November 8, 2011

ICD-10-CM and ICD-10-PCS: Outpatient Surgical Coding Exercise

By

Below is an example of a percutaneous endoscopic procedure of the knee as well as the ICD-10-CM and ICD-10-PCS codes that should be assigned for this outpatient encounter.

Preoperative Diagnosis: Derangement of right lateral meniscus

Postoperative Diagnosis: Derangement of right lateral meniscus

Procedure: Meniscectomy, right knee, arthroscopic approach

Anesthesia: General

Procedure Description

After obtaining informed consent, the arthroscope was introduced through the right knee with a lateral meniscectomy being accomplished without difficulty. The patient tolerated the procedure well.

Procedure and Findings

The patient was identified in same-day surgery, and her right leg was marked.  She was taken to the operating room, and a timeout was performed after a general anesthetic was administered. The right leg was prepped and draped in the usual sterile manner, and the leg was secured in the leg holder with the pneumatic tourniquet infiltrated to 300 mmHg.

An inflow portal was established superiorly and laterally, the arthroscope was introduced inferiorly and laterally, and an instrument portal inferiorly and medially. Attention was turned to the medial compartment, which was found to be relatively smooth, and the medial meniscus was intact. Evaluation of the lateral compartment in this valgus knee revealed a complex tear of the majority of the lateral meniscus, which basically obscured the entire lateral joint.

There were significant arthritic changes on the femoral and tibial side of the joint laterally, as well. A combination of the Stryker surface, different basket forceps, and the intraarticular shaving system were used to debride the lateral meniscus and basically perform almost a subtotal lateral meniscectomy. Hemostasis was achieved, as well, over here with the Stryker surface. The knee was then thoroughly irrigated, and lateral compartment was found to be relatively clean.

The instruments were removed, and the knee was infiltrated with 30 cc of 0.25% Marcaine with epinephrine. Polysporin and a bulky dressing were applied, and the patient was awakened and transferred to the recovery room. She tolerated the procedure well. The estimated blood loss was negligible. Tourniquet time was 40 minutes. She left the operating room in stable condition, and there were no complications.

Code Assignments

In the first table below is a comparison of the ICD-9 diagnosis codes and the ICD-10 diagnosis codes. As you can see, the descriptors are similar.

ICD-9-CM Diagnosis Codes

ICD-10-CM Diagnosis Codes

717.5 Derangement of knee

M23.261 Internal derangement of lateral meniscus due to old tear or injury, right knee

The first code listed under ICD-10-CM diagnosis codes (M23.261) would be broken down as follows:

  • M = Chapter 13: Disease of the Musculoskeletal System and Connective Tissue
  • M23 = Internal derangement of knee
  • 26 = Other lateral meniscus due to old tear or injury;
  • 1 = Right knee

 


 

Now review the second table below, which lists the ICD-9 procedure codes against the ICD-10 procedure codes, where you will see similar descriptors. Even though ICD-9-CM procedure codes would not be reported in the outpatient setting (per HIPAA guidelines), we are providing them below for illustrative purposes.

ICD-9-CM Procedure Codes

ICD-10-PCS

80.26 Arthroscopy of knee

80.6 Excision of semilunar cartilage of knee

OSBC4ZZ Arthroscopy, excision joint, right knee, lateral meniscus

Like the ICD-10 diagnosis codes, each digit in the ICD-10-PCS column identifies a specific feature in the first listed procedure code:

  • O = medical surgical
  • S = Lower joint
  • B = Excision, body part
  • C = knee joint, right
  • 4 = approach, percutaneous endoscopic, device
  • Z = no device
  • Z = no qualifier

In addition, for the above outpatient case, you will need to assign the following CPT procedure code: 29881—knee arthroscopy, surgical; with meniscectomy (lateral or medial).

Listed below are website links to the latest version of ICD-10-CM and ICD-10-PCS:

http://www.cdc.gov/nchs/icd/icd10cm.htm

http://www.cms.gov/ICD10/13_2010_ICD10PCS.asp

About the Author

Patricia A. Shell is a senior healthcare consultant with Medical Learning, Inc. (MedLearn®), St. Paul, MN. She has more than 30 years of experience in billing, coding, and compliance.

Contact the Author

To comment on this article please go to

Read 127 times Updated on September 23, 2013