Colorado Trauma Network/Colorado Trauma Registry
Health and Safety Data Services
Annual December Training
12/5/2014
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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
Health and Safety Data Services
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
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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
Health and Safety Data Services
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)
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#1 Definition: GCS <= 13 – new code
#4 Definition: Crash ejection (partial or complete) from automobile – new code
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
Health and Safety Data Services
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
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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
Health and Safety Data Services
2015 Physical Abuse
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
Health and Safety Data Services
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
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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
Health and Safety Data Services
NTDS 2015 – New Data Fields
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
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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
Health and Safety Data Services
NTDS 2015 – New Data Fields
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
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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
Health and Safety Data Services
NTDS 2015 – New Data Fields
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
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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
Health and Safety Data Services
2015 Comorbidity Conditions
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
Health and Safety Data Services
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)
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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
Health and Safety Data Services
2015 Primary Payment Method
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
Health and Safety Data Services
NTDS 2015 – Primary Payment MethodChanges
Retire values#5 No Fault Automobile#8 Workers Compensation#9 Blue Cross/Blue Shield
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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
Health and Safety Data Services
Trauma Registry Questions
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
Health and Safety Data Services
Trauma Registry Questions
• 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…”
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
Health and Safety Data Services
Trauma Registry Questions
• 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”
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
Health and Safety Data Services
Migration to ICD-10-CM/PCSTimeline
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
Health and Safety Data Services
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”
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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
Health and Safety Data Services
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
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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
Health and Safety Data Services
ICD-10 Procedure Coding SystemICD-10-PCS
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
Health and Safety Data Services
Number of Codes
86% of these codes are in the
medical and
surgical section
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
Health and Safety Data Services
ICD-10-PCS Migration
Why change?• Completeness – Unique for each procedure• Expandability – no more waiting for
maintenance – e.g., new device• Standardized Terminology
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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
Health and Safety Data Services
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
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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
Health and Safety Data Services
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
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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
Health and Safety Data Services
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
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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
Health and Safety Data Services
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
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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
Health and Safety Data Services
General Guidelines
Guideline B6. Device – only if a device remainsDoes not include:
Sutures Ligatures Radiological markers Temporary post-operative wound drains
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• 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
Health and Safety Data Services
ICD-10-PCS TablesExample – 0FT Table
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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
Health and Safety Data Services
Table Example – 0JH Table
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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
Health and Safety Data Services
Device Category
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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
Health and Safety Data Services
Device - Character 6
• Only devices that remain (e.g., pins in a fixation of a fx, monitoring device; B6.1a)
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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
Health and Safety Data Services
Example Devices
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The default value to indicate that NO device was involved is Z
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
Health and Safety Data Services
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”
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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
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
Health and Safety Data Services
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!)
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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
Health and Safety Data Services
6th and 7th Values
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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
Health and Safety Data Services
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)
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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
Health and Safety Data Services
ICD-10-PCS IndexBypassStep 1• Look up term in Alphabetic Index:
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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
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
Health and Safety Data Services
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
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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
Health and Safety Data Services
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
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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
Health and Safety Data Services
Excision versus Resection
Complete Right Open Mastectomy
Look up term in IndexResection
BreastBilateral 0HTV0ZZLeft 0HTU0ZZRight 0HTT0ZZSupernumerary 0HTY0ZZ
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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
Health and Safety Data Services
PCS Coding Process Step 2
0HTT0ZZ
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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
Health and Safety Data Services
Index ExampleLiver transplant with donor matched liver
Transplantation – in indexKidney
Left 0TY10ZRight 0TY00Z
Liver 0FY00ZLung
…
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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
Health and Safety Data Services
Check Your Progress
• The first step in coding in ICD-10-PCS is always to go to the Index.
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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
Health and Safety Data Services
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.
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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
Health and Safety Data Services
Check Your Progress
The purpose of the index is to locate thecorrect table.
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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
Health and Safety Data Services
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.
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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
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
Health and Safety Data Services
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
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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
Health and Safety Data Services
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
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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
Health and Safety Data Services
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
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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
Health and Safety Data Services
Check Your Progress
• Which code would be a Medical-Surgical section procedure?
A. 021109WB. 10D07Z3C. 4A12X45D. D020JZZ
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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
Health and Safety Data Services
Answer
• Which code would be a Medical-Surgical section procedure?
A. 021109WB. 10D07Z3C. 4A12X45D. D020JZZ
Medical-Surgical section always starts with a zero (0)
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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
Health and Safety Data Services
Character 3: Root Operation
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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
Health and Safety Data Services
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
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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
Health and Safety Data Services
Root Operation - Character 3
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Colonoscopy 0DJD8ZZ
Look up term in Index
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
Health and Safety Data Services
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
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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
Health and Safety Data Services
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
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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
Health and Safety Data Services
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
57
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
Health and Safety Data Services
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
58
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
Health and Safety Data Services
Procedures that take out or eliminate solid matter, fluids or gases from a body part
59
Search Index
Thoracentesis see Drainage, Anatomical Regions, General 0W9
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
Health and Safety Data Services
Procedures that involve putting in or on, putting back, or moving living body parts
Definition Explanation Examples
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
60
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
Health and Safety Data Services
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
61
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
Health and Safety Data Services
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
62
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
Health and Safety Data Services
Check Your Progress
• A thrombectomy is an example of which root operation?
A. ResectionB. ExcisionC. RemovalD. Extirpation
63
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
Health and Safety Data Services
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
64
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
Health and Safety Data Services
Procedures that only involve examination of body parts and regions
Definition Explanation Examples
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
65
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
Health and Safety Data Services
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
66
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
Health and Safety Data Services
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
67
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
Health and Safety Data Services
Check Your Progress
• Which root operation is assigned to PTCA?A. BypassB. DilationC. OcclusionD. Repair
68
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
Health and Safety Data Services
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.
69
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
Health and Safety Data Services
Procedures that always involve devices
Definition Explanation Examples
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
70
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
Health and Safety Data Services
Procedures involving cutting or separation only
Definition Explanation Examples
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
71
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
Health and Safety Data Services
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
72
•“Repair” when px documentation does not support a more specific operation
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
Health and Safety Data Services
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
73
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
Health and Safety Data Services
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
74
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
Health and Safety Data Services
Check Your Progress
• An amputation is an example of which root operation?A. ResectionB. DetachmentC. RemovalD. Extirpation
75
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
Health and Safety Data Services
Answer
• An amputation is an example of which root operation?
Root operation is Detachment• Disarticulation or cutting through the bone.
76
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
Health and Safety Data Services
Check Your Progress
• A closed reduction is an example of which root operation?A. ReplacementB. RevisionC. InsertionD. Reposition
77
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
Health and Safety Data Services
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.
78
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
Health and Safety Data Services
Check Your Progress
• An external skeletal fixation is an example of which root operation?A. ReplacementB. InsertionC. RepairD. Reposition
79
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
Health and Safety Data Services
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)
80
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
Health and Safety Data Services
Check Your Progress
• A suture is an examples of which root operation?A. RepositionB. InsertionC. RepairD. Reattachment
81
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
Health and Safety Data Services
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
82
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
Health and Safety Data Services
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
83
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
Health and Safety Data Services
Check Your Progress
• Inspection is the Not Elsewhere Classified (NEC) in the root operations.
84
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
Health and Safety Data Services
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
85
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
Health and Safety Data Services
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
86
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
Health and Safety Data Services
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
87
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
Health and Safety Data Services
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
88
Note: What can be seen and what needs an instrument? – Not clearly defined…
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
Health and Safety Data Services
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
89
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
Health and Safety Data Services
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
90
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
Health and Safety Data Services
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
91
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
Health and Safety Data Services
ICD-10-PCS Coding Structure
Suzy Buys Root Beer At Dairy Queen
92
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
Health and Safety Data Services
PCS Coding ScenariosExample
What are the PCS codes?What body system are we working on?What is the root operation?What is the approach?
93
Suzy Buys Root Beer At Dairy Queen
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
Health and Safety Data Services
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
94
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
Health and Safety Data Services
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
95
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
Health and Safety Data Services
Answer
D. ExternalThe tongue can be seen without the aid of instrumentation for excision.
96
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
Health and Safety Data Services
PCS Coding ScenariosExample 1
Patient admitted for right shoulder arthroscopy with coracoacromial ligament release –
What are the PCS codes?What body system are we working on?What is the root operation?What is the approach?
97
Suzy Buys Root Beer At Dairy Queen
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
Health and Safety Data Services
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
98
Patient admitted for right shoulder arthroscopy with coracoacromial ligament release –
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
Health and Safety Data Services
PCS Coding ScenariosExample 2
Patient admitted for right foot open flexor digitorum brevis tendon transfer –
What are the PCS codes?What body system are we working on?What is the root operation?What is the approach?
99
Suzy Buys Root Beer At Dairy Queen
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
Health and Safety Data Services
PCS Coding ScenariosExample 2 - Answer
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
100
Patient admitted for right foot open flexor digitorum brevis tendon transfer -
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
Health and Safety Data Services
PCS Coding ScenariosExample 3
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?
101
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
Health and Safety Data Services
PCS Coding ScenariosExample 3 - Answer
Section Body System Root Operation
Body Part
Approach Device Qualifier
Medical Surgica
l
Anatomic regions, lower
extremities
Detachment Lower Leg,
Right
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
102
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
Health and Safety Data Services
PCS Coding ScenariosExample 4
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?
103
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
Health and Safety Data Services
PCS Coding ScenariosExample 4 - Answer
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
104
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 -
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
Health and Safety Data Services
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
105
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
Health and Safety Data Services
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
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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
Health and Safety Data Services
• Peggy Berkey – Flyers– CTN website– For scheduling this meeting
• All of you!– Suggestions, comments, participation
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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
Health and Safety Data Services
For More InformationScott Beckley, Ph. D.Health Facilities and EMS DivisionColorado Department of Public Health & Environment4300 Cherry Creek Drive SouthDenver, CO [email protected]: (303) 692-2851F: (303) 691-7720 www.coems.info
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