ICD-10-CM & ICD-10-PCS CODING
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Emergency Room Scenarios
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ICD-10-CM: Diagnosis Coding
Chapter 19
• Injury, poisoning and certain other consequences of external causes
– Includes codes beginning with S00 through codes beginning with T88
– Examples of codes in Chapter 19 include:
• Fractures
• Nerve, blood vessel, superficial, muscle, or tendon injuries
• Open wounds
Chapter 19 Guidelines
Most categories in chapter 19 have a 7th character requirement for each applicable code. This requirement will describe the type of encounter. • A: Initial Encounter
– Used while the patient is receiving active treatment for the condition.
– Examples of “active treatment”: surgical treatment, emergency department encounter, and evaluation & treatment by a new physician.
• D: Subsequent Encounter • S: Sequela
**Categories for traumatic fractures have a separate set of 7th character values.
Injuries
• When coding injuries, assign separate codes for each injury unless a combination code is provided, in which case the combination code is assigned. – Traumatic injury codes (S00-T14.9) are
not to be used for normal, healing surgical wounds or to identify complications of surgical wounds.
• The code for the most serious injury, as determined by the provider and the focus of treatment, is sequenced first.
Superficial Injuries
• Superficial injuries such as abrasions or contusions are not coded when associated with more severe injuries of the same site.
Nerves & Blood Vessels
• When a primary injury results in minor damage to peripheral nerves or blood vessels, the primary injury is sequenced first with additional code(s) for injuries to nerves and spinal cord (such as category S04), and/or injury to blood vessels (such as category S15).
• When the primary injury is to the blood vessels or nerves, that injury should be sequenced first.
Traumatic Fractures
• Displaced and nondisplaced are new terms that have been added in ICD-10.
– A fracture not indicated whether displaced or not displaced should be coded to displaced.
• A fracture not indicated as open or closed should be coded to closed.
• Be on the lookout for new classifications and types of fractures in ICD-10 codes:
– Gustilo Classification
– Salter-Harris Type
– Barton’s, Colle’s, Smith, etc.
Fracture: Encounter Type
• Initial Encounter for Fracture (Receiving active treatment) – Examples of active treatment: surgical treatment,
emergency department encounter, and evaluation and treatment by a new physician.
– The appropriate 7th character for initial encounter should also be assigned for a patient who delayed seeking treatment for the fracture or nonunion.
• Subsequent Encounter for Fracture (Routine care during recovery)
– With Routine Healing
– With Delayed Healing
– With Nonunion
– With Malunion
• Sequela (Indicates a late effect of the fracture)
Multiple Fractures
• Multiple fractures are sequenced in accordance with the severity of the fracture.
LET’S PRACTICE Diagnosis Coding!
Scenario #1 SEE PRINTOUT AND
ASSIGN CODES!
Coding Scenario #1 Answers
S42.032A - Displaced fracture of lateral end of left clavicle, initial encounter for closed fracture
W18.30XA - Fall on same level, unspecified, initial encounter
Z86.73 - Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
Z95.0 - Presence of cardiac pacemaker
I10 - Essential (primary) hypertension
Scenario #2 SEE PRINTOUT AND
ASSIGN CODES!
Coding Scenario #2 Answers
S43.315A - Dislocation of left scapula, initial encounter
W19.XXXA - Unspecified fall, initial encounter
Y92.129 - Unspecified place in nursing home as the place of occurrence of the external cause
I10 - Essential (primary) hypertension
E75.5 - Other lipid storage disorders
E31.9 - Polyglandular dysfunction, unspecified
Z86.73 - Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
Scenario #3 SEE PRINTOUT AND
ASSIGN CODES!
Coding Scenario #3 Answers
F07.81 - Postconcussional syndrome
I10 - Essential (primary) hypertension
E03.9 - Hypothyroidism, unspecified
E11.9 - Type 2 diabetes mellitus without complications
Scenario #4 SEE PRINTOUT AND
ASSIGN CODES!
Coding Scenario #4 Answers
S82.831A - Other fracture of upper and lower end of right fibula, initial encounter for closed fracture
W07.XXXA - Fall from chair, initial encounter
K21.9 - Gastro-esophageal reflux disease without esophagitis
M81.0 - Age-related osteoporosis without current pathological fracture
E78.0 - Pure hypercholesterolemia
I10 - Essential (primary) hypertension
Scenario #5 SEE PRINTOUT AND
ASSIGN CODES!
Coding Scenario #5 Answers
S10.93XA - Contusion of unspecified part of neck, initial encounter
S30.0XXA - Contusion of lower back and pelvis, initial encounter
W20.8XXA - Other cause of strike by thrown, projected or falling object, initial encounter
Scenario #6 SEE PRINTOUT AND
ASSIGN CODES!
Coding Scenario #6 Answers
S92.211A - Displaced fracture of cuboid bone of right foot, initial encounter for closed fracture
S92.001A - Unspecified fracture of right calcaneus, initial encounter for closed fracture
S92.251A - Displaced fracture of navicular [scaphoid] of right foot, initial encounter for closed fracture
J45.909 - Unspecified asthma, uncomplicated
F17.210 - Nicotine dependence, cigarettes, uncomplicated
W10.9XXA - Fall (on) (from) unspecified stairs and steps, initial encounter
Y92.814 - Boat as the place of occurrence of the external cause
Scenario #7 SEE PRINTOUT AND
ASSIGN CODES!
Coding Scenario #7 Answers
S62.501A - Fracture of unspecified phalanx of right thumb, initial encounter for closed fracture
W22.8XXA - Striking against or struck by other objects, initial encounter
Y93.64 - Activity, baseball
Scenario #8 SEE PRINTOUT AND
ASSIGN CODES!
Coding Scenario #8 Answers
S71.112A - Laceration without foreign body, left thigh, initial encounter
W27.8XXA - Contact with other nonpowered hand tool, initial encounter
ICD-10-CM: Question and
Answer Session
ICD-10-PCD: Procedure Coding
Procedure Sections
• Medical and Surgical – Drainage, Repair
• Placement – Packing, Immobilization, Compression,
Dressing
• Administration – Transfusion, Irrigation
• Extracorporeal Assistance and Performance – Restoration
Medical and Surgical Section
• Includes 31 root operations
– Be sure to keep the definitions of these root operations handy. Look for them at the front of your ICD-10-PCS codebook.
• Procedure codes from this section will always have a first character of…
… 0
Medical and Surgical Section
• Drainage
– Taking or letting out fluids and/or gases from a body part.
– Example: Percutaneous chest tube placement for right pneumothorax
• 0W9930Z
Medical and Surgical Section
• Repair
– Restoring, to the extent possible, a body part to its normal anatomic structure and function.
– Example: Bilateral Inguinal Open Herniorrhaphy
• 0YQA0ZZ
• Remember that if MESH is used during a hernia repair it will be considered a different root operation
Placement Section
• Includes 7 root operations.
– The root operations represent procedures for putting a device in or on a body region for the purpose of protection, immobilization, stretching, compression, or packing.
• Procedure codes from this section will always have a first character of…
… 2
Placement Section
• Packing
– Putting material in a body region or orifice.
– Example: Packing of abdominal wall wound
• 2W43X5Z
Placement Section
• Immobilization
– Limiting or preventing motion of an external body region
– Example: Application of cast to right wrist
• 2W3CX2Z
Placement Section
• Compression
– Putting pressure on a body region
– Example: Placement of intermittent pneumatic compression device, covering right lower leg
• 2W1LX7Z
Placement Section
• Dressing
– Putting material on a body region for protection
– Example: Sterile dressing placement to wound of the chest wall
• 2W24X4Z
Administration Section
• Includes 3 root operations.
– The root operations represent procedures for putting in or on a therapeutic, prophylactic, protective, diagnostic, nutritional, or physiological substance.
• Procedure codes from this section will always have a first character of…
… 3
Administration Section
• Transfusion
– Putting in blood or blood products
– Example: Bone marrow transplant using donor marrow from identical twin, central vein infusion
• 30243G1
Administration Section
• Irrigation
– Putting in or on a cleansing substance
– Example: Peritoneal dialysis via indwelling catheter
• 3E1M392
Extracorporeal Assistance and Performance Section
• Includes 3 root operations – The root operations represent
procedures that use equipment outside the body to assist or perform a physiological function.
– Example: Mechanical ventilation for greater than 96 consecutive hours. • 5A1955Z
• Remember that there are now three time classifications for mechanical ventilation (<24 hours, 24-96 hours, >96 hours)
Extracorporeal Assistance and Performance Section
• Restoration
– Returning, or attempting to return, a physiological function to its natural state by extracorporeal means
– *This root operation includes only one procedure code.
LET’S PRACTICE Procedure Coding!
Scenario #1 SEE PRINTOUT AND
ASSIGN CODE!
Coding Scenario #1 Answer
•Therapeutic percutaneous paracentesis is done to remove the patient’s peritoneal ascites.
–0W9G3ZZ
Scenario #2 SEE PRINTOUT AND
ASSIGN CODE!
Coding Scenario #2 Answer
• Nasal packing is placed for patient’s epistaxis.
– 2Y01X5Z
Scenario #3 SEE PRINTOUT AND
ASSIGN CODE!
Coding Scenario #3 Answers
• Splint is applied to patient’s left hand for immobilization of a fracture.
– 2W3FX1Z
Scenario #4 SEE PRINTOUT AND
ASSIGN CODE!
Coding Scenario #4 Answer
• Pressure dressing is applied to patient’s abdominal wall for compression of wound.
– 2W13X6Z
Scenario #5 SEE PRINTOUT AND
ASSIGN CODE!
Coding Scenario #5 Answers
• Sterile dressing applied to patient’s head wound.
– 2W20X4Z
Scenario #6 SEE PRINTOUT AND
ASSIGN CODE!
Coding Scenario #6 Answers
• Patient is transfused one unit of packed red blood cells from blood bank through peripheral IV.
– 30233N1
Scenario #7 SEE PRINTOUT AND
ASSIGN CODE!
Coding Scenario #7 Answers
• Attempted cardiac defibrillation for patient’s cardiac arrest.
– 5A2204Z
Scenario #8 SEE PRINTOUT AND
ASSIGN CODE!
Coding Scenario #8 Answers
• Patient’s eye was flushed with saline.
– 3E1CX8Z
Scenario #9 SEE PRINTOUT AND
ASSIGN CODE!
Coding Scenario #9 Answers
• Left forearm skin laceration was closed with sutures.
– 0HQEXZZ
ICD-10-PCS: Question and
Answer Session