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Why Words Matter Through a Critical Care/Pulmonary Lens

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Key Objectives for Today’s Session

1. Develop understanding of the role documentation plays in determining

patient severity of illness (SOI), risk of mortality (ROM) and physician quality

scores

2. Understand definition and key terminology changes in ICD-10-CM and ICD-

10-PCS

3. Understand the concepts of linking conditions and manifestations for more

accurate depiction of patient’s clinical status

©2014 The Advisory Board Company advisory.com

Road Map for Discussion

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Concepts Drive Documentation Requirements

Examples of Critical Care/Pulmonary Diagnoses in ICD-10-CM

Importance of Documentation and Basics of ICD-10-CM/PCS


The Evolution of Clinical Documentation

What was once a tool for communication between providers and clinicians is now the primary data

source to determine quality of patient care. Market forces are leading to Increase in documentation

scrutiny.

Who is the audience for your notes?

Other

Doctors

Care Team

Patients

State

Government

Federal

Government

Insurance

Companies Self


Increased Transparency For Patients

MyCigna.com

HealthGrades- all material and images are sourced from www.healthgrades.com (accessed on 6/18/2012)

Leapfrog- all material and images are sourced from www.leapfroggroup.org (accessed on 6/18/2012)

http://www.healthgrades.com/

http://www.leapfroggroup.org/


Transition from ICD-9-CM to ICD-10-CM/PCS

Per Bill H.R. 4302, “The Secretary of Health and Human Services may not, prior to October 1, 2015,

adopt ICD–10-CM/PCS code sets”.

2011, The Clinical documentation Improvement Specialist's Guide to

ICD-10 p.9 Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPR, C-CDI,

CCDS and Sylvia Hoffman, RN, C-CDI, CCDS.

Benefits and Goals of ICD-10-CM/PCS

• Provides better detail, a more accurate depiction, and improved

communication of patients clinical status

• Allows for more accurate payment for new procedures

• Improves capture of morbidity and mortality data

• Reduces the number of miscoded, rejected and improper claims for

reimbursement


ICD-9-CM vs. ICD-10-CM/PCS: A Comparison

Source: Nichols, J.C. (2011). ICD-10 – Physician impacts. Advisory

Board Applications and Technologies Collaborative; CMS (2013).

ICD-10 Implementation guide for small hospitals 1) Code Volume Expansion in ICD-10-CM/PCS

The main difference between ICD-9-CM

and ICD-10-CM/PCS codes, outside of

structural changes, is the SPECIFICITY of

the code.

ICD-10-CM/PCS codes specify several

components not found ICD-9-CM, such as

causal agent, type, laterality, approach,

episode of care, root operation, etc.

Why so many new codes?

14,000

69,000

4,000

72,000

ICD-9 ICD-10

Diagnosis Codes Procedure Codes


Introduction to ICD-10-CM Diagnosis Coding Structure

ICD-10-CM Codes will Contain 3-7 Alphanumeric Characters with the Following Structure

α # α/#

α/# α/# α/#

Category Sub-categories (Etiology, Anatomic Site, Severity, Laterality,

Complication)

Extension

(3-16 options

depending on

category)

α/#

Key ICD-10-CM Documentation Concepts

Specific anatomical location

Degree (mild, moderate, severe, or

unspecified; total/complete vs.

partial/incomplete)

Type (primary, secondary, unspecified) Episode of Care (Initial, Subsequent,

Sequelae)

Acuity (acute, subacute, chronic, acute on

chronic, or unspecified ) Laterality (Right, Left, bilateral, or unspecified)

Trimester (1,2,3,unspecified) Number of fetus (1-5, other)


Introduction to ICD-10-PCS Coding Structure

In this exercise, we will dissect the structure of an ICD-10-PCS code

Source: AHIMA; The Advisory Board Company research

α/#

α/# α/# α/# α/#

Body

System

Root

Operation

Body

Part

Approach Device Qualifier

α/#

α/#

1. Section –16 options identifying the general type of procedure. Example:

Medical/Surgical Section represents the vast majority of procedures

reported in an inpatient setting

2. Body System - e.g. circulatory system, respiratory system

3. Root Operation - 31 options, based on the objective of the procedure

4. Body Part - e.g. pericardium, coronary artery, heart, atrium, mitral valve

5. Approach - 7 options, e.g. open, percutaneous, percutaneous endoscopic

6. Device - 4 basic groups: Grafts/prostheses, implants, simple or mechanical

appliances, and electronic appliance

7. Qualifier - e.g. identify destination site in a Bypass, Diagnostic, Full

thickness burn

Physician documentation

required:

• Type and intent of procedure

(root operation)

• Specific anatomic sites

treated

• Approach

• Specific type of device used

• Validate surgical

complications

• Diagnoses that support

inpatient medical necessity

Section



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Key Concepts To Capture in Your Documentation

Examples of Critical Care/Pulmonary Diagnoses in ICD-10



Remember: Signs, Symptoms & Test Results Must Be Linked to Related

Diagnoses

While important pieces of the medical record, signs, symptoms and test results are not sufficient for

coders to assign a diagnosis.

Reminder: The attending physician is responsible for:

• Documenting all conditions in the progress notes

and discharge summary

• Resolving conflicts in the documentation

• Linking signs and symptoms to diagnoses may increase

SOI and ROM in the inpatient setting. (The terms

‘probable’, ‘likely’, or ‘suspected’ are all acceptable on the

inpatient record)

• In the ambulatory setting, documentation regarding patient

condition should be to the highest level known, treated or

evaluated

• Abnormal findings (laboratory, x-ray, pathology and other

diagnostic test results) cannot be coded and reported

unless the clinical significance is identified by the treating

provider ICD-10-CM Official Coding Guidelines III.B


Linking Conditions Critical to Capturing Patient Severity

Examples: Linking Diseases

• Hypertension with heart disease

• Endocarditis due to staph aureus

• Right heart failure due to primary pulmonary hypertension

Use terms like “due to” or “with”

Note: Lists, commas, and the word “and” do not link conditions

There is a significant increase in the number of “combination codes” available in the ICD-10-CM/PCS

code set. These codes can help capture the highest level of complexity and acuity in the public eye.

Linking clinically relevant conditions, where appropriate, is the key

takeaway for physicians. Coders cannot assume clinical relationships.


Severity of Illness (SOI) and Risk of Mortality (ROM)

Documentation drives SOI and ROM level assignment. These levels are used to measure patient

acuity, and therefore drive expected patient LOS and mortality rate.

Level Assigned SOI/ROM Category

Minor 1

Moderate 2

Major 3

Extreme 4

Breakdown of SOI/ROM and their Implication on Quality Measures

Four mutually exclusive SOI/ROM categories exist (1-4), and are determined

based on a number of factors including primary and secondary diagnoses,

comorbidities, demographics, patient history, treatment/procedure delivered, etc.



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Key Concepts To Capture in Your Documentation

Examples of Critical Care/Pulmonary Diagnoses in ICD-10



ICD-10-CM/PCS Critical Care/Pulmonary Topics Covered Today

Let’s start with these diagnoses to help explain what documentation will be like in ICD-10-CM/PCS

1 Cerebral Vascular Accidents/

Glasgow Coma Scale

2 Respiratory

3 Acute Myocardial Infarctions

4 Heart Failure

5 Sepsis

6 Kidney Disease

7 Tobacco Exposure

8 Asthma

9 COPD & Emphysema


Glasgow Coma Scale

1) ¹Indicates MCC designation

16

GCS Score can now be captured in ICD-10-CM

GCS Score

Criteria Type

& Points 1 2 3 4 5 6

Eyes Open Never¹ To pain¹ To sound Spontaneous N/A N/A

Best Verbal

Response None¹

Incomprehensible

words¹

Inappropriate

words

Confused

conversation

Oriented;

converses

normally

N/A

Best Motor

Response None¹

Extension to painful

stimuli¹

Abnormal flexion

to painful stimuli

Flexion

withdrawal from

painful stimuli¹

Localizes

painful

stimuli

Obeys

commands

Used in conjunction with:

• Traumatic brain injury

• Acute Cerebrovascular disease

• Other sequelae of cerebrovascular disease

Note

Scale:

• Minor, GCS > 13

• Moderate, GCS 9-12

• Severe, GCS <9

• Report each of the subcategory scores rather

than just the total score

• Some coma diagnoses codes are categorized as

MCCs

Documentation Tip


CVA Documentation

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Key Points

• Acuity

• Laterality

• Identify if hemorrhage or infacrtion

• Site of non-traumatic intracerebral hemorrhage

• Hemisphere

• Brain stem

• Cerebellum

• Intraventricular

• Multiple localized

• Cerebral infarctions documentation must include:

• Embolism

• Thrombosis

• Stenosis/occlusion

• Artery if known

• Associated symptoms

• Presence of hemiparesis and/or hemiplegia

• Hand dominance of patient (right, left, or ambidextrous)

• tPA administration in a different facility in the last 24 hours


Sequelae (Late Effects)

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4 Critical Components to Capture for all Sequelae/Late Effects Identified:

1. Document Deficits Present

Can include:

• Cognitive deficits

• Speech & Language deficits

• Aphasia

• Dysphasia (include type)

• Dysarthria

• Fluency disorder

• Stuttering following non-traumatic SAH

• Monoplegia

• Hemiplegia & hemiparesis

2. Document Time Onset for Each

Sequelae

• Is this deficit “new” or “old”?

• Clearly link all deficits to the appropriate event

3. Document Laterality of Deficit Example: “hemiplegia on left side, non-dominant side”

4. Document Patient’s Dominance

• Left-handed

• Right-handed

• Ambidextrous

• There is no time limit on when a sequelae (late effect) codes can be used

• The term “sequelae” replaces the term “late effect” in ICD-10-CM. This diagnosis will require the

provider documentation to link the sequelae to the initial event

Documentation Tip


Pneumonia & Influenza

ICD-10-CM Pneumonia & Influenza Documentation Concepts

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Pneumonia

Identify the organism

Viral or Bacterial

Known or suspected organism

Example: “Probable pneumonia due to

MRSA”

Remember: Probable, likely and suspected are

acceptable terms in the inpatient setting

Link any associated

conditions to the

pneumonia

• Sepsis due to pneumonia

• Acute respiratory failure due to pneumonia

Aspiration Pneumonia Due to

• solids or liquids

• anesthesia during labor and delivery

• anesthesia during puerperium

Influenza

Type • Influenza virus

Associated conditions • Pneumonia

• Respiratory illness (laryngitis, pharyngitis)

• Encephalopathy

• Myocarditis

• Remember to document

tobacco use

• Do not need a + CXR or

culture

• Documentation of CAP,

HCAP, FAP, or HAP doesn’t

capture severity of illness

Documentation Tips:


Respiratory Failure

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ICD-10-CM Documentation Concepts

Acuity • Acute

• Chronic

• Acute on Chronic

Specificity With

• Hypoxia

• Hypercapnia

• Unspecified

Tobacco Use

Document if patient has

• exposure to environmental tobacco smoke

• history of tobacco use

• occupational exposure to tobacco smoke

• Mild, moderate or severe respiratory distress and respiratory insufficiency do not equal

respiratory failure

• Clarify the need for continuous home oxygen – dependence on home oxygen does not capture

severity of illness

• Blood gases and mechanical ventilation are not required

Documentation Teaching Point:


Understanding Implications for AMI Changes

Limited time frame for acute designation will require increased specificity

Patient enters ER with

symptoms MD identifies AMI of

the anterior wall

Patient history of STEMI

two weeks ago

Specify in days for accurate code

selection Understand implications for MIs

• Acute MI – within the last 28 days

• Subsequent MI – additional MI within 28

days

• New Acute MI – additional MI after 28 days

• Old MI – MI more than 28 days old

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PMH: Patient suffered a STEMI involving the left circumflex coronary artery two

weeks ago and was discharged home. Same patient is admitted today for a

STEMI of the anterior wall.

“a month ago”

> 28 Days?

≤ 28 Days

Notes


Acute Myocardial Infarction

Initial ST elevation (STEMI) myocardial infarction of anterior wall involving left main coronary artery

Consistent across all AMIs Type and

Site

Specific

artery

Order

Myocardial Infarction

Initial

STEMI

Inferior Wall

STEMI

Anterior Wall

Left main coronary artery

Left anterior descending coronary artery

Other coronary artery

Subsequent

STEMI Unspecified site

STEMI

Other site

NSTEMI

0 I 2 1 1

22


Specify: STEMI or NSTEMI

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Documentation Requirements:

• Specific Wall – i.e. Anterior, Inferior

• Specific Artery – i.e. Left main, Left anterior descending

• Was tPA administered? At transferring facility or current facility?

• Tobacco exposure

• Current complication of STEMI

• Hemopericardium will need further clarification if related to and a complication of

the MI; or unrelated and not a complication of the MI.

• Unless otherwise specified, AMI defaults to STEMI in ICD-10-CM

• Carry all clinically significant information from the cath report / echo report or other testing

results into the progress notes to ensure it will be captured in the coded record



Look Out For These Conditions

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Atherosclerosis, Angina, and Acute Coronary Syndrome (ACS)

Key Points:

• ICD-10-CM assumes Angina pectoris is to due atherosclerosis unless otherwise documented

• Acute coronary syndrome (ACS) sequences to a nonspecific diagnosis of unspecified acute

ischemic heart disease

• Clarifying ACS and Angina (unstable, with spasm, other, unspecified) can impact SOI/ROM

and DRG assignment


A Valid Question

25

Some doctors might have noticed

unspecified options for both the

vessel type and angina. Why should

I document them both if a coder can

code without it?

“

”


Specificity Drives Severity

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Which means that vessel type and angina type matter. In some cases, presence of angina serve as a

severity driver

Unspecified Coronary

Bypass Graft

Angina

(Unspecified)

No comorbid condition

(CC) present

Comorbid condition (CC)

present

Comorbid condition (CC)

present

Native Coronary Artery Of

Transplanted Heart

Autologous Vein Coronary

Artery Bypass Graft

Unstable Angina

Pectoris

Angina with

Documented Spasm


Heart Failure Specificity for Severity of Illness

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Link all pieces of an illness to get the highest severity of illness to support tests, procedures or

therapies

Components to Best Practice Documentation

• Specify Acuity: Acute, Chronic or Acute on Chronic Heart Failure

• Specify Type: Systolic, Diastolic, or Combined systolic and diastolic

• Clarify the relationship of the hypertension to the heart disease or heart failure

Linking together may impact the severity of illness and risk of mortality of the patient

• Identify, if known, the underlying etiology of the failure

Is it an exacerbation of stable heart failure, due to fluid overload, or due to missed

dialysis

• Echocardiogram Findings

If available, document findings of systolic, diastolic or combined heart failure from the

echo in your progress notes and discharge summary

• Hypertensive heart disease with heart failure

• Heart failure following surgery

Heart Failure Combination Codes Examples:


What Are They CCs and MCCs?

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Comorbid Conditions (CCs) and Major Comorbid Conditions (MCCs). To capture severity of illness

(SOI), please specify in your documentation

Major Comorbid Conditions (MCCs) Comorbid Conditions (CCs)

• Systolic heart failure

• Chronic systolic heart failure

• Diastolic heart failure

• Chronic diastolic heart failure

• Combined systolic and diastolic

heart failure

• Heart failure due to hypertension

with CKD Stage 5 or ESRD

• Rheumatic heart failure

• Left ventricular heart failure

• Acute systolic heart failure

• Acute on chronic systolic heart

failure

• Acute diastolic heart failure

• Acute on chronic diastolic heart

failure

• Acute combined systolic and

diastolic heart failure

• Acute on chronic combined

systolic and diastolic heart

failure

• Acute pulmonary edema of lung

without heart disease or heart

failure

CHF→ Systolic Heart Failure (CC) → Acute Systolic Heart

Failure (MCC)

Chest Pain → Unstable Angina (CC) → Probable NSTEMI

(MCC)

Specificity Matters


Heart Failure

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Acute systolic heart failure

Heart Failure

Diastolic

Systolic

Acute

Chronic

Acute on Chronic

Unspecified

Combined Systolic + Diastolic

Unspecific

I 0 5 2

Heart Failure Type of

Heart Failure

1

Severity

If a patient has HTN and CHF, the physician

documentation needs to identify a cause and effect

relationship.

Example: Hypertensive heart disease with

acute systolic heart failure due to medication

noncompliance



Documenting Practice: Echocardiogram Evidence

30

Be sure to document any of the following complications identified on Echocardiogram

• Aneurysm

• Intracavitary thrombus

• Papillary muscle rupture

• Thrombosis in the atrium, appendage, or

ventricle

• Pericardial effusion

• Right ventricular infarction

• Pseudoaneurysm

• Septal defect: atrial or ventricular

A Comprehensive Chart is Always Best Practice!


Sepsis, Severe Sepsis and Septic Shock

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Properly documenting sepsis in ICD-10-CM has a significant impact on severity captured.

Documentation Concepts

Bacteremia vs Sepsis in the coding world

• It is imperative the physician clarifies if the patient has a

systemic infection (sepsis) or only has the finding of bacteria in

the bloodstream

• “Bacteremia” is an abnormal lab finding and is considered a sign

and symptom, it does not represent a systemic process

• “Sepsis” replaces the term “Septicemia” used in ICD-9-CM

Sepsis Documentation Should:

• Link the underlying local infection (e.g. PNA) to the systemic

infection

• Identify the suspected/known organism and any drug resistance

• Clarify if there is associated shock or organ failure

Severe Sepsis is sepsis with documented organ failure.

Documentation required:

• Identification of the suspected/known organism

• Identification of associated organ failure

Example: Acute renal failure due to E Coli sepsis

Septic Shock generally refers to circulatory failure

associated with severe sepsis. Documentation required:

• Identification of the suspected/known organism

• Identification of associated organ failure

SIRS Criteria

Temp < 96.8°F(36°C) or

> 100.4°F (38°C)

Pulse > 90 bpm

RR > 20 breaths/min or

PaCO2 < 32 mmHg

WBC

12,000 or

< 4,000 cells/mm3

or > 10% bands

Septic Shock

Severe Sepsis

Sepsis


Kidney Disease

ICD-10-CM provides further specificity of type of kidney damage in order to reflect accurate severity

32

Acute Renal Failure/Injury

Document the

Type of Damage

Acute Renal Failure or Acute Kidney Injury “with”:

• Tubular necrosis (N17.0)

• Acute cortical necrosis (N17.1)

• Medullary necrosis (N17.2)

• Associated underlying condition

Chronic Kidney Disease

Identify the Stage Stage I-V

(stages IV-V are CCs)

Is the CKD related to Hypertension or Diabetes? If so, document the

linkage (“due to”/ “with”)

Transplant Status Document if the patient has had a transplant

or

If the patient is a candidate for a transplant

CKD as a Manifestation,

link diseases

Examples:

• Type 2 DM with diabetic

CKD stage 5

• Hypertensive heart

disease with CKD stage

3 and with chronic

diastolic heart failure

• Hypertensive with CKD

Stage 4

Use terms like

“due to” or “with”

Note: Lists, commas, and the

word “and” do not link

conditions


Tobacco Exposure

ICD-10-CM requires documentation of tobacco exposure, specifically for:

• Pulmonary disease

• Diseases of the head, neck, mouth and esophagus

• During pregnancy, birth and puerperium

Document Level of Usage Type of Usage/Exposure

No Use

Exposure • During pregnancy, birth and

puerperium

• Environmental tobacco smoke (2nd

hand smoke)

Use • Tobacco use (current)

• Tobacco use (past)

Dependence • Nicotine dependence and source ( e.g.

cigarettes, chewing tobacco, other)

• Nicotine dependence in remission

‒ With or without other nicotine-

induced disorders


Asthma

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ICD-10-CM Documentation Concepts (now aligned with National Heart, Lung, and Blood Institute

(NHLBI) guidelines)

Document (if present):

• Exercise-induced

bronchospasm

• Cough variant asthma

• Detergent asthma

• Eosinophilic asthma

• Miners asthma

• Wood asthma

• Wheezing

Always document tobacco

exposure

Documentation Tip:

J 4 5 1 5 Chronic lower respiratory diseases

(Asthma)

Type and

acuity

“With”

Severe persistent asthma with acute exacerbation

Types:

Intermittent

Persistent

Acuity:

Mild

Moderate

Severe

“With”

Uncomplicated

Acute exacerbation

Status asthmaticus


Severity of Asthma Classification

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Presentation of Asthma Before Treatment*

Acuity Symptoms Nighttime

Awakenings Lung Function

Mild Intermittent • Symptoms ≤ 2x/week

• Asymptomatic/normal PEF

between exacerbations

• Exacerbations of varying

intensity are brief

≤ 2x/month • FEV or PEF ≥ 80%

predicted

• PEF variability < 20%

Mild Persistent • Symptoms > 2x/week but

< 1x per day

• Exacerbation may affect

activity

> 2x/month • FEV or PEF ≥ 80%

predicated

• PEF variability 20-30%

Moderate Persistent • Daily Symptoms

• Daily use of inhaled short-

acting beta-agonist

• Exacerbations affect activity

• Exacerbation ≥ 2x/week or

≥1 per day

> 1x/week • FEV or PEV 60-80%

predicted

• PEF variability >30%

Severe Persistent • Symptoms throughout the

day

• Limited physical activity

• Frequent exacerbations

Frequent • FEV or PEV ≤ 60%

predicted

• PEF variability > 30%

Source: based on the National Heart, Lung, and Blood

Institute (NHLBI) asthma severity classification scale


COPD & Emphysema

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ICD-10-CM Documentation Concepts

Reminder:

• Always document tobacco

exposure

Key Concepts to Remember:

COPD • Associated with acute lower respiratory infection

• Acute exacerbation?

Emphysema

• Specify type

‒ Unilateral

‒ Panlobar

‒ Centrilobular

Other considerations

• Compensatory

• Secondary to inhalation of chemical gases, fumes, or vapors

• Chronic obstructive bronchitis

• Interstitial

• Mediastinal

• Surgical subcutaneous

• Traumatic subcutaneous


Documentation of Complications of Care

37

ICD-10-CM coding terminology will change to more accurately identify when complications occur

Two Key Components to Remember:

ICD-10-CM has replaced the term post-operative with “post-procedural” or “post-surgical”

Conditions occurring in the post-operative period should be clarified as:

• An expected post-procedural or post-surgical condition

• An unexpected post-procedural or post-surgical condition related to surgical care (a

complication of care)

• An unexpected post-procedural or post-surgical condition, unrelated to surgical procedure

• An unexpected post-procedural or post-surgical condition, related to the patient’s underlying

medical comorbidities


For Reference: Root Definitions for ICD-10-PCS Terms

Term Definition

Alteration Modifying the natural anatomic structure of a body part without affecting the function of the body part

Bypass Altering the route of passage of the contents of a tubular body part

Change Taking out or off a device from a body part and putting back an identical or similar device in or on the same body part without

cutting or puncturing the skin or a mucous membrane

Control Stopping, or attempting to stop, post procedural bleeding

Creation Making a new genital structure that does not take over the function of a body part

Detachment Cutting off all or a portion of the upper or lower extremities

Dilation Expanding an orifice or the lumen of a tubular body part

Division Cutting into a body part without draining fluids and/or gases from the body part in order to separate or transect a body part

Drainage Taking or letting out fluids/or gases from a body part

Excision Cutting out or off, without replacement, a portion of a body part

Extirpation

Taking or cutting out solid matter from a body part (the solid matter may be an abnormal byproduct, imbedded or may be or may

not have been broken into pieces)

Extraction Pulling or stripping out or off all or a portion of a body part by the use of force (A qualifier of diagnostic is used for biopsies)


Root Definitions Continued

Term Definition

Fragmentation Breaking solid matter in a body part into pieces

Fusion Joining together portions of an articular body part rendering the articular body part immobile

Insertion Putting in a nonbiological appliance that monitors, assists, performs or prevents a physiological function but does not physically

take the place of a body part

Inspection Visually and/or manually exploring a body part

Map Locating the route of passage of electrical impulses and/or locating functional areas in a body part

Occlusion Completely closing an orifice or lumen of a tubular body part

Reattachment Putting back in or on all or a portion of a separated body part to its normal location or other suitable location

Release Freeing a body part from an abnormal physical constraint by cutting or by use of force

Removal Taking out or off a device from a body part


Root Definitions Continued

Term Definition

Repair Restoring, to the extent possible, a body part to its normal anatomic structure and function

Replacement Putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part

Reposition Moving to its normal location or other suitable location all or a portion of a body part

Resection Cutting out or off, without replacement, all of a body part

Restriction Partially closing the orifice or lumen of a tubular body part

Revision Correcting, to the extent possible, a malfunctioning or displaced device

Supplement Putting in or on biological or synthetic material that physically reinforces and/or augments the function of a portion of a body part

Transfer Moving, without talking out, all or a portion of a body part to another location to take over the function of all or a portion of a body

part

Transplantation Putting in or on all or a portion of a living body part taken from another individual or animal to physician take the place and/or

function of all or a portion of a similar body part


ICD-10-PCS: Approach

www.cms.gov/Medicare/Coding/ICD10/.../pcs_2013_guidelines.pdf

Approach Definition

1. Open Cutting through the skin or mucous membrane and any other body layers necessary to

expose the site of the procedure

2. Percutaneous Entry, by puncture or minor incision, of instrumentation through the skin or mucous

membrane and/or any other body layers necessary to reach the site of the procedure

3. Percutaneous Endoscopic Entry, by puncture or minor inclusion, of instrumentation through the skin or mucous

membrane and/or any other body layers necessary to reach and visualize the site of the

procedure

4. Via Natural or Artificial

Opening

Entry of instrumentation through a natural or artificial external opening to reach the site

of the procedure


Opening Endoscopic

Entry of instrumentation through a natural or artificial external opening to reach the site

of the procedure


Opening Endoscopic with

Percutaneous Endoscopic

Assistance

Entry of instrumentation through a natural or artificial external opening to reach and

visualize the site of the procedure, and entry, by puncture or minor incision, of

instrumentation through the skin or mucous membrane and any other body layers

necessary to aid in the performance of the procedure

7. External Procedures performed directly on the skin or mucous membrane and procedures

performed indirectly by the application of external force through the skin or mucous

membrane

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