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As hospitals begin to incorporate ICD-10-PCS into their daily operations, a number of issues have become increasingly prevalent. Many complex surgical procedures actually are fairly simple to code in ICD-10, while other simple procedures present a number of coding issues. On the physician side, we are now at an early awareness phase regarding ICD-10 engagement.

Most physicians have not yet considered the impact on their workflow that could arise if repetitive coding queries are necessary to code their procedures appropriately. If we can anticipate many of these potential issues, we can facilitate a more collaborative process, increasing satisfaction of coders, documentation specialists, and physicians.

In preparation for phased implementation of ICD-10-PCS documentation and coding, I would like to suggest an approach that may be beneficial. Through existing internal databases, ICD-10 teams can identify the most common procedures by specialty for any given provider. Don’t focus on the most complex procedures, but rather identify those performed with the greatest frequency. These cases should be analyzed by each team and segregated into two primary groups: those with potential physician documentation issues, and those with potential coding ambiguity.

At many facilities, total hip replacement procedures would appear somewhere atop the list of commonly performed orthopedic procedures. What are the potential challenges for coders if one examines the coding tables, though? There is little ambiguity regarding the section (medical/surgical), the body system (lower joints), the root operation (replacement), the body part (hip, with laterality), or the approach (open). The only areas of potential ambiguity are the device and/or whether the implant is cemented. To achieve 100-percent accurate coding on the first pass through (whether or not the coding is computer-assisted), we need the physician to specify regarding those two elements. This procedure should be assigned to the “physician education” sub-list. Another common example would be a PTCA, in which the procedural coding challenge is to ensure that the interventional cardiologist documents how many sites are dilated and what device is utilized for each site.

On the other hand, consider a very minor but also very common procedure: infant circumcision. Recently, there was an interesting discussion about the correct coding of this procedure. The key question was this: is the root operation for an infant circumcision a resection or an excision (both are available options in ICD-10-PCS)? The ultimate consensus is that typical infant circumcision is intended to remove all of the foreskin (a designated body part), therefore the correct coding would be resection. Possible applications of excision could include an adult partial resection necessitated by a variety of clinical conditions. Note that this discussion is a coding discussion (which should be completed before Oct. 1, 2014), not a clinical documentation issue.

If ICD-10 teams review the most common 10-20 procedures for each specialty in your institution and identify early whether ICD-10-PCS challenges represent clinical documentation or coding issues, this will greatly enhance your ability to address potentially problematic areas in advance of the ICD-10 implementation date.

Additionally, consider the impact it might have on productivity enhancement, rework minimization and collaborative coder and physician satisfaction if greater than 90-95 percent of all procedures have complete documentation with coder concurrence.

About the Author

Paul Weygandt, MD, JD, MPH, MBA, CCS, CPE, is a Certified Physician Executive (CPE) with more than 20 combined years of experience in medical management, legal counsel, and orthopedic surgery. He has served as a hospital VPMA, improving documentation across all DRG payers. Paul is vice president of physician services for J.A. Thomas & Associates (a Nuance company). He is also an AHIMA-approved ICD-10-CM/PCS trainer.

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