ICD-10-PCS: How to Obtain Documentation Needed to Facilitate Accurate Coding While Maintaining Productivity Deborah Gardner-Brown, RHIT,CCS,CDIP,C-CDI,CI-CDI AHIMA Approved ICD-10-CM/PCS Trainer AHIMA ICD-10-CM/PCS Ambassador July 31, 2013 Objectives Pinpoint top procedures performed to develop pertinent education and process change Understand the coder data collection process needed to efficiently assign PCS codes and maintain productivity Demonstrate an understanding of PCS tables and how to abstract and assign appropriate components for “code building” Identify the sources of information within the health record that contain PCS coding details, such as device information Review of High Volume, High Revenue Procedures to Obtain the Specific Details of Data Collection Required for ICD-10-PCS and to Evaluate Coding Pinpoint Top High Weight DRG and High Charge Procedures Orthopedic/Trauma Pinpoint Top High Weight DRG and High Charge Procedures Cardiac Intervention Pinpoint Top High Weight DRG and High Charge Procedures Neurosurgery/Trauma Steps to Evaluate Top Volume Procedures Evaluate the timeliness of operative report dictation by service and MD specialty - in terms of the # of days from procedure to when the operative report is available Identify which surgeons, groups or specialties exceed chart completion requirements for delinquent operative report dictation Identify which doctors/procedure(s) are the most frequently queried and having the greatest impact on DNFB/Final billing High risk, high cost, high payment DRG’s pose the greatest risk to productivity and coding accuracy. MD’s identified as bottlenecks in the DNFB and coding process require special education/intervention. These providers will need coaching and should be required to comply with hospital bylaws for timeliness of operative report completion, or face non-renewal of privileges. Optimize and Leverage Your EMR for PCS Procedures • Complete the analysis of procedures that are high volume, high risk, high cost, and high reimbursement • Spend time NOW before October 1, 2014 to design, create and implement EMR templates that will help to do the following: – Eliminate or at least minimize the number of queries to surgeons for clarification of procedure details – Reduce the number of incomplete or incorrectly coded procedures – Prevent delays in final billing Example of Customized Debridement EMR Template Understand the New Clinical Review/Data Collection Process Needed to Efficiently Assign PCS Codes Expanded Codes, Key Terms and Added Components of the Collection Process Needed to Efficiently Assign PCS Codes and Maintain Productivity Excision of Follicular Cyst with Peritoneal Lysis of Adhesions via Laparoscopic Robotic Assisted Surgery ICD-9 ICD-10 I-9 clinical procedure information needed for coding • Peritoneal lysis of adhesion, excision of cyst surgery robotic assisted • Approach: Open or laparoscopic? • Lysis of peritoneal tissue • Excision of follicular cyst • Robotic assisted • Application adhesion barrier I-10 Clinical information needed for coding • Excision of follicular cyst, surgery robotic assisted with peritoneal lysis of adhesion – • Lysis of what in the peritoneum? – – • • – Approach: Open? Percutaneous? Percu – Endo? – Diagnostic or non-diagnostic? Robotic assisted procedure? What anatomical location? Approach: Open? Percu? Percu-endo? Introduction Adhesion barrier? – What location? – RRA, Inc. Lysis of what? Intestine, large, small, left, right, sigmoid,? Peritoneum? Lesser omentum? Greater omentum? Approach: Open? Percutaneous? Percu-Endo? Excision of cyst from what location/organ? Sigmoid colon? – – • Approach: Open? Percutaneous,? Percu – Endo? Approach: Open? Example #1: Excision of Follicular Cyst with Peritoneal Lysis of Adhesions via Laparoscopic Robotic Assisted Surgery Be sure what is planned is actually performed by the surgeon Example #1: Continued Example #1: Continued Pathology Report as a Resource Document to PCS code Utilize the pathology report to help verify procedure(s) performed Demonstrate an Understanding of PCS Tables and How to Abstract and Assign Appropriate Components for “Code Building” Root Operation “Excision” of Cyst Root Operation “Release “ (Lysis) of Adhesions of Bowel and Peritoneal Structures Root Operation “Inspection” of Bladder Root Operation “Introduction “ of Adhesion Barrier in Peritoneal Cavity Root Operation “Other Procedures” Robotic Assisted Surgery Final Procedure Codes for Excision of Follicular Cyst What else to code? Are all of the sites and approaches accounted for? What to Query? Abstracting Changes for Surgical Chart Review Will be Necessary to Improve Coding Productivity Develop a plan to review surgical cases efficiently Collect only the data you need Start communication with surgeons now Identify new locations In the EMR for clinical information Leverage EMR customization at every opportunity Example of PCS Abstracting Form for I-10 coding Form © of RRA, Inc. Understand the Key Terms Collection Process Needed to Efficiently Assign PCS Codes ICD-9 ICD-10 I-9 Clinical procedure information needed for coding • • • • Laparoscopic right colectomy converted to open procedure Control of bleeding Repair of Ileo-colic pedicle injury Side to side anti-mesenteric to anti-mesenteric anastomosis I-10 Clinical information needed for coding • • • • • • • Right colectomy (resection) – Approach: Open, Percu?, Percu – Endo? Converted to open? Release adhesions lesser omentum? Greater omentum? Intestine, other? – Approach: Open? Percu?, Percu – Endo? Control bleeding? – Approach: Open? Percu? Percu-endo? Repair of Ileo-colic pedicle – Approach: Open? Percu? Percu-endo? Resection of lymph nodes 15 open? – Approach: Open? Percu? Percu-endo? Destruction of omentum, — Approach: open? Percu? Percu-endo? Side to side anti-mesenteric to anti-mesenteric anastomosis, – Approach: Open? Percu? Percu-endo? Laparoscopic right colectomy converted to open right colectomy with intra-operative complications and repairs RRA, Inc. Example #2: Laparoscopic Right Colectomy Converted to Open with Repair and End-to-End Anastomosis Example #2: Continued Keep track of specific anatomical portions, differing structures or sites treated and the specific root operation and the approach Example #2: Review the Closure of the Operative Site It will be necessary to include in the chart review, while abstracting procedures, the site and type of any drains placed in the wound, implants, grafts, devices or appliances. Example #2: Pathology Report Pathology report as a coding resource New information indicating a major procedure not Documented in the operative description Example #2: Potential ICD-10-PCS Codes for Example* How will a post discharge query on delinquent operative dictation impact your DNFB for high cost high revenue surgical cases? Was the bowel ultimately removed by open or percu-endo ? Query on procedures may create major DNFB delays! *Some final codes may be dependent on response to query of surgeon Root Operation “Resection” Right-Sided Large Intestine Root Operation “Release “ (Lysis) Adhesions of Bowel and Peritoneal Structures Root Operation “Inspection “ of Mesentery Structures Root Operation “Bypass “ of Intestinal Structures Root operation “Control” of Bleeding Peritoneal Cavity Root operation “Resection” of Mesenteric Lymph Nodes Root operation “Repair ” of Mesenteric Ileo-Colic Pedicle Understand the Key Terms & Collection Process Needed to Efficiently Assign PCS Codes ICD-9 ICD-10 I-9 Clinical procedure information needed for coding • Decompression laminectomy of which vertebrae? • Approach: Open or percutanous, pecu-endo, or external? • Type of fusion method and approach • How many vertebrae and which ones • Types of grafts or appliances used? I-10 Clinical information needed for coding • Decompression laminectomy of which vertebrae( upper , lower or both)? • Release spinal cord from tumor compression by excision and dissection • Corpectomy complete? Partial? How many? • Approach: Open or percutaneous, pecuendo, or external ? • Type of fusion method and what is the specific approach • How many vertebrae, bones or joints? Specifically which ones? • Types of grafts, screws, cage or appliances used? Decompression laminectomies, thoracic, corpectomies, posterolateral fusions with allograft, and bone matrix, stabilization of cervical/thoracic spine with screws RRA, Inc. Example #3: Decompression Laminectomy, Corpectomy, Postero-Lateral Fusion with Allografts and Demineralized bone, Stabilization with Screws Example #3: Continued Example #3: Continued Example #3: Continued Example #3: Continued Example #3: Continued Root Operation “Release” Root Operation “Excision” Was a complete resection of T2 performed? Root Operation “Fusion” of Vertebral Joints Root Operation “Insertion” Root Operation “ Resection” Example #3: Continued What else to code? Are all procedures and approaches accounted for? What to Query? THANK YOU! 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 10 days providing a link to the CE Certificate, the webinar recording and the presentation slides References • PCS tables 2013 https://www.wellingtonware.com/docs/pdfs/PCS_2013.pdf