Inpatient volume 3 Overview

INPATIENTICD-9-CM VOLUME 3

FORMAT OF VOLUME 3

The format of Volume 3, Alphabetic Index and Tabular List, follows the same format and conventions that are used in Volume 1, Tabular List of Diseases and Injuries, and Volume 2, Alphabetic Index of Disease and Injuries.

The procedural codes are used to code hospital inpatient procedures.

ICD-9-CM procedures codes are not used by hospital outpatient departments or by physician practices.

Physicians and hospital outpatient services are coded using Current Procedural Terminolgy(CPT) for procedural coding.

FORMAT OF VOLUME 3

The use of ICD-9-CM procedure codes is restricted to the reporting of inpatient procedures by hospitals. (Ref : CC 2008 1Q P.15)

A hospital may still collect ICD-9-CM procedural data but only for internal or non-claim-related purposes.

Volume 3 consists of 17 chapters. Most of these chapters are classified by body system.

It should be noted that Chapter 0 contains procedures and interventions that represent new technology.

VOLUME 3 TABLE OF CONTENTS 0. Procedures and Interventions, Not Elsewhere classifiable(00) 1. Operations on the Nervous System (01-05) 2. Operations on the Endocrine System (06-07) 3. Operations on the Eye (08-16) 4. Operations on the Ear (18-20) 5. Operations on the Nose, Mouth, and Pharynx (21-29) 6. Operations on the Respiratory System (30-34) 7. Operations on the Cardiovascular System (35-39) 8. Operations on the Hemic and Lymphatic System (40-41) 9. Operations on the Digestive System (42-54) 10.Operations on the Urinary System (55-59) 11.Operations on the Male Genital Organs (60-64) 12.Operations on the Female Genital Organs (65-71) 13.Obstetrical Procedures (72-75) 14.Operations on the Musculoskeletal System (76-84) 15.Operations on the Integumentary System (85-86) 16. Miscellaneous Diagnostic and Therapeutic Procedures (87-99)

ALPHABETIC INDEX

The location of procedures in the Alphabetic Index can be found under the common name of a procedure (e.g., appendectomy, hysterectomy). However, procedures may be listed under the general type of procedure with terminology such as the following :Insertion Incision Excision ClippingRepair Implantation Examination

Removal

OMIT CODE

Omit code is an instructional note that is found only in the Alphabetic Index and Tabular List of Volume3.

This instruction denotes that no code is to be assigned.

The omit code instruction is generally found under codes that are used for approaches and closures and therefore may be integral to the operative procedure.

CODE ALSO

“Code also” is an instructional note found in Volume 3 that directs the coder to code an additional procedure if it was performed.

ADJUNCT CODES

Adjunct Codes are assigned as add-on codes to a primary procedure to provide additional information about the primary procedure performed. These codes cannot be used alone and are assigned as secondary procedure code.

Codes 00.45 and 00.40 are adjunct vascular system procedure codes. These codes cannot be used alone and are used only to provide more information about the procedure that was performed.

UHDDS DEFINITION

Uniform Hospital Discharge Data Set (UHDDS) definitions are used by acute care, short-term hospitals to report inpatient data elements in standardized manner. Definitions that pertain to the assignment of procedure codes are presented in the following sections.

PRINCIPAL PROCEDUREA principal procedure is one that was performed for definitive treatment rather than for diagnostic or exploratory purposes or for treatment of a complication. If two procedures appear to be principal, the one most related to the principal diagnosis should be selected as principal procedure.

SIGNIFICANT PROCEDURE

A significant procedure is considered significant if it Is surgical in nature Carries a procedural risk Carries an anesthetic risk Requires specialized training

It should be noted that a significant procedure does not have to be performed in an Operative Room.

Procedures can be done in the emergency room (ER) before admission, at the patient’s bedside, in a treatment room, or in an interventional radiology department.

These procedures can be easily missed because an operative report describing the procedure may not have been completed.

SIGNIFICANT PROCEDURE These procedures are documented with a brief, handwritten

note on the ER record or in a progress note or in a consultation note.

Consent for treatment may assist the coder in attempting to verify a procedure, but not all procedures require consent forms.

A signed consent form doesn’t confirm that the procedure was actually performed.

A complete review of the entire health record is necessary to ensure that all completed procedures have been coded.

Other UHDDS data elements that must be coded include the date of the procedure and the NPI (National Provider Identifier) of the person who performed the procedure. It may be the coder’s responsibility to abstract these data elements.

PROCEDURE CODES THAT SHOULD BE REPORTED Any procedures that affect payment or reimbursement

must be reported. Other procedures may be reported at a hospital’s

discretion or in accordance with hospital policy. Encoders(ICD9CM Coding Software) may also have special

popup notices that alert the coder about non-covered or limited coverage OR procedures.

After assigning procedure codes, the coder should review the diagnosis codes to ensure the assignment of diagnosis codes that support the performance of a procedure.

Example : If It was determined that lysis of peritoneal adhesion was sufficient to warrant a procedure code in this male patient. It would make sense that a diagnosis code should be assigned to identify the peritoneal adhesions.

Procedure : Lysis of Peritoneal Adhesions 54.59Diagnosis : Peritoneal Adhesions 568.0

PROCEDURE CODES THAT SHOULD BE REPORTED The Centers for Medicare and Medicaid Services (CMS) has

categorized procedures into different classifications through the Medicare Code Editor (MCE).

The Medicare Code Editor is software that detects errors in coding on Medicare Claims. For example, it would identify a male-only procedure performed on a female patient.

During a patient’s hospitalization, it may be necessary for a procedure to be performed at an outside facility. This could be for reasons such as the service may not be offered at the admitting hospital or equipment may malfunction. The patient may be transported by ambulance to this outside facility and after the procedure, returns for continued care at the admitting hospital. In these cases, the admitting hospital may assign procedure codes for services performed at the outside facility. The admitting hospital also would include these charges on the hospital bill, and the admitting hospital would reimburse the outside facility for the procedure.

VALID OR PROCEDURE

A Valid OR Procedure is a procedure that may affect MS-DRG assignment.

Designation of a procedure as a valid OR procedure doesn’t mean that it must be performed in the inpatient setting.

Many surgical procedures can be safely performed on an outpatient basis, and many third party payers and/or insurance companies require that certain surgical procedures be performed in an outpatient setting. Repair of direct inguinal hernia is designated as a valid OR procedure, but this procedure is usually performed and billed as an outpatient procedure.

NON-OR PROCEDURE AFFECTING MS-DRG ASSIGNMENT

A procedure designated as “non-OR procedure affecting MS-DRG assignment” is a procedure that may affect MS-DRG assignment, even though the procedure is not routinely performed in the OR.

In some case, the procedure code 86.07, will make a difference in MS-DRG assignment; in other cases, it will not. The patient was admitted with progressive CKD V. A VAD was

implanted for future hemodialysis. (585.5, 86.07)In this case, the codes group to surgical MS-DRG:675, Kidney & Urinary Tract Procedures without CC/MCC

The Patient was admitted with primary liver cancer. It was decided to implant a VAD for future chemotherapy (155.0, 86.07)In this case, the codes group to medical MS-DRG 437, Malignancy of Hepatobiliary System or Pancreas without CC/MCC.

NON-COVERED OR PROCEDURE

Non-covered OR procedure codes are identified by the Medicare Code Editor as procedures for which Medicare does not provide reimbursement.

Sterilization procedures are identified by the Medicare. It is possible to assign an MS-DRG but that does not guarantee payment.

LIMITED COVERAGE

Limited Coverage procedures are identified by the Medicare Code Editor as procedures covered under limited circumstances.

For transplant facility to obtain Medicare coverage for organ transplantation, it must meet preapproved guidelines. Criteria are set forth and updated in Federal Register Notices.

SURGICAL HIERARCHY

The MS-DRG grouper software (computer program that assigns an MS-DRG), using diagnosis and procedure codes, identifies whether a particular patient falls into a medical MS-DRG or a surgical MS-DRG.

The MS-DRG grouper is able to determine which procedure is most resource intensive and assigns the procedure to that particular surgical MS-DRG.

SURGICAL HIERARCHY

In the above case, the patient was admitted and after study was determined to have breast cancer of the right upper outer quadrant (174.4). She also has a comorbidities of congestive heart failure (428.0). The principal procedure is one that is performed for definitive treatment; in this case, that would be the modified radical mastecotmy (85.43). The mastectomy is more resource intensive than a breast biopsy. It is appropriate to code the diagnostic breast biopsy (85.12) as an additional procedure code.

SURGICAL HIERARCHY

In the above case, all codes are same, but the breast biopsy is incorrectly sequenced as the principal procedure instead of the mastectomy. Because of the surgical hierarchy within the grouper, it groups to the mastectomy MS-DRG, so the reimbursement and MS-DRG assignment would be correct. Even if the grouper will automatically arrange the codes to fit the surgical hierarchy, the code should be sequenced as the principal procedure on the basis of the UHDDS definition.

SURGICAL HIERARCHY

In the above case, a data entry error was made and congestive heart failure was incorrectly sequenced as the principal diagnosis, resulting in a 983 MS-DRG assignment. Although MS-DRG 983 may be the correct assignment in some cases, it is not appropriate in this case, and the coder should review the entered codes.In this case, the principal diagnosis combined with the procedure codes resulted in the MS-DRG assignment. If the data entry error had not been corrected before billing, the facility would have been incorrectly reimbursed.

BILATERAL PROCEDURES A bilateral procedure occurs when the same

procedure is performed on paired anatomic organs or tissues (i.e., eyes, ears, joints such as shoulder or knee).

According to CC 1988 1Q P.9, “when the same procedures are performed bilaterally and ICD-9-CM provides a single code that identifies the procedures as bilateral, assign that code. When the same procedure is performed bilaterally and ICD-9-CM does not provide a code to identify that procedure as being performed bilaterally, record the procedure code twice. When there is difference in the procedure performed on one side as opposed to the other side involving different code assignments, report both codes.”

BILATERAL PROCEDURES

The coding of bilateral procedures should be addressed by facility policy.

For major procedures such as joint replacements, the coder must assign two codes.

OPERATIVE APPROACHES & CLOSURES

An important convention in Volume 3 is the “Omit code.”

Main terms in the Alphabetic Index may be used to identify incisions. If an incision is made only for the purpose of performing further surgery, the instruction “omit code” is given.

OPERATIVE APPROACHES & CLOSURES

It is Coder’s responsibility to review the entire operative report to determine the extent of the procedure and to decide what should be coded.

Closure of the operative wound is a routine part of most surgical procedures, so it is not necessary to code this separately. In some instances, a surgical wound is not closed at the time of surgical operation but is allowed to heal and will be closed at a later date. In this case, a closure would be added since it is like a “delayed type closure.”

CLOSED SURGICAL PROCEDURES

As technology has advanced, procedures are increasingly being performed through scopes which are less invasive than open procedures. This has resulted in quicker recoveries, shorter hospital stays, a fewer complications.

Common closed surgical approaches include laparoscopic, thoracoscopic and arthroscopic procedures.

Closed procedures may be diagnostic and/or therapeutic in nature.

CONVERSION TO OPEN PROCEDURE

A surgical procedure may start with a closed approach that may need to be converted to an open procedure. V codes describe the conversion from a closed surgical procedure to an open procedure. These codes are found in the index under the main term “Conversion.”

In the case of conversion from closed to open, only assign the open procedure code. Some reasons for conversion to an open procedure include adhesions, bleeding, technical difficulties due to anatomic body structure and/or inflammatory changes, and injury to an organ.

CONVERSION TO OPEN PROCEDURE

“Until specific codes for laparoscopic and thoracoscopic approaches can be created, the codes for open approaches must be applied. Do not assign a separate code for the laparoscopy or thoracoscopy.” (CC 1992 3Q P.12)

It may be the policy of some facilities to assign an additional procedure code for the laparoscopy (54.21) so that data can be collected on the number of laparoscopic procedures performed.

ENDOSCOPIC APPROACHES

Endoscopic examinations and procedures are performed with an instrument that allows examination of any cavity of the body through a rigid or flexible scope. The scope usually inserted into the body through an orifice or stoma. When a colonoscopy is performed, the anus is the body orifice that allows entry of the scope.

As the scope is inserted and various parts of the body are examined, the coder would not code every body part that is viewed. The coder would code the farthest site that was reached. If a procedure such as a biopsy is performed, only the biopsy code is assigned.

PLANNED & CANCELLED PROCEDURES

If a patient’s procedure is cancelled prior to the time that he or she presents to the hospital, no code will be required because no services were provided, no bill was generated, and there is no health record.

If a patient presents to have a procedure performed, but for some reasons the procedure has cancelled, the principal diagnosis in this case is the reason for why the patient was going to have the procedure performed. If a complication arose that resulted in the cancellation, a diagnosis code for that condition would be assigned as a secondary diagnosis. Also V codes describe the reason for the cancellation.

PLANNED & CANCELLED PROCEDURES

If a surgical procedure will be started that for whatever reason cannot be completed. The surgical procedure should be coded to the extend that it was performed. These circumstances are different from those surrounding a procedure that is cancelled, in that the patient received anesthesia and surgery was begun. No V codes are available for these situations.

BIOPSY

Biopsy is a very common diagnostic procedure that is often performed before more definitive treatment is provided.

Biopsy is defined as “the removal of tissue followed by pathologic examination to establish a precise diagnosis.”

Biopsies may be performed in a number of different ways such as by aspiration, brush, core, endoscopic, excisional, incisional, percutaneous, punch, shave, stereotactic, and washing methods.

Different codes may be assigned depending on the biopsy method used.

BIOPSY

Biopsies that are performed by endoscopy or percutaneous aspiration are coded as “closed” biopsies. (CC 1984 J-A P.3-4)

An incisional approach for removal of tissue is coded as an “open biopsy.” (CC 1984 J-A P.3-4)

A patient may be undergoing an open abdominal procedure while a percutaneous biopsy of the liver is also performed. Biopsy of the liver would be coded to percutaneous and not to open biopsy, even though the abdominal cavity was open at the time per (CC 1988 4Q P.12)

ROBOTIC ASSISTED SURGERY Robotic-assisted surgery is the most recent development in minimally

invasive surgery. This new technology is designed to enhance surgical capabilities by facilitating the performance of complex surgery through small incisions. Robotics requires the use of a surgical robot (computerized system with a motorized construction, usually an arm, capable of interacting with the environment).

Note that although a computer console with 3-D imaging is used with robotic assisted surgery, it is not the same as computer assisted surgery (00.31-00.35, 00.39). Computer assisted surgery does not use robotic arms, devices, or other systems to perform surgical tasks (e.g., excision or resection.) A key difference of robotic-assisted surgery over computer-assisted surgery is its ability to repeat identical motions. Although robotic-assisted surgeries may use computer assistance, computer-assisted surgeries do not use robots. Computer-assisted surgery (CAS) is any computer-based procedure that uses technologies such as 3D imaging and real-time sensing in the planning, execution and follow-up of surgical procedures. CAS allows for better visualization and targeting of sites as well as improved diagnostic abilities.

ROBOTIC ASSISTED SURGERY Robotic assistance is classified on the basis of the

approach used, such as open (17.41), laparoscopic (17.42), percutaneous (17.43), endoscopic (17.44), thoracoscopic (17.45), and other and unspecified (17.49). Examples of procedures performed with robotic assistance include prostatectomies, hysterectomies, and cholecystectomies.

THIS PRESENTATION DEDICATED TO ALL MY IP CODING FRIENDS RMI

Prakash.A. – CPCSenior Inpatient Medical Coder

RevenueMed India Pvt LtdE-mail : [email protected]