1. science
2. medicine
3. surgery

Important Information for receiving
your CE Certificate
You will receive an email within 3-5 business
days providing a LINK to the CE Certificate,
the webinar recording and the presentation
slides. This webinar offers an AHIMA
certificate.
Only attendees of the live event are eligible
for CE
If you are attending with a group everyone in
the group is eligible. When the email arrives
to the person who registered please forward
the link to the rest of the attendees so they
can download their certificate
The webinar will begin shortly
ICD-10-PCS Top
Reported Surgical
& Non-Surgical
Procedures
Sara Clark, RHIA, MLS
Provider Consulting Solutions, Inc.
March 19, 2015
| 3
Objective
• Objective – proficiency coding common
procedures

Proficiency = Accuracy and productivity
• Common procedures


Surgical
Non-surgical
| 4
Agenda
1. Other Fetal Monitoring
2. Repair OB Laceration
3. Manually Assisted
Delivery NOS
4. Low Cervical C-section
5. Venous Catheter NEC
6. Circumcision
7. Left Heart
Catheterization
8. Hemodialysis
9. Procedure on Single
Vessel
10. Artificial Rupture of
Membrane NEC
11. EGD with Closed
Biopsy
12. Percutaneous
Transluminal Coronary
Angioplasty
Proc #1 – 75.34
Other Fetal Monitoring
• 75.34 in ICD-9 maps to 63 codes in ICD-10
A few examples are:
4A1HXHZ: Monitoring of POC, Cardiac Sound, Extern Approach
4A1H7CZ: Monitoring of POC, Cardiac Rate, Via Natural/Artificial
Opening
4A0H8FZ: Measurement of POC, Cardiac Rhythm, Endo
4A0JX2Z: Measurement of POC, Nervous Conductivity, External
Approach
Procedure #2 – Repair Obstetric Laceration
• Repair of obstetric lacerations
 Episiotomy
 1st – 4th degree
Episiotomy=Division
An episiotomy is a surgical incision used to enlarge the
vaginal opening to help deliver a baby.
The mediolateral cut is angled down, away
from the vagina and the perineum, into the
muscle.
Index: Division/perineum/female
Root Operation: Division
Body System: Anatomical Regions General
0W8NXZZ
Note:
DO NOT CODE THE REPAIR (EPISIORRHAPHY) 0WQNXZZ
Coding Perineal Laceration: 1st Degree
• First-degree tears are the least severe, involving only the
skin around the vaginal opening.
• ICD-10-PCS root operation table 0HQ would be used to
report the repair of the perineum skin. (0HQ9XZZ)
• This is different than a high vaginal laceration wall tear.
Coding Perineal Laceration: 1st Degree
| 10
Coding Perineal Laceration: 2nd Degree
• Second-degree vaginal tears involve vaginal tissue
and the perineal muscles — the muscles between the
vagina and anus that help support the uterus, bladder
and rectum.
•2nd degree should be coded as 0KQM0ZZ (Muscles,
Repair, Perineum Muscle, Open)
11
2nd Degree Laceration Repair
• Second degree perineum lacerations:
-Involves:
- Vaginal tissue
- Underlying tissue
- Pelvic floor muscles
-Requires stitches
12
2nd Degree Laceration Repair Guideline
• ICD-10-PCS Official Coding Guideline B3.5:
 Overlapping body layers: If the root operations
Excision, Repair or Inspection are performed on
overlapping layers of the musculoskeletal system, the
body part specifying the deepest layer is coded
13
Approach: 2nd Degree Laceration Repair Approach
• Approach
Open: Cutting through the skin or mucous membrane
and any other body layers necessary to expose the site
of the procedure
• The laceration has cut through the external body layers
exposing the muscle
Coding Perineal Laceration: 2nd Degree
| 15
Coding Perineal Laceration: 3rd Degree
• Third-degree vaginal tears involve the vaginal tissues,
perineal muscles and the muscle that surrounds the anus (anal
sphincter)
•3rd degree perineal laceration repair requires 2 codes and
should be coded as:
0KQM0ZZ (Muscles, Repair, Perineum Muscle, Open) and
0DQR0ZZ (Gastrointestinal System, Repair, Anal
Sphincter, Open)
| 16
Coding Perineal Laceration: 3rd Degree
| 17
Coding Perineal Laceration: 4th Degree
• Fourth-degree vaginal tears are the most severe. They
involve the perineal muscles and anal sphincter as well as the
tissue lining the rectum. Fourth-degree tears usually require
repair in an operating room — rather than the delivery room —
and might take months to heal.
•4th degree perineal laceration repair requires 3 codes and
should be coded as:
0KQM0ZZ (Muscles, Repair, Perineum Muscle, Open),
0DQR0ZZ (Gastrointestinal System, Repair, Anal Sphincter,
Open)
0DQP0ZZ (Gastrointestinal System, Repair, Rectum, Open)
| 18
Coding Perineal Laceration: 4th Degree
Proc #3 – 73.59
Manual Assisted Delivery
10E0XZZ
Index look up:
Delivery
Cesarean see Extraction, Products of
Conception 10D0
Forceps see Extraction, Products of
Conception 10D0
Manually assisted 10E0XZZ
Proc #3 – Manual Assisted Delivery
10E0XZZ - Table
Proc #4 – 74.1
Low Cervical C-Section
10D00Z1
• Low cervical is also known as transverse
• The 7th character (qualifier) for classical and
extraperitoneal c-sections is different – be
careful on table
Proc #4 – Low Cervical C-Section
10D00Z1
Index look up:
Extraction continued
Products of Conception continued
Ectopic 10D2
Extraperitoneal 10D00Z2
High Forceps 10D07Z5
Internal Version 10D07Z7
Low Cervical 10D00Z1
Low Forceps 10D07Z3
Mid Forceps 10D07Z4
Proc #4 – Low Cervical C-Section
10D00Z1 - Table
Proc #5 – 38.93
Venous Cath NEC
• In ICD-10, 38.93 can map up to 28 codes
• 38.93 commonly reported for PICC line placement
02HV33Z (insertion of infusion device into superior
vena cava, percutaneous approach)
Proc #5 – Venous Cath NEC
Root operation is
Insertion.
Note that the index
instructs you to use a
device for PICC.
USE is different than
SEE.
Proc #7 – Venous Cath NEC
Proc #6 - 64.0
CIRCUMCISION
0VTTXZZ
Index look up:
Resection continued
Toe
Left 0QTR0ZZ
Right 0QTQ0ZZ
Pharynx 0CTM
Pineal Body 0GT1
Prepuce 0VTT
Products of Conception, Ectopic 10T2
Prostate 0VT0
Proc #6 - CIRCUMCISION
0VTTXZZ – Table
Proc #7 – 37.22
Left Heart Cardiac Catheterization
4A023N7 (LT heart)
• The root operation for a heart catheterization is
Measurement with the code for a left heart
catheterization being 4A023N7.
• The seventh character identifies if the procedure is
performed on the left, right, or is bilateral.
• Unlike ICD-9-CM, ICD-10-PCS differentiates the
various approaches to performing this procedure with
the fifth character capturing the approach.
| 30
Proc #7 - Left Heart Cardiac Catheterization
Proc #8 – 39.95
Hemodialysis
5A1D00Z
• Hemodialysis is under root operation
PERFORMANCE. Definition of performance =
completely taking over a physiological function by
extracorporeal means
Index look up:
Dialysis
Hemodialysis 5A1D00Z
Peritoneal 3E1M39Z
Proc #8 - Hemodialysis
5A1D00Z – Table
Procedure #9 – Procedure on Single Vessel
• ICD-9-CM code is 00.40
 Commonly used to report the number of vessels
involved when doing a PTCA
• There is no code in ICD-10-PCS that matches this code
 In ICD-10-PCS we would code multiple procedures if
multiple body parts are involved
Proc #10 – Artificial Rupture of Membranes NEC
AROM = when a women’s membranes are ruptured by
a health care provider to induce or accelerate their
labor
Root operation = DRAINAGE
Proc #10 – Artificial Rupture of Membranes NEC
• ICD-9 code is 73.09
• Maps to 2 ICD-10 codes:
10907ZC: Drainage of Amniotic Fl, Therapeutic from
POC, Via Natural or Artificial Opening
10908ZC: Drainage of Amniotic Fluid, Therapeutic
from POC, Via Natural or Artificial Opening
Endoscopic
Proc #10 – Artificial Rupture of Membranes NEC
2 Index lookups
Drainage
Proc #10 – Artificial Rupture of Membranes NEC
Proc #11 – 45.13
Small Bowel Endoscopy NEC
This is commonly referred to as an
Esophagogastroduodenoscopy (EGD). This is a
procedure in which a thin scope with a light and camera
at its tip is used to look inside the upper digestive tract -the esophagus, stomach, and first part of the small
intestine, called the duodenum.
Proc #11 – Small Bowel Endoscopy NEC
0DJ08ZZ: Inspection of
Upper Intestinal Tract
2 options for Index look ups:
Proc #11 - Small Bowel Endoscopy NEC
0DJ08ZZ: Inspection of Upper Intestinal Tract
Note body part choice is limited and not the same
as an EGD with biopsy.
Proc #11 – 45.16
EGD with biopsy
0DB68ZX: Excision of Stomach
EGD with stomach biopsy = Excision
(doctor will remove a small tissue sample for further
study)
Proc #12 – Percutaneous Transluminal Coronary
Angioplasty
• ICD-9 code is 00.66
• Maps to 8 ICD-10 codes
• Examples:
1027034Z: Dilation of Coronary Artery 1 site, intraluminal
device, drug–eluting, Percutaneous
1027134Z: Dilation of Coronary Artery 2 sites,
intraluminal device, Percutaneous
Proc #12 – Percutaneous Transluminal Coronary
Angioplasty
Medical and Surgical Section Guidelines (section 0)
B4.4 – Body Part Guidelines
Coronary arteries
• The coronary arteries are classified as a single body part
that is further specified by number of sites treated and
not by name or number of arteries. Separate body part
values are used to specify the number of sites treated
when the same procedure is performed on multiple sites
in the coronary arteries.
Proc #12 – Percutaneous Transluminal Coronary
Angioplasty
Thank you!
Sara Clark, RHIA, MLS, AHIMA Approved ICD-10-CM/PCS Trainer
Provider Consulting Solutions, Inc
3 Corporate Drive, Suite 201
Clifton Park, New York 1265
Phone: (518)-371-3036 ext. 420
Web: providercs.com
Questions?
[email protected]
| 46
Wrap Up
Thank you for attending our
webinar!
Please complete the survey, your
feedback helps us to design
training to meet your needs.
You will receive an email within
3-5 business days providing a
link to the CE Certificate, the
webinar recording and the
presentation slides.