As the largest outsource coding provider in the country we have identified trends and gained unique insights from our coders throughout the transition to ICD-10. We are sharing these insights with the broader HIM Community through our bi-weekly blog series "ICD-10 Quick Tips."
The subject matter for this series is currated based on the trending topics in our online question and answer system which services over 1,200 of our HIM professionals. Our Subject Matter Experts have an average of 20 years of experience and are considered leaders in their field.
This week's post comes from National Compliance Manager, Melissa McLeod, CDIP, CCDS, CCS, CPC, CPC-1, and AHIMA Approved ICD-10 Trainer.
Selection of the Root Operation is a new concept in ICD-10-PCS and is causing some ripples in the industry. In ICD-9-CM, the classification system was global in terms of concepts and anatomy comprehension, i.e., an excision was an excision. There was no distinction whether the intent of the excision was to remove an entire organ. An incision and drainage of skin and subcutaneous tissue was one code without further distinction related to tissue involvement or the intent of the procedure, approach or devices utilized. The “intent” of the procedure is a new element to the thought process for the coding profession and understanding this is vital to correct classification of procedures. Operationalizing the fundamentals is a critical to coding procedures in ICD-10-PCS.
As a result, there have been many questions related to root operations in the ICD-10-PCS coding system. Let's discuss and address some frequent coding questions related to common procedures performed in both the inpatient and outpatient care settings.
INCISION AND DRAINAGE
When a provider performs an incision and drainage on the skin or subcutaneous tissue/fascia, there may be many different and multiple root operations being performed. The possible selections are:
Drainage – draining of an abscess
Extirpation – removal of a foreign body
Excision – excisional debridement
Destruction – cauterizing bleeding or lesion
Extraction – non-excisional debridement
Repair – suture of a vessel, ligament, muscle, tendon, etc.
It is important to understand the “intent” of the procedure being performed, and there may be more than one of these “root operations” being performed during a single episode.
Additional factors to consider are:
Tissue involved in the procedure – a critical component of I&D procedures is knowing the depth of tissue involved in the incision and drainage. Possible tissue involvement includes:
himagine solutions, Inc. has gathered data through audits and documentation assessments performed over the past few years, and recommends for clients to review emergency department (ED) templates to ensure the key documentation elements are included in the record to facilitate coding these type of procedures, thus diminishing the need for retrospective queries. We recognize many I&Ds are performed in the ER (ED) and often the documentation is insufficient, particularly as it relates to tissue involvement. It is often not clear if just the skin is involved or if deeper layers such as the subcutaneous tissue/fascia are also being operated on.
When multiple layers are involved, code only to the deepest level of tissue involvement. Using the ICD-10-PCS Coding guideline:
Overlapping body layers
If the root operations Excision, Repair or Inspection are performed on overlapping layers of the musculoskeletal system, the body part specifying the deepest layer is coded.
We understand from this guideline, to use the deepest layer of tissue involved in the procedure. So, for example, if excisional debridement is performed on skin, subcutaneous tissue/fascia and muscle – code only excision of muscle.
EXCISION VS. DRAINAGE FOR BIOPSY PURPOSES
Frequent questions come into the hotline related to whether excision or drainage is being performed particularly as it pertains to biopsies. Generally speaking, the rule of thumb would be if fluid or gases are being aspirated or drained, then drainage would be the appropriate root operation; if tissue is being excised (may or may not be sent to pathology), then excision would be the appropriate root operation. Examples of drainage may be: drainage of an abscess, paracentesis, thoracentesis, needle aspiration of abscess or other fluids. An example procedure:
Patient with a deep subcutaneous abscess of the left foot. The patient is prepped and draped and a needle aspiration of the abscess is performed and fluid sent to cytology for organism identification. The wound is then incised and drainage of the abscess is performed via open approach. The tissue is then debrided of necrotic tissue with scalpel down to viable bleeding tissue. Subcutaneous tissue is then sutured with 3-0 vicryl and skin is sutured with 4-0 prolene. The patient is sent to the recovery room in satisfactory condition.
0J9R3ZX – drainage of abscess for diagnostic purposes, left foot, percutaneous approach
0J9R0ZZ – drainage of abscess for therapeutic purposes, left foot, open approach
0JBR0ZZ – excisional debridement, left foot, open approach
INSERTION OF DEVICES
Among coders there seems to be some confusion when deciding if an operation is being performed for the insertion of a device vs. the reason for the insertion of the device. Many times a device is being inserted to perform a different root operation than just “insertion”. Examples include:
Dilation – Insertion of a stent into coronary artery or common bile duct to enlarge the lumen, stent insertion for ureteral strictures
Replacement – joint, radial or humeral head, breast implant, AAA excision with graft replacement
Drainage – drainage with a drainage device remaining at the end of the procedure, foley catheter insertion
Supplement – hernia repair with mesh
Restriction – insertion of a stent graft for repair of AAA, insertion of extraluminal device for clipping a cerebral aneurysm, Cervical cerclage using Shirodkar technique.
Occlusion – insertion of band or clip for variceal or gastrointestinal arterial bleeds, tubal ligation with clips or bands, embolization of uterine artery with coils
Bypass – tracheostomy with tube, ventriculoperitoneal shunt, LIMA bypass to coronary artery
So as you can see, device insertions serve many purposes and perform many functions. When coding a device insertion, always keep in mind the purpose of the device being inserted and the root operation it is meant to perform.
The definition of insertion is: Putting in a non-biological device that monitors, assists, performs or prevents a physiological function but does not physically take the place of a body part. The root operation Insertion represents those procedures where the sole objective is to put in a device without doing anything else to a body part. Procedures typical of those coded to Insertion include putting in a vascular catheter, a pacemaker lead, or a tissue expander.
Examples for insertion [only] of devices includes:
Insertion of a tissue expander in the breast
Central line infusion device into the superior vena cava
Swan Ganz catheter insertion
Brachytherapy seed insertion into the prostate
IVC filter insertion into the inferior vena cava
Bone growth stimulator insertion into the femur
In conclusion, the root operation identification is based on the intent and objective of the procedure. We as coders, must change our thinking as it relates to the coding of procedures and must understand the objective of procedures. We must ask ourselves, “What is the Provider trying to accomplish?” For the past 35 years we have not had to identify the difference between an excision or resection procedure, or had to ask ourselves, “what is this device meant to accomplish?” The in depth comprehension of anatomy we now need is also a new concept for us. To overcome these challenges we must understand the fundamentals of the ICD-10 PCS coding system.
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