into SVC

    02HV33Z

    Port Catheter;Port-O-Cath

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    SpinalInfusionPumpwithSpinalCatheter

    Totally Implantable Spinal Reservoir

    and Pump

    Code: Insertion, SubQ if abdomen, Pump 0JH80VZ PLUS

    Infusion device, into Spinal Canal 00HU33Z

    See Coding Clinic3Q 2014 pages 19-20Baclofen Pump

    TotallyImplantableSpinalReservoirandPump

    Threecodes.ReservoirimplantationpluspumpimplantationpluscentralcatheterinsertionNeedleaccessthroughskintoreachreservoirtofillit.CodingClinic4Q2015pages2632alsoaddressedthisbutitisveryconfusing.http://www.cancernetwork.com/palliativeandsupportivecare/neuraxialinfusionmanagementcancerpain/page/0/2

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    ArterialLinesforMonitoring

    PROBLEM:

    AdebateexistsonhowtoassignICD10PCScodeforplacementofarteriallinesforthepurposeofmonitoringbloodpressureorforABGdraws.SomecodesaffectDRGassignment.

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    ArterialLineforMonitoring

    4A133B14 Monitoring/MeasuringA PhysiologicalSystems1 Monitoring3 Arterial3PercutaneousBPressure1 Peripheral

    03HY32Z0 Medical/Surgical3 UpperArteriesH InsertionY UpperArtery3 Percutaneous2 MonitoringDeviceZ NoQualifier

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    If I10 as PDX; DRG 305, HypertensionRW 0.6626

    If I10 as PDX; DRG 254, Other Vascular ProceduresRW 1.7232

    ArterialLineforMonitoring

    AHACodingClinic3Q2015page35forSwanGanzrecommendsbothcodes;02HP32ZforinsertionofSwanGanzand4A1239Zforarterialpressure.(02HP32ZdoesNOTtakeyoutoasurgicalDRG)ThisisprobablyaDRGassignmenterrorforarteriallines.MostfacilitiesareNOTreportingtheinsertioncodetoavoidthelargeDRGpaymenttoavoidproblemslater.AHIMATraintheTrainerbookstatesifadeviceusedtoperformthemeasurementormonitoringisleftin,insertionofthedeviceiscodedasaseparateprocedure.RACwillmostlikelyreviewtheseretrospectively.Developafacilitypolicyafterconsultingcompliancedepartmentsocodersareallonthesamepage.

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    ControlofBleeding

    PROBLEM:

    ThereisconfusiononwhetherornotintraoperativebleedingwithclipsshouldbecodedinICD10PCStoControlofthesite.SomecodersarecodingControl,othersarecodingRepairofsiteandothersnothingatall.

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    ControlofBleeding

    AHACodingClinic3Q2013page23statesthatcontrolofbleedingatthetimeoftheprocedureisinherentintheoverallprocedureandnotreportedseparately,evenifitrequiresadditionaltimeandeffort.RootoperationRepairisusedwhenclipsareusedtostopbleedingfromaduodenalulcer,forexample.DonotuserootoperationControlinthissituationasthisisnotapostoperativebleeding.SeeAHACodingClinic4Q2014page20forControlofbleedingofduodenalulcer,0DQ98ZZRepairofduodenum.

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    Control:OCGB3.7

    TherootoperationControlisdefinedas,Stopping,orattemptingtostop,postprocedural bleeding.Ifanattempttostoppostproceduralbleedingisinitiallyunsuccessful,andtostopthebleedingrequiresperforminganyofthedefinitiverootoperationsBypass,Detachment,Excision,Extraction,Reposition,Replacement,orResection,thenthatrootoperationiscodedinsteadofControl.

    Example:ResectionofspleentostoppostproceduralbleedingiscodedtoResectioninsteadofControl.

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    EndarterectomyofMultipleVesselswithPatchGraft

    PROBLEM:

    Howmanyextirpationcodesareassignedifplaqueisremovedfromseveralarterieswithdifferentbodypartvalues?Isthepatchgraftdoneafterthesurgerycoded?

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    EndarterectomyofMultipleVesselswithPatchGraft

    ExamplesenttoAHACodingClinic:Endarterectomyofleftexternaliliacartery,leftcommonfemoralartery andleftprofundafemoralartery.Superficialfemoralarteryportionexcisedtobeusedasapatchgrafttotheleftexternaliliacuponclosure.Isanextirpationcodeassignedthreetimes,oneeachforthearteriesnamedabove?Shouldtheharvest/excisionofSFAforthegraftbecodedalongwiththepatchgrafttotheleftexternaliliacartery?

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    EndarterectomyofMultipleVesselswithPatchGraft

    0Medical&Surgical4LowerArteriesCExtirpationJExternalIliacartery,Left0OpenZNoDeviceZNoQualifierLtexternaliliac

    endarterectomy(only1extirpationcode)

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    0Medical&Surgical4LowerArteriesU SupplementJ ExternalIliacartery,Left0Open7 AutologousTissueSubstituteZNoQualifierFor the patch graft to left external iliac artery

    EndarterectomyofMultipleVesselswithPatchGraft

    0MedicalandSurgical4LowerArteriesBExcisionLFemoralartery,left0OpenZNoDeviceZNoQualifierLeftsuperficialfemoralartery

    harvestforgraftplacedtosupplementleftexternaliliacartery

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    NOTE: This answer is based on 1Q2016 page 31

    AHA considers the plaque as one continues lesion and thus only assigned one extirpation code for left external iliac artery.

    Profunda femoral artery (also called deep femoral artery) assigns to body part Femoral artery (Guideline B3.2b)

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    CodingofSkinGrafts

    PROBLEM:

    ThereisconfusiononhowtoassignICD10PCScodesforvariousgrafts.CodersseemtogetconfusedastowhentoassignTransferorReplacement.

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    CodingofSkinGrafts

    Iftissueisbeingrearranged,itiscodedtorootoperationTransferbecausetheflapisnotdisconnectedfromthevascularandnervesupply.AfreeskingraftiscodedtorootoperationReplacement.Anadditionalcodeisassignedfortheexcisionofthedonorskinifautograftisperformed.Thisisagraftofskincompletelyremovedfromitsoriginallocation.Lookattheobjectivesoftheproceduresbeingperformed.

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    REPLACEMENTRootOperationR

    Definition:Puttinginoronbiologicalorsyntheticmaterialthatphysicallytakestheplaceand/orfunctionofalloraportionofabodypart.Explanation:Thebiologicalmaterialisnonliving,orthebiologicalmaterialislivingandfromthesameindividual.Thebodypartmayhavebeenpreviouslytakenout,previouslyreplacedormaybetakenoutconcomitantlywiththeReplacementprocedure.Ifthebodyparthasbeenpreviouslyreplaced,aseparateRemovalprocedureiscodedfortakingoutthedeviceusedinthepreviousreplacement.Examplesincludefreeskingraft,totalhipreplacement,breastreconstructionaftermastectomy.

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    FreeSkinGrafts

    TRANSFERRootOperationX

    Definition:Moving,withouttakingout,alloraportionofabodyparttoanotherlocationtotakeoverthefunctionofalloraportionofabodypart.Explanation:Thebodyparttransferredremainsconnectedtoitsvascularandnervoussupply.Examplesincludeskinpedicleflaptransfer,rotationflapgraft,tendontransfer.

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    Rotation(Transfer)SkinGraft/Flap

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    TypesofGrafts

    Tissueculturedepidermalautograftutilizespatientsownskinthatispreviouslyharvestedandgrowninalab.14dayslateritisusedasaskinreplacement.

    UseDevicevalue7,AutologoustissueforskinUseQualifiervalue4,Partialthicknessforskin

    TRAM(transverserectusabdominismyocutaneous)flapisafreeflap(Replacement)OR apedicledflap(transfer).DIEP(deepinferiorepigastricarteryperforator)isafreeflapandcodedtoReplacementinICD10PCS

    Freeflapsorgraftsaredisconnectedfromtheiroriginalvascularandnervoussupply

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    GraftscodedtoTransfer

    WhentissueflapsarecodedtotherootoperationofTransfer,thebodysystemvalueuseddescribesthedeepesttissuelayerintheflap.Thequalifierissometimesusedtodescribewhenmorethanonetissuelayeristransferred.Example:

    Skinandsubcutaneoustissue.Skin,subcutaneoustissueandfascia.Example,Transferofsubcutaneoustissueviarotationalgraftfromrightsideoftrunktoabdomen.ThebodypartisSubcutaneoustissueandfascia,Abdomen,thequalifierisB,SkinandSubcutaneousTissue.

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    ExamplesofSkinSyntheticSubstitutes

    DeviceorSixthcharacterJSyntheticSubstituteArtificialskin,nototherwisespecifiedCreationofNeodermisIntegumentarymatriximplantsProstheticimplantofdermallayerofskinRegeneratedermallayerofskin

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    GraftQuestions

    WhatisthesiteofthegraftWhattypeofgraftisbeingplaced?Freegraft?Pediclegraft?Isitstillattachedtothevascularandnervesupplyorisittotallyexcisedfromthebody?Isitautologous,nonautologous,orsynthetic?Iftissue,whatlayersareinvolvedinthegraft?Skin?Subcutaneoustissue?Fascia?Muscle?Whatisthepurposeofthegraft?Whatisthesiteofthedonorgraftiffromthesamepatient?(autograft)

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    Summary

    ContinuetostudytheICD10PCSGuidelines.BecomeveryfamiliarwiththerootoperationsandtheirdescriptionforuseinICD10PCS.CarefullyreviewCodingClinicandifasituationisnotaddressed,sendintoCodingClinicforofficialadvice.LookatcodingforumssuchasEngagetoseeifsomeoneelseencounteredthesameproblemandfoundasolution.Checkwithvendorstoseeiftheyhaveresolvedtheissue.

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