ICD-10-CM & ICD-10-PCS CODING ROUNDTABLES

1 ICD-10-CM & ICD-10-PCS CODING ROUNDTABLES Emergency Room Scenarios THANK YOU TO OUR CODING roundtable SPONSOR CHANNEL PUBLISHING! 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.

2 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 ( ) 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.

3 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.

4 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!

5 CODING Scenario #1 Answers - Displaced fracture of lateral end of left clavicle, initial encounter for closed fracture - Unspecified fall, initial encounter - Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits - Presence of cardiac pacemaker I10 - Essential (primary) hypertension Scenario #2 SEE PRINTOUT AND ASSIGN CODES! CODING Scenario #2 Answers Other dislocation of left shoulder joint, initial encounter - Unspecified fall, initial encounter - Unspecified place in nursing home as the place of occurrence of the external cause I10 - Essential (primary) hypertension Hyperlipidemia, unspecified - Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits Scenario #3 SEE PRINTOUT AND ASSIGN CODES!

6 CODING Scenario #3 Answers - Postconcussional syndrome I10 - Essential (primary) hypertension - Hypothyroidism, unspecified - Type 2 diabetes mellitus without complications Scenario #4 SEE PRINTOUT AND ASSIGN CODES! CODING Scenario #4 Answers - Other fracture of upper and lower end of right fibula, initial encounter for closed fracture - Fall from chair, initial encounter - Gastro-esophageal reflux disease without esophagitis - Age-related osteoporosis without current pathological fracture - Pure hypercholesterolemia I10 - Essential (primary) hypertension Scenario #5 SEE PRINTOUT AND ASSIGN CODES! CODING Scenario #5 Answers - Contusion of other specified part of neck, initial encounter - Contusion of unspecified back wall of thorax, initial encounter - Other cause of strike by thrown, projected or falling object, initial encounter Scenario #6 SEE PRINTOUT AND ASSIGN CODES!

7 CODING Scenario #6 Answers - Displaced fracture of cuboid bone of right foot, initial encounter for closed fracture - Unspecified fracture of right calcaneus, initial encounter for closed fracture - Displaced fracture of navicular [scaphoid] of right foot, initial encounter for closed fracture - Unspecified asthma, uncomplicated - Nicotine dependence, cigarettes, uncomplicated - Fall (on) (from) unspecified stairs and steps, initial encounter - Boat as the place of occurrence of the external cause Scenario #7 SEE PRINTOUT AND ASSIGN CODES! CODING Scenario #7 Answers - Fracture of unspecified phalanx of right thumb, initial encounter for closed fracture - Striking against or struck by other objects, initial encounter - Activity, baseball Scenario #8 SEE PRINTOUT AND ASSIGN CODES!

8 CODING Scenario #8 Answers - Laceration without foreign body, left thigh, initial encounter - Contact with other nonpowered hand tool, initial encounter ICD-10-CM : Question and Answer Session ICD-10-PCS : 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 .. 0 Medical and Surgical Section Drainage Taking or letting out fluids and/or gases from a body part.

9 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 0 YQA0ZZ 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 .. 2 Placement Section Packing Putting material in a body region or orifice.

10 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.