3. Abbreviations - General
• CC = chief complaint
• DS = discharge summary
• DX = diagnosis
• H&P = history and physical
• PE = physical exam
• PMH = past medical history
• ROS = review of systems
4. Abbreviations - Orthopedic
• FX = fracture
• C1-C7 = cervical vertebrae
• DIP = distal interphalangeal (joint)
• L1-L5 = lumbar vertebrae
• LLE = left lower extremity
• LUE = left upper extremity
• RLE = right lower extremity
• RLU = right upper extremity
5. • ORIF = Open reduction and internal fixation
• PIP = proximal interphalagenal (joint)
• ROM = range of motion
• S1 = first sacral vertebra
• T1-T12 = thoracic vertebrae
• THR = total hip replacement
• Tib-fib = tibia-fibula
37. Compression
Vertebrae Could be
compressed traumatic (from a
together. fall on the
buttocks) or
pathologic (due
to disease where
it collapses on
itself)
58. Snapshot of the systems
ICD-9-CM ICD-10-CM
• Numeric • Alphanumeric
• 3 to 5 digits • 3 to 7 characters
• 3 digits then a decimal • 3 characters then a decimal
• Covered Chapter 17 • Covered chapter 19
– 486 Pneumonia, NOS – J18.9 Pneumonia, NOS
– 401.9 HTN, NOS – I10 Essential HTN
– 034.0 Strep sore throat – J02.0 Strep pharyngitis
Official Coding Guidelines Conventions and General
Guidelines are very similar – instructional
notes, manifestation of disease coding, sequencing
59. Basically the same
• Assign separate codes for each injury
• Most serious injury sequenced first
– Most serious FX sequenced first if multiple
• FX not indicated as open or closed = closed
• Still required
– External Cause
– Place of occurrence
– Activity
– Status
• We just don’t call these E-codes anymore – they are V-Y
60. New Guidelines
• FX not indicated as displaced or not displaced
= displaced (displaced does not = open).
• FX code includes info to indicate which
encounter this is
– Aftercare is now included in the ICD-10-CM
diagnosis code (in I-9 we used a V code)
– Late effects now called sequela. There is one
combination code that includes both the sequela
and the original fracture.
61. Three Big Differences in Orthopedic
diagnosis codes
Laterality 7th character
• Right side / Left side • Type of Fracture
(open/closed)
Specificity • Initial Encounter /
subsequent encounter
• Type of fractures
• Reason for subsequent
– Greenstick
encounter
– Transverse
– Delayed healing
– Spiral
– Nonunion, malunion
– oblique
• Sequela (late effect)
62. Laterality
Fracture of the fifth metatarsal bone of the left foot
ICD-9-CM ICD-10-CM
825.25 Fracture, Closed S92.352- Displaced fracture of
metatarsal bone(s) fifth metatarsal bone, left foot
No code for fifth metatarsal *also need 7th character to
explain encounter
63. Specificity to Fracture Type
Greenstick Fracture of the Right Radial Shaft
ICD-9-CM ICD-10-CM
813.21 Fracture, Shaft, Radius S52.311- Greenstick Fracture
alone of shaft of radius, right arm
*also requires a seventh character to
No code for “greenstick denote encounter
fracture” – just codes to radial
shaft
65. Initial Encounters
ICD-9-CM ICD-10-CM
• Fracture fifth metatarsal • Fracture fifth metatarsal
bone left foot bone left foot
– 825.25 Fracture, Closed – S92.352A Displaced fracture
metatarsal bone(s) of fifth metatarsal bone, left
foot, initial encounter
• Greenstick Fracture Right • Greenstick Fracture Right
Radial Shaft Radial Shaft
– S52.311A Greenstick Fracture
– 813.21 Fracture, Shaft, Radius
of shaft of radius, right
alone
arm, initial encounter
66. Malunion
Malunion of a previously displaced transverse fracture of the
shaft of the right femur
ICD-9-CM ICD-10-CM
733.81 malunion fracture S72.321P Displaced Transverse
fracture of the shaft of the
905.4 Late effect of fracture of right femur, subsequent
lower extremities encounter for fracture with
malunion
68. Getting to Know – ICD-10-PCS
• Totally different from ICD-9-CM
• How?
– Structure
– Organization
– Expandability
69. Other Important Features of ICD-10-
PCS
• Standardized terminology
• Specificity
• No explicit “NOS” code options
• Limited use of “NEC” code options
70. Format / Structure of ICD-10-PCS
Codes
• 7 Characters
• Any character can be alpha or numeric
• Numerals 0 – 9 used
• 24 letters used, A – H, J – N, and P – Z are used
– Letters I and O are not used
• Decimals are not used
• ICD-10-PCS Code
1 2 3 4 5 6 7
71. Valid Code Example Using ICD-10-PCS
• Open fracture reduction right tibia – 0QSG0ZZ
73. Value Approach Definition Examples
0 Open Cutting through skin or mucous membrane and any CABG
other body layers necessary to expose the site of ORIF
the procedure
3 Percutaneous Entry, by puncture or minor incision, of Needle biopsy of thyroid
instrumentation through the skin or mucous
membrane and any other body layers necessary to
reach the site of the procedure
4 Percutaneous Endoscopic Entry, by puncture or minor incision, of Arthroscopy
instrumentation through the skin or mucous
membrane and any other body layers necessary to
reach the site AND visualize the site of the
procedure
7 Via Natural or Artificial Opening Entry of instrumentation through a natural or Foley catheter
artificial external opening to reach the site of the
procedure
8 Via Natural or Artificial Opening Entry of instrumentation through a natural or Colonoscopy
Endoscopic artificial external opening to reach the site of the
procedure AND visualize the site of the procedure
F Via Natural or Artificial Opening Entry of instrumentation through a natural or Laproscopic assisted vaginal
With Percutaneous Endoscopic artificial external opening and entry, by puncture or hysterectomy
Assistance minor incision, of instrumentation through the skin
or mucous membrane and any other body layers
necessary to aid in the performance of the
procedure
X External Procedures performed directly on the skin or Closed reduction of fracture
mucous membrane and procedures performed
indirectly by application of external force through
77. Resources
• ICD-10-CM Official Coding Guidelines FY11
http://www.cdc.gov/nchs/data/icd10/10cmguide
lines2012.pdf
• ICD-9-CM Official Coding Guidelines FY11
http://www.cdc.gov/nchs/data/icd9/icdguide10.
pdf
• Root Operations: Key to Procedure Coding in ICD-
10-PCS, Anne Barta, MSA, RHIA & Ann
Zeisset, RHIT, CCS, CCS-P
• Microsoft Clip Art
Editor's Notes
Because ICD-10-PCS has these three characteristics the codeset is able to be complete, flexible, and expandable. All ICD-10-PCS codes contain 7 characters that identify a category of specific information. ICD-10- PCS has a unique code that be assigned for every significant procedure. Each code retains its own unique definition. Codes are not reused in ICD-10-PCS.Expandability is also a characteristic of ICD-10-PCS. Unlike ICD-9 procedure codes that require whole codes to be added each year to account for the changes in technology and new procedures; ICD-10-PCS changes can be made within existing structure because whole codes are not added.
In ICD-9 you will find procedure codes that use terminology that includes eponyms, such as the name of a procedure named after a doctor, for example Collis Nissen, you will also see acronyms and other common terms such as CABG, or procedures that include the diagnosis in the code such as “wide excision of lesion on lip”. In ICD-10-PCS you will not find procedure names, diagnostic information, or eponyms. Instead each procedure is coded to the root operation that identifies the outcome of the procedure. The use of codes identified by “NOS and NEC” is not an option for “NOS” and limited for “NEC” that is because in ICD-10-PCS each character in the code defines information about the procedure and all 7 characters must contain a specific value from a single row of a table when you build a code. Let’s look at the format and structure of ICD-10-PCS codes.
The format and structure of ICD-10-PCS code consist of 7 characters, any character can be alpha or numeric, numerals 0 through 9 are used, 24 letters are used, letters I and O are no used so that coders do not become confused with 1 and 0. Decimals are not used. The ICD-10-PCS code is identified like this:1 = The section2 = The body system3 = The root operation4 = The body part5 = The approach6 = The device7 = The qualifierLet’s look at a valid code in ICD-10-PCS
As you can see on this slide the first three characters are identified by 0QS which is the section, body system, and operation. The last four characters identify the location of the fracture, right tibia, how the procedure was done, in this case it was open and the last two characters represent whether a device was used and other information about the procedure. You always have to have 7 characters in order for the code to be valid in ICD-10-PCS.
Great job everyone!
Now this is a jeopardy game so remember your answer must be in the form of “What is”!
Key words you should note “reposition, insertion, placement” These words will be helpful to know when looking up codes for procedures in ICD-10-PCS
Okay now we are going to take a look at some case scenarios. Feel free to work in groups!
