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COMMONICD10CODINGERRORS POSTIMPLEMENTATION

VirginiaHealthInformationManagementAssociationAnnualMeeting

April,2016ICD10EducationSeries

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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

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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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