“navegar e codificar” congresso...to decipher the icd-10-pcs root operations, learn the...

“NAVEGAR E CODIFICAR”

9º Congresso da AMACC 3 e 4 de Março de 2017

"Codificação pela ICD-10CM/PCS"

Isabel Carvalho

2 "Navegar e Codificar"

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"Navegar e Codificar" 23

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O CODIFICADOR

ATRIBUTOS DE UM CODIFCADOR EXCECIONAL

Six factors that remote coders need to consider

• Your home office needs to be very secure: HIPAA is very strict about how patient information is handled. You become responsible for compliance. Even without federal law, you have an obligation to protect patient information. This means only you have access to the records you will work on. Think about how you want your medical information to be handled.

• Working in isolation: Working without coworkers can create a very productive environment because there are fewer distractions. (Unless you have a very active home with children for example.) But the lack of interaction may make you feel isolated in a not so good way. Some people need the interaction found in a workplace.

• Productivity counts: Because a healthcare provider will have less direct supervision, it will want quantifiable results from you. Be prepared to track how many medical records and claims you can process.

• Flexibility equals opportunity: This will favor freelancers. Healthcare providers' needs may not be best served by hiring full-time employees. But maybe a few hours here and there are needed to keep cash flow healthy.

• You can work from anywhere: That is an advantage and disadvantage. While working from the beach sounds like a selling point, it sucks to have to take your laptop on vacation. This mainly pertains to freelancers. You need to have backups in case you need to take time off for vacation, family emergencies or sickness.

IMPLEMENTAÇÃO ICD10

MMI - The Medical Management Institute Online ICD-10 classes for effective learning

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To Decipher the ICD-10-PCS Root Operations,

Learn the Definitions

• In the ICD-10 procedural coding system (PCS), identifying the root operation— the

third character in the PCS code—is integral to assigning codes. This character defines the “objective” of the procedure, and 31 root operations are included in the medical and surgical section of the PCS.

• While some of the terms are similar to ICD-9-PCS, the definitions differ except in a few cases (such as the following terms: resection, excision and removal). It is important for coders to understand the differences between the root operations, which can be divided into nine categories. Each category has several terms with specific definitions.

• Per CMS guidelines, it is the coder’s responsibility to determine what the documentation in the medical record equals in the PCS definitions. The physician is not expected to use the terms that are in the PCS code descriptions. As such, learning the definitions of these terms and being able to apply them to the physician documentation is an important part of a coder’s ICD-10 PCS education.

• The rest of this article separates the root operations by category and then lists theCenters for Medicare & Medicaid Services’ definitions of each operation.

Root Operation: Removing Some or All of a Body Part (.....)

How to Approach Fascia Release Coding in ICD-10-PCS

In this session of TEN TIPS, we are going to explain how to go about assigning ICD-10-PCS codes for fasciotomy procedures. If you have been practicing with ICD-10-PCS coding for a while, you may notice that sometimes the correct root operation to assign is not always obvious. A fasciotomy for release of compartment syndrome is one of these weird situations.

Tep Tips for ICD-10 PCS Coding February 2015

Posted in Education on February 02, 2015 by HIA connect

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Adelaide M. La Rosa, RN, BSN, CCDS, AHIMA-Approved

ICD-10-CM/PCS Trainer/Ambassador

Director, Clinical Documentation Improvement Program

St. Francis Hospital

Roslyn, NY

ICD-10 … The Journey Continues

"Navegar e Codificar"

Fractures

• Type (Gustilo open fracture classification)

• Specific anatomical site

• Displaced or not

• Laterality

• Type of encounter

Bone, Joint, and Muscle

• Site

• Laterality

• Stages at healing

• Episode of care

Laterality (Right/Left)

• Cancers

• Cerebral infarction

• Pressure ulcers

• Extremity atherosclerosis

• Arthritis

• Fractures

• Sprains

• Injury

• Joint pain

• Joint effusion

• Tears, meniscus, cruciate ligament

• Dislocation

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Celebrate these ICD-10 codes on Valentine's Day

We're supposed to be celebrating love on Valentine's Day but it's a day of danger. So brush up on these ICD-10 coding scenarios:

Cupid's arrow strikes the patient's heart

• W45 — Foreign Body or Object Entering Through Skin

• W21.89xA – Struck by arrow, initial encounter

• S26.99xA – Other injury of heart, initial encounter

• R00.2 — Palpitations

• R06.4 — Hyperventilation

• R61 — Hyperhidrosis

Some people may be tempted to get to a man's heart through his stomach:

• R73.9 Hyperglycemia, Unspecified (Which is sweeter? Love or a box of chocolates?)

• X10.1XXS, contact with hot food (Fondue) • T61.8X1A, toxic effect of other seafood (Oysters

may be an aphrodisiac but a trip to the emergency department isn't)

• Y92.511, restaurant or cafe as the place of occurrence

And it can get even worse:

• I51.81 – Takotsubo syndrome (aka “Broken heart syndrome”)

• Z63.0 —problems in relationship with spouse or partner

• R45.83 — Excessive Crying

• F33 — Recurrent Depressive Disorder (The winter blues?)

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ICD-10 coding for tonsillitis

• The tonsils are part of the lymphatic and immunologic system. They

are oval shaped, pink structures in the back of the throat and act as filters by trapping germs that pass through the nose and mouth. They also produce antibodies that help fight infection. They are the body’s first line of defense, and are similar to lymph nodes located in the neck, groin, and armpits.

• Tonsillitis may be either viral or bacterial. Streptococcus pyogenes, the bacteria that causes strep throat, is a common bacterial cause, accounting for approximately 30 percent of tonsillitis in children and 10 percent in adults. Other causes include adenovirus, influenza virus, and Epstein-Barr virus.

• ICD-10-CM codes for acute tonsillitis are contained in subcategory J03:

J03.00 Acute streptococcal tonsillitis, unspecified

J03.01 Acute recurrent streptococcal tonsillitis

J03.80 Acute tonsillitis due to other specified organism

J03.81 Acute recurrent tonsillitis due to other specified organism

An instructional note for J03.80 and J03.81 directs us to use an additional code from B95-B97 to identify the infectious agent.

J03.00 Acute streptococcal

tonsillitis, unspecified

J03.01 Acute recurrent

streptococcal tonsillitis

J03.80 Acute tonsillitis due to other specified

organism

J03.81 Acute recurrent tonsillitis

due to other specified organism

J03.90 Acute tonsillitis,

unspecified

J03.91 Acute recurrent tonsillitis,

unspecified

J35.03 Chronic tonsillitis and

adenoiditis

J35.01 Chronic tonsillitis

To provide specificity to code in ICD-10-CM, good clinical documentation includes the time parameter (acute, chronic, or recurrent and the causal organism (e.g., bacterial, such as streptococcus, staphylococcal, and adenovirus, influenza).

• Example: A 10-yr-old patient comes in with her mother for recurrent, acute

staphylococcal aureus tonsillitis. The patient was referred for evaluation and management options.

In this example, documentation supports recurrent, acute staphylococcal aureus tonsillitis. J03.81 Acute recurrent tonsillitis due to other specified organism is the first listed ICD-10-CM code. Based on the instructional note included with J03.81, B95.61 Methicillin susceptible staphylococcus aureus infection as the cause of diseases classified elsewhere should be used also.

• Example: A patient is brought into the operating room for an adenoidectomy due to chronic adenoiditis. Code J35.02 Chronic adenoiditis is appropriate.

All codes in chapter 10, Diseases of the Respiratory System, have an instructional note to also identify any current, history of, or exposure to environmental smoking or tobacco dependence.

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Some hot ICD-10 codes for winter

Yes, winter is here. And with it comes some season-specific injuries. RT Welter identifies one very plausible use of ICD-10-CM coding:

• S32.2XXA: Fracture of coccyx

• W00.0XXA: Fall due to slipping on ice

• Y93.H1XA: Shoveling snow

• Y92.014: Place of occurrence, driveway

Even if a prolific plow industry suppresses the number of snow-shoveling injuries, there are many possible ICD-10 diagnoses that could be used this season.

Most winter activities that don't involve a snow show shovel can be found in the Y93.2 neighborhood. For example:

• Y93.23: Snow (alpine) (downhill) skiing, snow boarding, sledding, tobogganing, and snowtubing

• Y93.24: Cross country skiing • And X37.2 may be needed to document the presence

of a blizzard (either snow or ice). if it's extremely cold, warm up these two diagnoses:

• T68: Hypothermia • X31: Exposure to excessive cold of natural origin

Even if patients manage to keep warm and safe inside, they still could suffer from a few more diagnoses:

• F34.8: Seasonal Affective Disorder

• R45.1: Cabin fever

• E55.9: Vitamin D deficiency

• X16.XXXA: Burned by electric blanket

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Five ways to use results from a coding audit

• Coding audits are designed to find mistakes. There is a great incentive for healthcare providers to conduct their own audits instead of waiting for regulators or healthcare payers to find mistakes for them. Those kinds of audits could result in financial penalties.

• The goal of coding audits should be to identify problems and create action plans to fix those problems. The result should be a more secure revenue stream

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IDC10 ANNUAL SUMMIT

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Obrigada!

“navegar e codificar” congresso...to decipher the icd-10-pcs root operations, learn the...

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