why words matter words matter through a critical ... (1-4), and are determined ... glasgow coma...
TRANSCRIPT
©2014 The Advisory Board Company • advisory.com
Why Words Matter Through a Critical Care/Pulmonary Lens
Revenue Cycle Solutions Consulting & Management Services
©2014 The Advisory Board Company advisory.com 2
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
2
3
1
3
Concepts Drive Documentation Requirements
Examples of Critical Care/Pulmonary Diagnoses in ICD-10-CM
Importance of Documentation and Basics of ICD-10-CM/PCS
©2014 The Advisory Board Company advisory.com 4
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
©2014 The Advisory Board Company advisory.com 5
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)
©2014 The Advisory Board Company advisory.com 6
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
©2014 The Advisory Board Company advisory.com 7
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
©2014 The Advisory Board Company advisory.com 8
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)
©2014 The Advisory Board Company advisory.com 9
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
©2014 The Advisory Board Company advisory.com
Road Map for Discussion
2
3
1
10
Key Concepts To Capture in Your Documentation
Examples of Critical Care/Pulmonary Diagnoses in ICD-10
Importance of Documentation and Basics of ICD-10-CM/PCS
©2014 The Advisory Board Company advisory.com 11
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
©2014 The Advisory Board Company advisory.com 12
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.
©2014 The Advisory Board Company advisory.com 13
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.
©2014 The Advisory Board Company advisory.com
Road Map for Discussion
2
3
1
14
Key Concepts To Capture in Your Documentation
Examples of Critical Care/Pulmonary Diagnoses in ICD-10
Importance of Documentation and Basics of ICD-10-CM/PCS
©2014 The Advisory Board Company advisory.com 15
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
©2014 The Advisory Board Company advisory.com
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
©2014 The Advisory Board Company advisory.com
CVA Documentation
17
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
©2014 The Advisory Board Company advisory.com
Sequelae (Late Effects)
18
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
©2014 The Advisory Board Company advisory.com
Pneumonia & Influenza
ICD-10-CM Pneumonia & Influenza Documentation Concepts
19
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:
©2014 The Advisory Board Company advisory.com
Respiratory Failure
20
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:
©2014 The Advisory Board Company advisory.com
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
21
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
©2014 The Advisory Board Company advisory.com
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
©2014 The Advisory Board Company advisory.com
Specify: STEMI or NSTEMI
23
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
Documentation Teaching Point:
©2014 The Advisory Board Company advisory.com
Look Out For These Conditions
24
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
©2014 The Advisory Board Company advisory.com
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?
“
”
©2014 The Advisory Board Company advisory.com
Specificity Drives Severity
26
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
©2014 The Advisory Board Company advisory.com
Heart Failure Specificity for Severity of Illness
27
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:
©2014 The Advisory Board Company advisory.com
What Are They CCs and MCCs?
28
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
©2014 The Advisory Board Company advisory.com
Heart Failure
29
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
Documentation Teaching Point:
©2014 The Advisory Board Company advisory.com
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!
©2014 The Advisory Board Company advisory.com
Sepsis, Severe Sepsis and Septic Shock
31
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
©2014 The Advisory Board Company advisory.com
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
©2014 The Advisory Board Company advisory.com 33
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
©2014 The Advisory Board Company advisory.com
Asthma
34
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
©2014 The Advisory Board Company advisory.com
Severity of Asthma Classification
35
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
©2014 The Advisory Board Company advisory.com
COPD & Emphysema
36
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
©2014 The Advisory Board Company advisory.com
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
©2014 The Advisory Board Company advisory.com 38
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)
©2014 The Advisory Board Company advisory.com 39
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
©2014 The Advisory Board Company advisory.com 40
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
©2014 The Advisory Board Company advisory.com 41
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
5. Via Natural or Artificial
Opening Endoscopic
Entry of instrumentation through a natural or artificial external opening to reach the site
of the procedure
6. Via Natural or Artificial
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