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ICD-10-PCS Top

Reported Surgical

& Non-Surgical

Procedures

Sara Clark, RHIA, MLS

Provider Consulting Solutions, Inc.

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• Objective – proficiency coding common

procedures



Proficiency = Accuracy and productivity

• Common procedures



Surgical



Non-surgical

Objective

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1. Other Fetal Monitoring 2. Repair OB Laceration 3. Manually Assisted

Delivery NOS

4. Low Cervical C-section 5. Venous Catheter NEC 6. Circumcision 7. Left Heart Catheterization 8. Hemodialysis 9. Procedure on Single Vessel 10. Artificial Rupture of Membrane NEC 11. EGD with Closed

Biopsy

12. Percutaneous

Transluminal Coronary Angioplasty

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Proc #1 – 75.34

Other Fetal Monitoring

• 75.34 in ICD-9 maps to 63 codes in ICD-10 A few examples are:

4A1HXHZ: Monitoring of POC, Cardiac Sound, Extern Approach

4A1H7CZ: Monitoring of POC, Cardiac Rate, Via Natural/Artificial

Opening

4A0H8FZ: Measurement of POC, Cardiac Rhythm, Endo

4A0JX2Z: Measurement of POC, Nervous Conductivity, External

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Procedure #2 – Repair Obstetric Laceration

• Repair of obstetric lacerations  Episiotomy

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Episiotomy=Division

The mediolateral cut is angled down, away from the vagina and the perineum, into the muscle.

Index: Division/perineum/female Root Operation: Division

Body System: Anatomical Regions General

0W8NXZZ

An episiotomy is a surgical incision used to enlarge the vaginal opening to help deliver a baby.

Note:

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Coding Perineal Laceration: 1st_Degree

• First-degree tears are the least severe, involving only the skin around the vaginal opening.

• ICD-10-PCS root operation table 0HQ would be used to report the repair of the perineum skin. (0HQ9XZZ)

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• Second-degree vaginal tears involve vaginal tissue and the perineal muscles — the muscles between the vagina and anus that help support the uterus, bladder and rectum.

•2nd_{degree should be coded as}_0KQM0ZZ_(Muscles,

Repair, Perineum Muscle, Open)

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2nd_{Degree Laceration Repair}

• Second degree perineum lacerations:

-Involves:

-

Vaginal tissue

-

Underlying tissue

-

Pelvic floor muscles

-Requires stitches

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2nd_{Degree Laceration Repair Guideline}

• ICD-10-PCS Official Coding Guideline B3.5:

 Overlapping body layers: If the root operations Excision, Repair or Inspection are performed on

overlapping layers of the musculoskeletal system, the body part specifying the deepest layer is coded

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Approach: 2nd_{Degree Laceration Repair Approach}

• Approach

Open: Cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure

• The laceration has cut through the external body layers exposing the muscle

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• Third-degree vaginal tears involve the vaginal tissues,

perineal muscles and the muscle that surrounds the anus (anal sphincter)

•3rd_{degree perineal laceration repair requires 2 codes and}

should be coded as:

0KQM0ZZ (Muscles, Repair, Perineum Muscle, Open) and

0DQR0ZZ (Gastrointestinal System, Repair, Anal Sphincter, Open)

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• Fourth-degree vaginal tears are the most severe. They

involve the perineal muscles and anal sphincter as well as the tissue lining the rectum. Fourth-degree tears usually require repair in an operating room — rather than the delivery room — and might take months to heal.

•4th_{degree perineal laceration repair requires 3 codes and}

should be coded as:

0KQM0ZZ (Muscles, Repair, Perineum Muscle, Open),

0DQR0ZZ (Gastrointestinal System, Repair, Anal Sphincter,

Open)

0DQP0ZZ (Gastrointestinal System, Repair, Rectum, Open)

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Proc #3 – 73.59

Manual Assisted Delivery

10E0XZZ

Index look up: Delivery

Cesarean see Extraction, Products of Conception 10D0

Forceps see Extraction, Products of Conception 10D0

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Proc #3 – Manual Assisted Delivery

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Proc #4 – 74.1

Low Cervical C-Section

10D00Z1

• Low cervical is also known as transverse

• The 7th character (qualifier) for classical and

extraperitoneal c-sections is different – be

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Proc #4 – Low Cervical C-Section

10D00Z1

Index look up:

Extraction continued

Products of Conception continued Ectopic 10D2 Extraperitoneal 10D00Z2 High Forceps 10D07Z5 Internal Version 10D07Z7 Low Cervical 10D00Z1 Low Forceps 10D07Z3 Mid Forceps 10D07Z4

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Proc #4 – Low Cervical C-Section

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Proc #5 – 38.93 Venous Cath NEC

• In ICD-10, 38.93 can map up to 28 codes

• 38.93 commonly reported for PICC line placement

02HV33Z (insertion of infusion device into superior vena cava, percutaneous approach)

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Proc #5 – Venous Cath NEC

Root operation is

Insertion.

Note that the index instructs you to use a device for PICC.

USE is different than SEE.

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Proc #6 - 64.0 CIRCUMCISION

0VTTXZZ

Index look up:

Resection continued Toe Left 0QTR0ZZ Right 0QTQ0ZZ Pharynx 0CTM Pineal Body 0GT1 Prepuce 0VTT

Products of Conception, Ectopic 10T2 Prostate 0VT0

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Proc #6 - CIRCUMCISION

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Proc #7 – 37.22

Left Heart Cardiac Catheterization

4A023N7 (LT heart)

• The root operation for a heart catheterization is Measurement with the code for a left heart

catheterization being 4A023N7.

• The seventh character identifies if the procedure is performed on the left, right, or is bilateral.

• Unlike ICD-9-CM, ICD-10-PCS differentiates the

various approaches to performing this procedure with the fifth character capturing the approach.

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Proc #8 – 39.95 Hemodialysis

5A1D00Z

• Hemodialysis is under root operation

PERFORMANCE. Definition of performance =

completely taking over a physiological function by

extracorporeal means

Index look up:

Dialysis

Hemodialysis 5A1D00Z

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Proc #8 - Hemodialysis

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Procedure #9 – Procedure on Single Vessel

• ICD-9-CM code is 00.40

 Commonly used to report the number of vessels involved when doing a PTCA

• There is no code in ICD-10-PCS that matches this code  In ICD-10-PCS we would code multiple procedures if

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Proc #10 – Artificial Rupture of Membranes NEC

AROM = when a women’s membranes are ruptured by a health care provider to induce or accelerate their

labor

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• ICD-9 code is 73.09

• Maps to 2 ICD-10 codes:

10907ZC: Drainage of Amniotic Fl, Therapeutic from

POC, Via Natural or Artificial Opening

10908ZC: Drainage of Amniotic Fluid, Therapeutic

from POC, Via Natural or Artificial Opening Endoscopic

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2 Index lookups

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Proc #11 – 45.13

Small Bowel Endoscopy NEC

This is commonly referred to as an

Esophagogastroduodenoscopy (EGD). This is a

procedure in which a thin scope with a light and camera at its tip is used to look inside the upper digestive tract -- the esophagus, stomach, and first part of the small

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Proc #11 – Small Bowel Endoscopy NEC

0DJ08ZZ: Inspection of

Upper Intestinal Tract

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Proc #11 - Small Bowel Endoscopy NEC

0DJ08ZZ: Inspection of Upper Intestinal Tract

Note body part choice is limited and not the same as an EGD with biopsy.

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Proc #11 – 45.16 EGD with biopsy

0DB68ZX: Excision of Stomach

EGD with stomach biopsy = Excision

(doctor will remove a small tissue sample for further study)

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Proc #12 – Percutaneous Transluminal Coronary Angioplasty

• ICD-9 code is 00.66

• Maps to 8 ICD-10 codes • Examples:

1027034Z: Dilation of Coronary Artery 1 site, intraluminal

device, drug–eluting, Percutaneous

1027134Z: Dilation of Coronary Artery 2 sites,

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Medical and Surgical Section Guidelines (section 0) B4.4 – Body Part Guidelines

Coronary arteries

• The coronary arteries are classified as a single body part that is further specified by number of sites treated and not by name or number of arteries. Separate body part values are used to specify the number of sites treated when the same procedure is performed on multiple sites in the coronary arteries.

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Thank you!

Sara Clark, RHIA, MLS, AHIMA Approved ICD-10-CM/PCS Trainer Provider Consulting Solutions, Inc

3 Corporate Drive, Suite 201 Clifton Park, New York 1265 Phone: (518)-371-3036 ext. 420

Web: providercs.com

Questions?

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