Transcript icd-10-pcs general guidelines

MAY 9, 2016
INDIANA HEALTH INFORMATION MANAGEMENT
ASSOCIATION ANNUAL MEETING
INDIANAPOLIS, IN
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Tobacco Use
Contact with a knife?
Immunizations
 Z23
 3E0234Z
th
7
Digit Extensions
 When is a first visit a subsequent encounter and a
second visit an initial encounter?
What We Have Learned
 Coding Guidelines
 Common Findings for ICD-10-CM/PCS Errors
 Updates from 1st quarter Coding Clinic
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Coding Guidelines
 Excludes notes
 Code freeze prevented corrections prior to 10/1/16
 If two conditions are unrelated, both codes can be
assigned even with an excludes 1 note
 Coding Clinic 4th quarter 2015, pg 40
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Coding Guidelines
 X qualifier for ICD-10-PCS
 X = diagnostic
 Used for a biopsy or diagnostic procedure
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ICD-10-CM
 Infectious organisms
 Bacterial infection of unspecified site

A49
 Bacterial agents as the cause of disease classified
elsewhere

B96
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ICD-10-CM
 Abscess and cellulitis
 Spinal stenosis
 Knee osteoarthritis
 Elevated D-dimer
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ICD-10-CM
 Edema
 Localized R60.0
 Generalized R60.1
 Unspecified R60.9
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Obstetrics Principal Diagnosis
 Main circumstances or complications of the delivery
 Definition of principal diagnosis still applies
 Cesarean

Reason for cesarean is principal diagnosis unless another
condition meets definition of principal diagnosis
 Two or more conditions equally meeting the definition
of principal diagnosis
Obstetrics
 Rh Incompatibility
 Rh- mother receives prophylactic Rhogam during
admission
 O26.893, other specified pregnancy related conditions
 Can also assign code from Z67 category; Rh negative
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Non-obstetric Conditions
Complicating Pregnancy
 O99.0_, anemia
 O99.1_ , other diseases of blood/blood-forming organs
 O99.2_ , endocrine, nutritional and metabolic
 Includes obesity and other






O99.3_, mental disorders/nervous system diseases
O99.4_, circulatory system
O99.5_, respiratory system
O99.6_, digestive system
O99.7_, skin and subcutaneous
O99.8_, other specified
 Includes abnormal glucose, streptococcus B and other infection carrier
status, bariatric surgery status
 O99.89 – other specified diseases and conditions
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Anemia
 Anemia in chronic diseases classified elsewhere
 Neoplastic disease
 Chronic kidney disease
 Other chronic diseases classified elsewhere
 Sequencing
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Colon Polyps
 Hyperplastic polyps
 Coded to K63.5, colon polyp
 Adenomatous polyps
 Assign a code from D12, benign neoplasm

Fourth digit indicates specific segment of colon
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COPD Exacerbation
 J44.0 COPD exacerbation with acute lower respiratory
infection
 With pneumonia
 Sequencing
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Central Venous Catheter Insertion
 Body part value is the end placement of the device
 Can use postplacement x-ray
 Cavoatrial junction = Superior vena cava
 Coding Clinics:
 3rd quarter 2013, pg 18
 3rd quarter 2014, pg 5
 4th quarter 2015, pg 26
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Sterilization Procedures
 Occlusion of the fallopian tube(s)
 Body system: Female reproductive (U)
 Root operation: Occlusion (L)
 Body part: right and left fallopian tube (5, 6), bilateral
fallopian tubes (7)
 Approach: Open (0), percutaneous (3), percutaneous
endoscopic (4), via natural or artificial opening (7), via
natural or artificial opening endoscopic (8)
 Device: Extraluminal device (C), intraluminal device
(D), none (Z)
 Qualifier: None (Z)
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Sterilization Procedures
 Tubal procedures
 Body system: Female reproductive (U)
 Root operation: Destruction (5)
 Body part: right and left fallopian tube (5, 6), bilateral
fallopian tubes (7)
 Approach: Open (0), percutaneous (3), percutaneous
endoscopic (4), via natural or artificial opening (7), via
natural or artificial opening endoscopic (8)
 Device: None (Z)
 Qualifier: None (Z)
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Sterilization Procedures
 Tubal procedures
 Body system: Female reproductive (U)
 Root operation: Excision (B)
 Body part: right and left fallopian tube (5, 6), bilateral
fallopian tubes (7)
 Approach: Open (0), percutaneous (3), percutaneous
endoscopic (4), via natural or artificial opening (7), via
natural or artificial opening endoscopic (8)
 Device: None (Z)
 Qualifier: None (Z)
 Coding Clinic 3rd quarter 2015, pg 31
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Obstetrics
 Perineal lacerations
 1st degree – perineal skin and vaginal mucosa
 2nd degree – perineal body and deeper tissues
 3rd degree – capsule and muscle of the anal sphincter
 4th degree – through the sphincter and into the
anal/rectal mucosa
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Obstetrics
 Perineal laceration repairs
 1st degree:
 0HQ9XZZ, Repair perineum skin, external approach
 2nd degree
 0KQM0ZZ, Repair perineum muscle, open approach
 3rd degree
 0DQR0ZZ, Repair anal sphincter, open approach
 4th degree
 0DQP0ZZ, Repair rectum, open approach
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Heart Failure
 Heart failure with preserved ejection fraction
 Diastolic heart failure
 May also be called preserved systolic function
 Heart failure with reduced ejection fraction
 Systolic heart failure
 May also be called low ejection fraction or reduced
systolic function
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Diabetes
 Cause and effect assumed with
 Chronic kidney disease
 Polyneuropathy
 Circulatory system
 Cause and effect also assumed with foot ulcer
 Cause and effect is NOT assumed for osteomyelitis
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Diabetes
 Alphabetic index
 Polyneuropathy
 in (due to)
 diabetes
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Hemorrhage due to anticoagulant
 Assign code for site of hemorrhaging
 Assign D68.32, Hemorrhagic disorder due to extrinsic
circulating anticoagulant,
 Assign T45.515-, Adverse effect of anticoagulants
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ICD-10-PCS
 Excision is root operation for brush biopsies
 Drainage is root operation for bronchoalveolar lavage
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Endarterectomy
 Plaque extending from one artery into an adjacent
branch is one continuous lesion
 Assign one procedure code with a body part value for the
anatomical site furthest from point of entry


Endarterectomy started at the femoral bifurcation and into
the external iliac is coded to the external iliac
Endarterectomy started at the common carotid and ending in
the external carotid is coded to external carotid
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HPV Screening
 Preventative service every 5 years
 Ages 30 - 65
 Retroactive to 7/9/15
 HCPCS code G0476
 Must be billed by a lab entity until 1/1/17
HPV Screening
 Diagnosis codes
 Z11.51, encounter for screening for HPV WITH
 Z01.411, encounter for gynecological exam with
abnormal findings OR
 Z01.419, encounter for gynecological exam
(general)(routine) without abnormal findings
 CMS; MLN Matters Number: MM9434; Screening for
Cervical Cancer with Human Papillomavirus (HPV)
Testing —National Coverage Determination
(NCD) 210.2.1
Resources
 Leon-Chisen, Nelly; ICD-10-CM and ICD-10-PCS
Coding Handbook 2016; American Hospital
Association, 2016
 Centers for Medicare and Medicaid Services and
National Center for Health Statistics; ICD-10-CM
Official Guidelines for Coding and Reporting; FY2016
 Centers for Medicare and Medicaid Services and
National Center for Health Statistics; ICD-10-PCS
Official Guidelines for Coding and Reporting; FY2016
 American Hospital Association; Coding Clinic for ICD10-CM/PCS