A significant procedure is one that is:
• Surgical in nature, or
• Carries a procedural risk, or
• Carries an anesthetic risk, or
• Requires specialized training.
Since one of the goals of ICD-10-CM/PCS implementation is to improve the collection of healthcare data, no hospital can afford to under-report UHDDS data elements. Unfortunately, some hospitals do not currently consistently assign procedure codes to (and, as a result, do not report) significant procedures.
A series of articles based on previously held Web-based training presentations has been prepared to provide clinical documentation guidance for non-operating room and bedside procedures that should be assigned an ICD-10-PCS code if they meet the UHDDS significant procedure definition provided above.
Behavioral health therapy documentation and policy checklist:
- In which medical record document is behavioral health therapy reported?
- In the medical record document, is the type of behavioral health therapy or service documented?
Such services could include the following:
* Biofeedback
* Counseling
* Crisis intervention
* Electroconvulsive therapy
* Family psychotherapy
* Group psychotherapy
* Hypnosis
* Individual psychotherapy
* Light therapy
* Medication management
* Narcosynthesis
* Psychological testing
Psychological testing documentation and policy checklist:
- In which medical record document is psychological testing reported?
- In the medical record document, is each psychological test categorized as one of the following?
* Developmental
* Personality/behavioral
* Intellectual/psychoeducational
* Neuropsychological
* Neurobehavioral/cognitive status
Individual psychotherapy documentation and policy checklist:
- In which medical record document are individual psychotherapy services reported?
- Is the type of individual psychotherapy documented in the medical record?
Such services could include the following:
* Behavioral
* Cognitive
* Cognitive-behavioral
* Interactive
* Interpersonal
* Psychoanalysis
* Psychodynamic
* Psychophysiological
* Supportive
Electroconvulsive therapy documentation and policy checklist:
- In which medical record document is electroconvulsive therapy (ECT) reported?
- Is the type of ECT and number of sessions documented in the medical record?
* Unilateral - Single Seizure
* Unilateral – Multiple Seizures
* Bilateral – Single Seizure
* Bilateral – Multiple Seizures
* Other electroconvulsive therapy (specify)
Medication management documentation and policy checklist:
- In which medical record document(s) are psychotherapeutic medications reported?
- Is each psychotherapeutic medicationdocumented in the medical record?
- Is the route and approach used to administer each psychotherapeutic medication documented in the medical record?
Such services could include the following:
* Inhalation
* Intra-arterial
* Intradermal
* Intramuscular
* Intrathecal
* Intravenous - Central Vein, Open
* Intravenous - Central Vein, Percutaneous
* Intravenous - Peripheral Vein, Open
* Intravenous - Peripheral Vein, Percutaneous
* Iontophoresis
* Subcutaneous