April 9, 2013

100 Tips for ICD-10-PCS Coding: Tips 31-40

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ICD-10-PCS represents a major departure from ICD-9-CM procedure coding, and as such, many coding specialists find ICD-10-PCS much more challenging to learn than ICD-10-CM (which still shares many similarities with ICD-9-CM). In order to ease the transition from one code set to the other, we are providing tips for coding under this system.

 

To download the 2013 ICD-10-PCS root operation tables and resources, go online to http://www.cms.gov/Medicare/Coding/ICD10/2013-ICD-10-PCS-GEMs.html.

Tip No. 31

Body systems designated as “upper” or “lower” contain body parts located above or below the diaphragm, respectively. Likewise, the “upper muscle” and “lower muscle” body parts found in some of the root operation tables (such as 0K2) refer to muscles that are above or below the diaphragm, respectively.

Section

0

Medical and surgical

Body System

K

Muscles

Operation

2

Change: Taking out or off a device from a body part and putting back an identical or similar device in or on the same body part, without cutting or puncturing the skin or a mucous membrane

 

Body Part

Approach

Device

Qualifier

 

X Upper Muscle

Y Lower Muscle

 

 

 

X External

 

 

 

 

0 Drainage Device

Y Other Device

 

Z No Qualifier

 

 

 

Tip No. 32

Since there are no bilateral upper muscle or lower muscle body part values in the root operation tables (such as 0KH), bilateral upper muscle or bilateral lower muscle procedures must be coded separately. Per the 2013 ICD-10-PCS Official Guidelines for Coding and Reporting, specifically, guideline B4.3: “if no bilateral body part value exists, each procedure is coded separately using the appropriate body part value.”

Example:The percutaneous placement of stimulator leads into bilateral upper muscles would be coded as:

0KHX3MZ

0KHX3MZ

Section

0

Medical and surgical

Body System

K

Muscles

Operation

H

Insertion: Putting in a non-biological appliance that monitors, assists, performs, or prevents a physiological function, but does not physically take the place of a body part

 

Body Part

Approach

Device

Qualifier

 

 

X Upper Muscle

 

Y Lower Muscle

 

 

 

0 External

 

3 Percutaneous

 

4 Percutaneous

Endoscopic

 

 

 

 

 

 

 

M Stimulator Lead

 

 

 

Z No Qualifier

 

 

 

 

 

 


 

Tip No. 33

Be careful when coding the advancement of a body part (such as an advancement flap, consisting of skin and subcutaneous tissue). Review the documentation thoroughly to determine if the body part was repositioned or transferred.

The ICD-10-PCS Index lists the root operations Reposition and Transfer under the main term Advancement:

 

ICD-10-PCS Index excerpt:

 

Advancement

see Reposition

see Transfer

In ICD-10-PCS Reposition is defined as moving to its normal location, or another suitable location, all or a portion of a body part.

Transfer is defined as moving, without taking out, all or a portion of a body part to another location to take over the function of all or a portion of a body part.

Tip No. 34

A supercharged transverse rectus abdominis myocutaneous (TRAM) flap is a pedicled TRAM flap. Per the ICD-10-PCS Index, a pedicled TRAM flap is coded to the 0KX root operation table.

ICD-10-PCS Index excerpt:

TRAM (transverse rectus abdominis myocutaneous) flap reconstruction

Free see Replacement, Skin and Breast 0HR

Pedicled see Transfer, Muscles 0KX

Tip No. 35

As mentioned, body systems designated as “upper” or “lower”contain body parts located above or below the diaphragm, respectively. As with the aforementioned muscles, upper tendon and lower tendon body parts found in some of the root operation tables (such as 0LP) refer to upper tendons above or below the diaphragm, respectively.

 

Section

0

Medical and surgical

Body System

L

Tendons

Operation

P

Removal: Taking out or off a device from a body part

 

Body Part

Approach

Device

Qualifier

 

X Upper Tendon

Y Lower Tendon

 

 

 

0 Open

 

3 Percutaneous

 

4 Percutaneous

Endoscopic

 

 

0 Drainage Device

 

7 Autologous Tissue Substitute

 

J Synthetic Substitute

 

K Nonautologous Tissue

Substitute

 

 

 

Z No Qualifier

 

 

 

X Upper Tendon

Y Lower Tendon

 

X External

 

0 Drainage Device

Z No Qualifier

 

 


 

Tip No. 36

Since there are no bilateral upper tendon or lower tendon body part values in the root operation tables, bilateral upper tendon or lower tendon procedures must be coded separately. Per the 2013 ICD-10-PCS Official Guidelines for Coding and Reporting, specifically guideline B4.3: “if no bilateral body part value exists, each procedure is coded separately using the appropriate body part value.”

 

Tip No. 37

The 2013 ICD-10-PCS Body Part Key does not reference the SLAP or Bankart lesions; however, since they are both labral tears, use the shoulder bursa and ligament body part to classify the repair of these lesions:

 

A superior labral anterior posterior (SLAP) lesion occurs when the cartilage that lines the glenoid (labrum) tears away from the top part of the glenoid.

A Bankart lesion occurs when the cartilage that lines the glenoid (labrum) tears in the front part of the labrum.

STRUCTURE OF THE SHOULDER


Public Domain:

National Institute of Arthritis and Musculoskeletal and Skin Diseases

http://www.niams.nih.gov/health_info/shoulder_problems/

 

 

Tip No. 38

The ICD-10-PCS Body Part Key does not reference the following spinal ligaments; however, the most appropriate body part to use in coding is the trunk bursa and ligament, right, and trunk bursa and ligament, left. These are not bilateral ligaments, so consider assigning the body part based on the side of the ligament that is accessed for the procedure (left or right).

  • The anterior longitudinal ligament (ALL) runs the entire length of the spine and connects the front of the vertebral body to the front of the annulus fibrosis.
  • The posterior longitudinal ligament (PLL) runs the entire length of the spine and connects the back of the vertebral body to the front of the annulus fibrosis.

 

Public Domain:

National Institute of Arthritis and Musculoskeletal and Skin Diseases

http://www.niams.nih.gov/health_info/Spinal_Stenosis/

 

 

 

 

 

 

 

 


 

Tip No. 39

The ICD-10-PCS Body Part Key does not reference the following spinal thoracic muscles, which extend the vertebral column. The most appropriate body part to use in coding is the trunk muscle, right or trunk muscle, left. These are not bilateral muscles, so consider assigning the body part based on the side of the muscle that is accessed for the procedure (left or right).

  • Longissimus Thoracis
  • Iliocostalis Thoracis
  • Spinalis Thoracis.

Section

0

Medical and surgical

Body System

K

Muscles

Operation

8

Division: Cutting into a body part, without draining fluids and/or gases from the body part, in order to separate or transect a body part

 

Body Part

Approach

Device

Qualifier

 

0 Head Muscle

1 Facial Muscle

2 Neck Muscle, Right

3 Neck Muscle, Left

4 Tongue, Palate, Pharynx

Muscle

5 Shoulder Muscle, Right

6 Shoulder Muscle, Left

7 Upper Arm Muscle, Right

8 Upper Arm Muscle, Left

9 Lower Arm and Wrist Muscle,

Right

B Lower Arm and Wrist Muscle,

Left

C Hand Muscle, Right

D Hand Muscle, Left

F Trunk Muscle, Right

G Trunk Muscle, Left

H Thorax Muscle, Right

J Thorax Muscle, Left

K Abdomen Muscle, Right

L Abdomen Muscle, Left

M Perineum Muscle

N Hip Muscle, Right

P Hip Muscle, Left

Q Upper Leg Muscle, Right

R Upper Leg Muscle, Left

S Lower Leg Muscle, Right

T Lower Leg Muscle, Left

V Foot Muscle, Right

W Foot Muscle, Left

 

 

 

 

 

 

 

 

 

0 Open

 

3 Percutaneous

 

4 Percutaneous

Endoscopic

 

 

 

 

 

 

 

 

 

 

 

Z No  Device

 

 

 

 

 

 

 

Z No Qualifier

 

 

 

 

 


 

Tip No. 40

The ICD-10-PCS Body Part Key does not reference the following lumbar spinal muscle, which extends and rotates the vertebral column. The most appropriate body part is the trunk muscle, right or trunk muscle, left. This is not a bilateral muscle, so consider assigning the body part based on the side of the muscle that is accessed for the procedure (left or right).

  • Multifidus

 

Read all previous coding tips

Read Coding Tips 91-100

Read Coding Tips 81-90

Read Coding Tips 71-80

Read Coding Tips 61-70

Read Coding Tips 51-60

Read Coding Tips 41-50

Read Coding Tips 31-40

Read Coding Tips 21-30

Read Coding Tips 11-20

Read Coding Tips 1-10

NOTES

Colorado Comprehensive Spine Institute

Understanding Spinal Anatomy: Ligaments, Tendons and Muscles

http://www.coloradospineinstitute.com/subject.php?pn=anatomy-ligaments-17

Vic Goradia, MD, Go Orthopedics, Chester, Va.

Labral Tears: SLAP and Bankart Lesions

http://goortho.net/pdf/Shoulder/slaplesions-Bankart-Labral-tears.pdf

Lolita M. Jones, RHIA, CCS

Lolita M. Jones, RHIA, CCS, is the principal of Lolita M. Jones Consulting Services (LMJCS), founded in October 1998 in Fort Washington, MD. Ms. Jones has over 25 years of experience in coding and consulting. She started preparing for the implementation of ICD-10-CM/PCS by going back to school. On September 12, 2010, Ms. Jones became an AHIMA-approved ICD-10-CM/PCS trainer.