colorado trauma network/ colorado trauma registry health and safety data services annual december...

Colorado Trauma Network/Colorado Trauma Registry

Health and Safety Data Services

Annual December Training

12/5/2014

ICD9CM code Description ICD10CM main code

Description

820 Fracture of neck of femur S72.0 Fracture of head and neck of femur S72.1 Pertrochanteric fracture S72.2 Subtrochanteric fracture of femur S79.0 Physeal fracture of upper end of femur

Today’s Topics

• 2015 NTDS Data Dictionary updates:• Triage • Physical abuse• Comorbidity • Primary payment method

• Migration to ICD-10 timelines• ICD-10 Procedure Coding System

Description

2015 NTDS EMS Triage Changes

# NTDS DESCRIPTION1 GCS < 14 –old code

# NTDS DESCRIPTION4 Crash ejection (partial or complete)

from vehicle – old code

Trauma Center Criteria (NTDS 2015)

Vehicular, Pedestrian, Other Risk Injury (NTDS 2015)

#1 Definition: GCS <= 13 – new code

#4 Definition: Crash ejection (partial or complete) from automobile – new code

Description

NTDS 2015 – EMS Triage Additions

Vehicular, Pedestrian, Other Risk Injury (NTDS 2015)

# NTDS DESCRIPTION ADDITIONS

New CO Acronym

9 For adults >65; SBP <110

10 Patients on anticoagulants and bleeding disorders

11 Pregnancy > 20 weeks12 EMS Provider judgment13 Burns14 Burns with Trauma

Description

2015 Physical Abuse

Description

NTDS 2015 – New Data Fields

Report of Physical Abuse– A report of suspected physical abuse was made to

law enforcement and/or protective services– Yes/No– Not limited to but includes, a report of child,

elder, spouse or intimate partner physical abuse

Description

Investigation of Physical Abuse– An investigation by law enforcement and/or

protective services was initiated because of the suspected physical abuse

– Yes/No– Only complete when Report of Physical Abuse is Yes– “Not Applicable” where Report of Physical Abuse is No

Description

Caregiver at Discharge– The patient was discharged to a caregiver different

than the caregiver at admission due to suspected physical abuse

– Yes/No– Only complete when Report of Physical Abuse is Yes– Only complete for minors (age >xx)– “Not Applicable” where Report of Physical Abuse is

No or if the patient expires prior to discharge

Description

NTDS Field

Number

NTDE Field Name

Field Values

CO Change Location

New CO Field Name New CO Acronym

I_20 REPORT OF PHYSICAL ABUSE

Yes, No Add New pages, under “Variables related to the injury event” Same as NTDB I_21 INVESTIGATIO

N OF PHYSICAL ABUSE

Yes, No

I_22 CAREGIVER AT DISCHARGE

Yes, No

Description

2015 Comorbidity Conditions

Description

NTDS 2015 – Comorbidity ConditionChanges and Additions

Change the definition#2 Alcoholism Alcohol Use Disorder#10 CVA/residual neurological deficit Cerebrovascular Accident (CVA)#23 Respiratory disease Chronic Obstructive Pulmonary Disease (COPD)#28 Drug or dependence Drug Use DisorderRetire values#3 Ascites within 30 days#14 Esophageal Varices#22 Obesity#29 Prehospital cardiac arrest with resuscitative efforts by healthcare providerAdd the values#30 Attention deficit disorder / attention deficit hyperactivity disorder (ASS/ADHD)

Description

2015 Primary Payment Method

Description

NTDS 2015 – Primary Payment MethodChanges

Retire values#5 No Fault Automobile#8 Workers Compensation#9 Blue Cross/Blue Shield

Description

Trauma Registry Questions

Description

• A question to the state:

“Seeing more and more free standing EDs…with several locations– What should patients who arrive from these locations be

called?• Do they meet the definition of outreach or transfer?• Some have a state code and others do not…”

Description

• Q: “Revisit ED observation status…– Intoxicated and stays in ED for >12 hours for a trauma

sober evaluation…otherwise would have been discharged.– Should they count as a trauma patient? – They do use ED

resources but are only in OBS because they were intoxicated”

Description

Migration to ICD-10-CM/PCSTimeline

Description

Migration to ICD-10-CM/PCS

• US gov. scheduled implementation October 2015• NTDB already has the capability to receive ICD-10• Gov. deadlines:

– No longer accepting ICD-9 January 1, 2017– January 1, 2016, all AIS codes must be version

2005 with 2008 update• CODE “AIS Version” as “2008”

Description

Migration to ICD-10-CM/PCSDATES

Proposed State Plan:• Accept ICD-9 through December 31, 2015• Beginning January 1, 2016, ICD-9 codes will no longer be

accepted• Can start submitting ICD-10 October 1, 2015

Description

ICD-10 Procedure Coding SystemICD-10-PCS

Description

Number of Codes

86% of these codes are in the

medical and

surgical section

Description

ICD-10-PCS Migration

Why change?• Completeness – Unique for each procedure• Expandability – no more waiting for

maintenance – e.g., new device• Standardized Terminology

Description

ICD-10-PCS Downloadable files and Reference Manual

http://cms.gov/Medicare/Coding/ICD10/2015-ICD-10-PCS-and-GEMs.html

Click on “2015 Code Tables and Index” zip file and then PCS_2015.pdf

Description

Guidelineshttp://www.cms.gov/Medicare/Coding/ICD10/Downloads/2015-PCS-guidelines.pdf

• Body system• Root operation

• General guidelines• Multiple procedures• Discontinued procedures• Root specific guidelines

• Body parts• Approach• Device

Description

GuidelinesA11 It is the coder’s responsibility to determine what

the documentation in the medical record equates to in the PCS definitions. The physician is not expected to use PCS code descriptions

e.g., Physician states “partially removed…”.

Coder needs to correlate this to a root operation without querying the physician for clarification

Answer: Partial resection

Description

General Guidelines

B2.1b Diaphragm dividing line “Upper” and “lower” specifies body parts located above or

below the diaphragm

B3.3 Discontinued procedures e.g., planned aortic valve replacement…back out of procedure

following the initial thoracotomy because patient become hemodynamically unstable…

If no root actually done – code to “Inspection”Answer: Inspection of the mediastinum

Description

General Guidelines

Guideline B6. Device – only if a device remainsDoes not include:

Sutures Ligatures Radiological markers Temporary post-operative wound drains

• Tables are organized by the first three character values• Column: 4 through 7; Row: valid combinations• Tables must always be used to obtain the complete code

ICD-10-PCS TablesExample – 0FT Table

Description

Table Example – 0JH Table

Description

Device Category

Description

Device - Character 6

• Only devices that remain (e.g., pins in a fixation of a fx, monitoring device; B6.1a)

Description

Example Devices

The default value to indicate that NO device was involved is Z

Description

Qualifier - Character 7

• Additional attribute, if applicable, for specific root operations (e.g., amputation)

• Table will guide to the correct qualifier• The default value to indicate no device is “Z”

Upper arm and Upper leg

High(1): Amputation at the proximal portion of theshaft of humerus or femurMid(2): Amputation at the middle portion of the shaft of the humerus or femurLow(3): Amputation at the distal portion of the shaft of the humerus or femur

Description

Qualifier values for Transplants

Type of Transplant

Qualifier Character

Definition

Allogenic 0 Taken from different individuals of the same species

Syngeneic 1 Having to do with individuals or tissues that have identical genes (e.g., identical twins)

Zooplastic 2 Tissue from an animal to a human (oink oink!)

Description

6th and 7th Values

Description

ICD-10-PCS Index• Index Conventions

• Helps locate the correct table• Provides three or more characters

• Listing by • Root operation (replacement, bypass, inspection)• Procedure type (brachytherapy, fluoroscpy, Magnetic Resonance

Imaging, MRI)• Procedure name (colectomy, mastectomy, appendectomy)

Description

ICD-10-PCS IndexBypassStep 1• Look up term in Alphabetic Index:

Bypass Aorta, Thoracic 021W Aorta, Abdominal 0410 Artery, Axillary, Left 03160 Artery, Axillary, Right 03150 Artery, Brachial, Left 03180 Artery, Brachial, Right 03170 Artery, Common Carotid, Left 031J0 Artery, Common Carotid, Right 031H0

Description

ICD-10-PCS Index

Complete Right Open MastectomyStep 1• Look up term in Alphabetic Index:

• Mastectomy– See Excision, Skin and Breast 0HB– See Resection, Skin and Breast 0HT

• Secondary entries are underneath the main term • Include a PCS Table or an even more specific code

Description

Excision versus Resection

Excision - B• Cutting out or off, without replacement, a portion of a body part

• E.g., lumpectomy

Resection - T• Cutting out or off, without replacement, all of a body part

• E.g., Total lobectomy of lung

Description

Excision versus Resection

Complete Right Open Mastectomy

Look up term in IndexResection

BreastBilateral 0HTV0ZZLeft 0HTU0ZZRight 0HTT0ZZSupernumerary 0HTY0ZZ

Description

PCS Coding Process Step 2

0HTT0ZZ

Description

Index ExampleLiver transplant with donor matched liver

Transplantation – in indexKidney

Left 0TY10ZRight 0TY00Z

Liver 0FY00ZLung

Description

Check Your Progress

• The first step in coding in ICD-10-PCS is always to go to the Index.

Description

Answer

• While this is a normal process, Guideline A7 states that it is not required to consult the index first before proceeding to the tables to complete the code.

Description

Check Your Progress

The purpose of the index is to locate thecorrect table.

Description

Answer

Guideline A6 – The purpose of the alphabetic index is to locate the appropriate table that contains all information necessary to construct a procedure code.

Section Title # Codes

0 Medical and Surgical 61,898

1 Obstetrics 300

2 Placement 861

3 Administration 1,388

4 Measurement and Monitoring 339

5 Extracorporeal Assistance and Performance 41

6 Extracorporeal Therapies 42

7 Osteopathic 100

8 Other Procedures 60

9 Chiropractic 90

B Imaging 2,934

C Nuclear Medicine 463

D Radiation Oncology 1,939

F Physical Rehabilitation and Diagnostic Audiology 1,380

G Mental Health 30

H Substance Abuse Treatment 59

Total 71,924

Description

Character 1: General type of procedure

• 16 Sections, that can be broken into three groups: – Medical and Surgical Section (0) – Medical and Surgical Related Sections (1-9)

1 = Obstetrics, 2 = Placement, 3 = Administration, 4 = Measurement and Monitoring, 5 = Extracorporeal Assistance and Performance, 6 = Extracorporeal Therapies, 7 = Osteopathic, 8 = Other Procedures, 9 = Chiropractic

– Ancillary Sections (B,C,D,F,G,H)B = Imaging, C = Nuclear Medicine, D = Radiation Oncology, F = Physical Rehabilitation and Diagnostic Audiology, G = Mental Health, H = Substance Abuse Treatment

Description

Medical and Surgical Section

• Character 2: Body system – physiological system or anatomical region where the procedure is performed

• 31 different systems: some are sublevels of a larger body system

Description

Character 2: Body system physiological system or anatomical region where the procedure is performed

J Subcutaneous Tissue and FasciaK MusclesL TendonsM Bursae and LigamentsN Head and Facial BonesP Upper BonesQ Lower BonesR Upper JointsS Lower JointsT UrinaryU Female ReproductiveV Male ReproductiveW Anatomical Regions, GeneralX Anatomical Regions, Upper ExtremitiesY Anatomical Regions, Lower Extremities

0 Central Nervous1 Peripheral Nervous2 Heart and Great Vessels3 Upper Arteries4 Lower Arteries5 Upper Veins6 Lower Veins7 Lymphatic and Hemic8 Eye9 Ear, Nose, SinusB RespiratoryC Mouth and ThroatD Gastrointestinal F Hepatobiliary and PancreasG EndocrineH Skin and Breast

Musculoskeletal system subdividedA region, not a specific system – e.g., hernia repair in the inguinal (groin) regionCardiovascular system subdivided

Description

Check Your Progress

• Which code would be a Medical-Surgical section procedure?

A. 021109WB. 10D07Z3C. 4A12X45D. D020JZZ

Description

Answer

• Which code would be a Medical-Surgical section procedure?

A. 021109WB. 10D07Z3C. 4A12X45D. D020JZZ

Medical-Surgical section always starts with a zero (0)

Description

Character 3: Root Operation

Description

Root Operation - Character 3

• Defines the precise and distinct objective of the procedure actually performed

• 31 root operation values in the Medical and Surgical Section

• Procedure terms (e.g., colonoscopy) are not root operators – but the index may help you find a root operation from a procedure term

Description

Root Operation - Character 3

Colonoscopy 0DJD8ZZ

Look up term in Index

Description

Character 3: Root Operation A precise and distinct objective of the procedure actually performed

J InspectionK MapL OcclusionM ReattachmentN ReleaseP RemovalQ RepairR ReplacementS RepositionT ResectionV RestrictionW RevisionU SupplementX TransferY Transplantation

0 Alteration1 Bypass2 Change3 Control4 Creation5 Destruction6 Detachment7 Dilation8 Division9 DrainageB ExcisionC ExtirpationD ExtractionF FragmentationG FusionH Insertion

Description

Character 3: Root Operation

31 different root operations …arranged into nine groups based on similar attributes

Procedures…1. that take out or eliminate all or a portion 2. that involve putting in or on, putting back, or moving 3. that take out or eliminate solid matter, fluids or gases 4. that only involve examination 5. performed only on tubular body parts6. that always involve devices7. involving cutting or separation only8. involving other repairs9. with other objectives

Description

Procedures that take out or eliminate all or a portion of a body part Definition Explanation Examples

Excision Cutting out or off, without replacement, a portion of a body part

Qualifier Diagnostic is used to identify biopsies

Partial nephrectomy, Liver biopsy, breast reduction

Resection Cutting out or off, without replacement, all of a body part

Total nephrectomy, Total lobectomy of lung

Extraction Pulling or stripping out or off all or a portion of a body part by the use of force

Qualifier Diagnostic is used to identify biopsies

Dilation and curettage, Vein stripping

Destruction Physical eradication of all or a portion of a body part by the direct use of energy, force or a destructive agent

None of the body part is physically taken out.

Cautery of skin lesion, fulguration of endometrium

Detachment Cutting off all or part of the upper or lower extremities, without replacing extremity

Qualifier to specify where the extremity was detached

Below knee amputation, Disarticulation of shoulder

Description

Procedures that take out or eliminate solid matter, fluids or gases from a body part

Definition Explanation Examples

Drainage fluids and/or gases

Qualifier Diagnostic to identify drainage device, if applicable

Thoracentesis, Incision and drainage (I&Ds), aspiration, lumbar puncture

Extirpation Taking/cutting out solid matter

e.g., abnormal byproduct, foreign body; it may be imbedded or in the lumen of a tubular body part

Thrombectomy, excision foreign body, endarterectomy

Fragmentation Breaking solid matter into pieces

Physical force (e.g., manual, ultrasonic) applied directly or indirectly. The pieces of solid matter are not taken out

Extracorporeal shockwave lithotripsy of gallstones

Description

Procedures that take out or eliminate solid matter, fluids or gases from a body part

Search Index

Thoracentesis see Drainage, Anatomical Regions, General 0W9

Description

Procedures that involve putting in or on, putting back, or moving living body parts

Transplantation All /portion from another individual/ animal to physically take the place and/or function

The native body part may or may not be taken out

Kidney transplant

Reattachment Putting back in or on all/portion of a separated body part

Vascular circulation and nervous pathways may or may not be reestablished

Reattachment of finger or avulsed kidney

Reposition Moving to its normal location or other suitable location all/portion of a body part

Undescended testicle, Fracture reduction

Transfer Moving, without taking out, all/portion to another location to take over the function

The body part transferred remains connected to its vascular and nervous supply

Tendon transfer, Skin pedicle flap transfer, skin transfer flap

Description

Check Your Progress

• What qualifier value would be assigned for a transplanted kidney obtained from the patient’s mother?

A. 0 AllogeneicB. 1 SyngeneicC. 2 Zooplastic D. 3 Autologous

Description

Answer

• What qualifier value would be assigned for a transplanted kidney obtained from the patient’s mother?A. 0 AllogeneicB. 1 SyngeneicC. 2 Zooplastic D. 3 Autologous

Taken from different individuals of the same species

Description

Check Your Progress

• A thrombectomy is an example of which root operation?

A. ResectionB. ExcisionC. RemovalD. Extirpation

Description

Answer

• A thrombectomy is an example of which root operation?A. ResectionB. ExcisionC. RemovalD. Extirpation

Thrombus is solid matter (not an actual body part)

Taking or cutting out solid matter from a body part

Description

Procedures that only involve examination of body parts and regions

Inspection Visually and/or manually exploring a body part

With or without optical instrumentation.

Diagnostic arthroscopy, Exploratory laparotomy, Diagnostic cystoscopy

Note: If procedure attempted but not completed, code inspection

Map Locating the route of passage of electrical impulses and/or locating functional areas

Applicable only to the cardiac conduction mechanism and the central nervous system

Cardiac mapping, Cortical mapping, cardiac electrophysiological study

Description

Procedures that can be performed only on tubular body partsDefinition Explanation Examples

Bypass Altering the route of passage of the contents of a tubular body part

…to a downstream area of the normal route, to a similar route and body part, or to an abnormal route and dissimilar body part.

Coronary artery bypass graft (CABG), Colostomy formation

Dilation Expanding an orifice or the lumen of a tubular body part

Natural or an artificially created orifice. Stretching by intraluminal pressure or by cutting part of the orifice or wall

Laryngeal stenosis dilation,PTCA, dilation common bile duct

Occlusion Completely closing the orifice or lumen of a tubular body part

Natural or an artificially created orifice

Fallopian tube ligation, Ligation of inferior vena cava

Restriction Partially closing the orifice or lumen of a tubular body part

The orifice can be a natural orifice or an artificially created orifice

Esophagogastric fundoplication, Cervical cerclage

Description

Procedures that always involve devicesDefinition Explanation Examples

Insertion Appliance that monitors, assists, performs or prevents a physiological function but does not physically take the place of a body part

Radioactive implant, Central venous catheter,Pacemaker

Replacement Material that physically takes the place and/or function of all/portion

A Removal procedure is coded for taking out a device used in a previous replacement procedure, when applicable

Total hip replacement, bone graft, Free skin graft, heart valve replacement

Supplement Material that physically reinforces or augments the function of a body part

The biological material is non-living, or the biological material is living and from the same individual

Herniorrhaphy using mesh, (w/o mesh is Repair), new acetabular liner in a previous hip replacement

Description

Check Your Progress

• Which root operation is assigned to PTCA?A. BypassB. DilationC. OcclusionD. Repair

Description

Answer

• Which root operation is assigned to PTCA?A. BypassB. DilationC. OcclusionD. Repair

The PTCA involves the use of a balloon which is inflated within the coronary artery to crush plaque into the walls of the artery. Commonly stents are used to maintain the patency of the artery wall.

Description

Procedures that always involve devices

Removal Taking out or off a device from a body part Drainage tube removal, Cardiac pacemaker removal, central line removal

Change Taking out or off a device and putting back an identical or similar device without cutting or puncturing the skin or a mucous membrane

Urinary catheter change, Gastrostomy tube change, drainage tube change

Revision Correcting, to the extent possible, a malfunctioning or displaced device

Revision can include correcting a malfunctioning or displaced device by taking out or putting in components (e.g., screw)

Adjustment of position of pacemaker lead, adjustment of hip prosthesis

Description

Procedures involving cutting or separation only

Division Cutting into a body part without draining fluids and/or gasses from the body part in order to separate or transect a body part

All or a portion of the body part is separated into two or more portions

Spinal cordotomy, osteotomy, neurotomy, episiotomy

Release Freeing a body part from an abnormal physical constraint by cutting or by use of force

Some of the restraining tissue may be taken out but none of the body part is taken out

Adhesiolysis, Carpal tunnel release, manipulation of joint adhesions

Description

Procedures involving other repairsDefinition Explanation Examples

Control Stopping, or attempting to stop, post-procedure bleeding

Coded as an anatomical region and not to a specific body part

Control of post-prostatectomy hemorrhage, Control of post-tonsillectomy hemorrhage

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

Used only when the method to accomplish the repair is not one of the other root operations

Hemiorrhaphy, Colostomy takedown, Suture of laceration

•“Repair” when px documentation does not support a more specific operation

Description

Check Your Progress

• Freeing a body part from an abdominal physical constraint by cutting or by use of force is which root operation?

A. ExcisionB. Resection

C. ReleaseD. Destruction

Description

Answer

Freeing a body part from an abdominal physical constraint by cutting or by use of force is which root operation?A. ExcisionB. ResectionC. ReleaseD. Destruction

Description

Check Your Progress

• An amputation is an example of which root operation?A. ResectionB. DetachmentC. RemovalD. Extirpation

Description

Answer

• An amputation is an example of which root operation?

Root operation is Detachment• Disarticulation or cutting through the bone.

Description

Check Your Progress

• A closed reduction is an example of which root operation?A. ReplacementB. RevisionC. InsertionD. Reposition

Description

Answer

• A closed reduction is an example of which root operation?

Root operation is Reposition• Surgeon manipulates or reduces fractured bones

into anatomic alignment without making an incision.

Description

Check Your Progress

• An external skeletal fixation is an example of which root operation?A. ReplacementB. InsertionC. RepairD. Reposition

Description

Answer

• An external skeletal fixation is an example of which root operation?Root Operation is Insertion

• Insertion of percutaneous pins proximal and distal to the fracture and applies a frame that connects the pins externally

• The type of device can be selected (monoplanar, hybrid, ring, limb lengthening device)

Description

Check Your Progress

• A suture is an examples of which root operation?A. RepositionB. InsertionC. RepairD. Reattachment

Description

Answer

• A suture is an examples of which root operation?Root operation is Repair

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

Description

Procedures with other objectivesDefinition Explanation Examples

Alteration Modifying the anatomical structure of a body part without affecting the function of the body part

Principal purpose is to improve appearance

Face lift, Breast augmentation, cosmetic liposuction

Creation Making a new genital structure that does not take over the function of a body part

Used only for sex change operations

Creation of vagina in a male

Fusion Joining together portions of an articular body part rendering the articular body part immobile

Joined together by fixation device, bone graft, or other means

Spinal fusion, Ankle arthrodesis

Description

Check Your Progress

• Inspection is the Not Elsewhere Classified (NEC) in the root operations.

Description

Answer

• Repair is the NEC in the root operations. If nothing else fits, then repair is assigned.

• Inspection is assigned when a procedure is attempted but discontinued

Description

Body Part – Character 4

• Defines the specific anatomical site where the procedure is performed

• Tubular body parts– Hollow body parts that provide route of passage

for solids, liquids or gases

Description

Defines the technique used to reach the site of the procedure

Approach – Character 5

7 different approach values:• Open• Percutaneous• Percutaneous Endoscopic• Via Natural or Artificial Opening• Via Natural or Artificial Opening Endoscopic• Via Natural or Artificial Opening with Percutaneous Endoscopic Assistance • External

Description

Through the skin or mucous membrane

Definition ExampleOpen Cutting through skin, mucous membrane,

other layers Abdominal hysterectomy

PercutaneousEntry, by puncture or minor incision, of instrumentation

Needle biopsy of liver, liposuction

Percutaneous Endoscopic

Percutaneous + to reach and visualize the site of the procedure

Laparoscopic cholecystectomy, Arthroscopy

Note: What can be seen and what needs an instrument? – Not clearly defined…

Description

Through an orificeDefinition Example

Via Natural or Artificial Opening

Entry of instrumentation…to reach the site of the procedure

Endotracheal intubation, digital rectal exam

Via Natural or Artificial Opening Endoscopic

Entry of instrumentation…to reach and visualize the site of the procedure

Sigmoidoscopy, EGD, ERCP

Via Natural or Artificial Opening with Percutaneous Endoscopic Assistance

Entry of instrumentation…, by puncture or minor incision, to aid in the performance of the procedure

Laparoscopic-assisted vaginal hysterectomy

Description

External

Definition ExampleExternal Performed directly on the skin or mucous

membrane and indirectly by external forceClosed fracture reduction, excision of skin lesion

Note: Procedures performed without the aid of any instrumentation are coded to External

Tonsillectomy, biopsy of buccal mucosa

Description

ICD-10-PCS Code Structure

• All codes must have seven characters • If documentation is incomplete for coding purposes, the

physician should not be queried for the necessary information

• Possible values for each character• Digits 0-9• Letters A-H, J-N, P-Z

• I and O are excluded because they can be confused with # 1 and #0• Are not case-sensitive

1 2 3 4 5 6 7Section Body

SystemRoot Operation

Body Part

Approach Device Qualifier

Description

ICD-10-PCS Coding Structure

Suzy Buys Root Beer At Dairy Queen

Description

PCS Coding ScenariosExample

What are the PCS codes?What body system are we working on?What is the root operation?What is the approach?

Description

PCS Coding Scenarios - AnswerWhat are the PCS codes? 0XHH33ZWhat body system are we working on? Anatomical Regions, Upper ExtremitiesWhat is the root operation? InsertionWhat is the approach? Percutaneous

Description

Check Your Progress

• A biopsy is performed on the tongue. What approach is coded?

A. OpenB. Via Natural or Artificial OpeningC. Via Natural or Artificial Opening

EndoscopicD. External

Description

Answer

D. ExternalThe tongue can be seen without the aid of instrumentation for excision.

Description

PCS Coding ScenariosExample 1

Patient admitted for right shoulder arthroscopy with coracoacromial ligament release –

Description

PCS Coding ScenariosExample 1 - Answer

Medical Surgical

Bursa & Ligament

Release Shoulder Percutaneous Endoscopic

No Device

No Qualifier

0 M N 1 4 Z Z

What body system are we working on? Bursa & LigamentWhat is the root operation? ReleaseWhat is the approach? Percutaneous Endoscopic (Arthroscopy)

ICD-10-PCS Code = 0MN14ZZ

Patient admitted for right shoulder arthroscopy with coracoacromial ligament release –

Description

Patient admitted for right foot open flexor digitorum brevis tendon transfer –

Description

Section Body System

Root Operation

Body Part Approach Device Qualifier

Medical Surgical

Tendons Transfer Right Foot Tendon

Open No Device No Qualifier

0 L X V 0 Z Z

ICD-10-PCS Code = 0LXV0ZZ

Patient admitted for right foot open flexor digitorum brevis tendon transfer -

Description

Character Character Character Character Character Character Character1 2 3 4 5 6 7

Section Body System Root Operation Body Part Approach Device Qualifier

Patient admitted for below amputation of the right leg at the proximal tibia and fibula -

What are the PCS codes?What body system are we working on?What is the root operation?What body part?

Description

Section Body System Root Operation

Body Part

Approach Device Qualifier

Medical Surgica

Anatomic regions, lower

extremities

Detachment Lower Leg,

Open No Device High

0 Y 6 H 0 Z 1

Patient admitted for below amputation of the right leg at the proximal tibia and fibula -

ICD-10-PCS Code = 0Y6H0Z1

Description

Patient sustained a comminuted fracture of the shaft of her left tibia confirmed by x-ray done in the emergency room. Patient admitted for open reduction with internal fixation

What are the PCS codes?What body system are we working on?What is the root operation?What body part?

Description

Section Body System

Root Operation

Body Part Approach Device Qualifier

Medical Surgical

Lower Bones

Reposition Left Tibia Open Internal Fixation

No Qualifier

0 Q S H 0 4 Z

ICD-10-PCS Code = 0QSH04Z

Patient sustained a comminuted fracture of the shaft of her left tibia confirmed by x-ray done in the emergency room. Patient admitted for open reduction with internal fixation -

Description

Take Away

• Each ICD-10-PCS code has 7 characters• Each character has a well defined meaning• Indexed by root operation or procedure• Index locates correct Table• Stay in same Table row

Description

Take Away

• Approach is captured in every code• Multiple codes may be necessary to describe

the work• May need to improve your knowledge of

procedures in general. Watch procedures here:http://www.nlm.nih.gov/medlineplus/medlineplus.htmlhttp://ortho.broadcastmed.com/

• Need to learn the specific root and approach definitions

Description

• Peggy Berkey – Flyers– CTN website– For scheduling this meeting

• All of you!– Suggestions, comments, participation

Description

For More InformationScott Beckley, Ph. D.Health Facilities and EMS DivisionColorado Department of Public Health & Environment4300 Cherry Creek Drive SouthDenver, CO 80246-1530scott.beckley@state.co.usP: (303) 692-2851F: (303) 691-7720 www.coems.info

colorado trauma network/ colorado trauma registry health and safety data services annual december...

fracture of neck

fracture of head

pertrochanteric fracture

neck of femur s72

safety data services

physical abuse slide

safety data services

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