Root Operations that Involve Examination
by Lori Becks, RHIA - March 28, 2012
This week’s ICD-10-PCS root operation article will introduce the root operations that involve only examination. There are two specific root operations identified in this particular group—inspection and map. The inspection root operation is identified with a value of ‘J’ in the Medical and Surgical Section, and map is identified with a value of ‘K.’ The discussion of each root operation in this article will begin with their definition, procedural examples, and explanations.
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ICD-10 Corner: Monteggia and Galeazzi Fractures
by Lauri Gray, CPC, RHIT - March 28, 2012
Monteggia’s and Galeazzi’s fractures have been reclassified in ICD-10-CM. In ICD-9-CM, Monteggia’s fracture is classified as a fracture of the upper end of the ulna. In ICD-10-CM Monteggia’s fracture is classified as a fracture of the ulnar shaft (upper region of ulnar shaft).
In ICD-9-CM, Galeazzi’s fracture is classified as a fracture of the lower end of the radius. In ICD-10-CM, Galeazzi’s fracture is classified as a fracture of the radial shaft (lower region of radial shaft).
Tip of the Week: Add on code 32507
by Lori Becks, RHIA - March 28, 2012
Add on code 32507 Thoracotomy; with diagnostic wedge resection followed by anatomic lung resection, is intended to be reported along with a more extensive primary procedure to show that diagnostic wedge resection was performed on the lung first. The physician may use an intraoperative pathology consultation in order to determine that a more extensive resection procedure, such as pneumonectomy, is required at the same site.
Coding for Drug Resistant Microorganisms in ICD-10-CM
by Lauri Gray, CPC, RHIT - March 21, 2012
There are a growing number of pathogenic microorganisms that are resistant to some or all of the drugs previously used to treat the resulting infections. Until the 2012 ICD-10-CM Draft version, drug resistant infections were captured with a single code, Z16, Infection with drug resistant microorganisms. Even Methicillin resistant Staphylococcus Aureus (MRSA) infections did not have specific codes as they do in ICD-9-CM. In the 2012 Draft, combination codes have been added for MRSA infections and category Z16 has been expanded to include a number of supplementary codes for reporting infections caused by drug resistant microorganisms.
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ICD-10 Corner: A code from category Z16
by Lauri Gray, CPC, RHIT - March 21, 2012
A code from category Z16, Infection with drug resistant microorganisms, is used to report drug resistance to certain classes of antibiotics and antimicrobial drugs . Selecting the correct code may require some research to determine the antibiotic class. For example, if an infection is documented as resistant to Ceftin, the class of antibiotic must be determined. Ceftin is the brand name of cefuroxime which is a cephalosporin. Resistance to cephalosporins is reported with code Z16.19 which can be verified using both the alphabetic index and tabular list.
Tip of the Week: Code 706.2
by Lori Becks, RHIA - March 21, 2012
For code 706.2 Sebaceous cyst, there are many different types and/or names of cysts that may be documented and are still coded to 706.2: epidermal cyst, inclusion cyst, epithelial retention cyst, epidermal retention cyst, scrotal cyst, and auricular cyst. All of these may be named, but are still coded as sebaceous cyst. Pilar cyst and trichilemmal or trichidermal cysts were previously coded to 706.2 also, but each has been given its own unique code in 2012.
Evaluation & Management Coding – The Basics Part 2
by Lisa Hernandez, CPC, CPMA, CEMC - March 14, 2012
In Part 1, we discussed what was required for the History, Exam & Medical Decision Making. I did, inadvertently, leave out that a Chief Complaint is a required part of the History. I require a Chief Complaint on all visit types that I audit, including subsequent hospital visits. With the increase in auditing activity from the payers, I feel that it helps to drive medical necessity for the visit, especially when you have multiple providers following the same patient.
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ICD-10 Corner: Melanoma in situ
by Lauri Gray, CPC, RHIT - March 14, 2012
Melanoma in situ is a malignant neoplasm of the melanin (brown pigment producing) cells that is documented as in situ which includes melanoma that is described as Stage 0, Tis (tumor in situ), or epidermal layer only. In ICD-9-CM, melanoma in situ is reported with codes from category 172, Malignant melanoma of skin, along with melanoma “not otherwise specified” and melanoma that is described as having invaded the deeper dermal tissues and melanoma described as Stages I-IV. In ICD-10-CM, melanoma that has invaded deeper tissues and melanoma in situ are in two different blocks. Melanoma is classified with Melanoma and Other Malignant Neoplasms of the Skin (C43-C44) and Melanoma in situ is classified with In Situ Neoplasms (D00-D09). See category C43 for Melanoma (melanocarcinoma, melanoma NOS) codes and D03 for Melanoma in situ codes.
Tip of the Week: Add-on code 35683
by Lauri Gray, CPC, RHIT - March 14, 2012
Add-on code 35683 includes harvesting at least 3 segments of autologous vein from at least 2 different body sites and anastomosing the harvested segments together to fom a conduit of only autologous venous tissue that is long enough to be used in the bypass procedure. This code requires at least 2 anastomoses to form the conduit. This code is reported with specific femoral-, tibial-, and popliteal- type bypass procedures that are reported with codes 35556 and 35566, 35570-3557, and 35583-35587.
ICD-10-PCS Medical and Surgical Root Operations That Always Involve Devices, Part 2
by Lauri Gray, CPC, RHIT - March 8, 2012
Last week 3 of the 6 Medical and Surgical Section root operations that always involve the use of devices, insertion, replacement and removal, were reviewed. This week’s article will discuss change, supplement, and revision.
Before discussing these root operations the ICD-10-PCS definition of a device must be understood. ICD-10-PCS recognizes four general types of devices which include:
- Biological or synthetic material that takes the place of all or a portion of a body part, such as a skin graft or a joint prosthesis
- Biological or synthetic material that assists or prevents a physiological function, such as an intrauterine device
- Therapeutic material that is not absorbed by, eliminated by, or incorporated into a body part, such as a radioactive implant
- Mechanical or electronic appliances used to assist, monitor, take the place of or prevent a physiological function, such as a cardiac pacemaker or orthopedic pin
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