Updated on: November 29, -0001

ICD-10-PCS Coding of Significant Procedures not Performed in the Operating Room

By Lolita M. Jones, RHIA, CCS, AHIMA-Approved ICD-10-CM/PCS Trainer
Original story posted on: March 23, 2015

The Uniform Hospital Discharge Data Set (UHDDS) includes the hospital reporting requirements for all inpatient discharges. The UHDDS reporting requirements will remain in effect on and after Oct. 1, 2015, when ICD-10-CM/PCS goes into effect.

One data element that hospitals are required to report is the significant procedure(s) performed during each inpatient stay.

 

A significant procedure is one that:

• Is surgical in nature;
• Carries a procedural risk;
• 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 consistently assign procedure codes to (and as a result, do not report) significant procedures. 

A series of articles based on 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.

How to use these checklists:Health information management (HIM) coding managers should partner with clinical documen­tation improvement (CDI) specialists, cardiodiagnostic professionals, cardiac rehabilitation workers, and EPS technicians and/or Physicians to complete these checklists.

If any procedure service listed below is provided in your facility, answer each documentation question that is listed in the checklist. If you are unable to answer one or more of the questions then you must implement a corrective action plan (CAP) to ensure that the documentation is provided in the medical record for the procedure or service.

Heart and great vessel pressure sensor monitoring device documentation and policy checklist:

Examples of cardiac pressure sensor monitoring devices include CardioMEMS® pressure sensor, EndoSure® sensor, and implantable loop recorder.

1)  In which medical record document can the placement/insertion of this device be found?

  • Procedure/operative report
  • Progress note
  • Other (specify)

2)  Which body part(s) does the device monitor, per the medical record document list?

  • Atrium, left
  • Atrium, right
  • Coronary vein
  • Pericardium
  • Pulmonary artery, left
  • Pulmonary artery, right
  • Pulmonary trunk
  • Pulmonary vein, left
  • Pulmonary vein, right
  • Superior vena cava
  • Thoracic aorta
  • Ventricle, left ventricle, right 

3)  What approach should be used to place the device, per the medical record?

  • Open
  • Percutaneous
  • Percutaneous Endoscopic

Heart and great vessel monitoring device documentation checklist:

An example of a cardiac monitoring device includes a cardiac event recorder. 

1)  In which medical record document can the placement/insertion of this device be found?

  • Procedure/operative report
  • Progress note
  • Other (specify) 

2)  Which body part(s) does the device monitor, per the medical record document list?

  • Atrium, left
  • Atrium, right
  • Coronary vein
  • Pericardium
  • Pulmonary artery, left
  • Pulmonary artery, right
  • Pulmonary trunk
  • Pulmonary vein, left
  • Pulmonary vein, right
  • Superior vena cava
  • Thoracic aorta
  • Ventricle, left ventricle, right 

3)  What approach should be used to place the device, per the medical record document?

  • Open
  • Percutaneous
  • Percutaneous endoscopic

Cardiac measurement or monitoring device documentation checklist: Examples of cardiac measurement or monitoring devices include echocardiogram (ECHO), ejection fraction test, electrocardiogram (EKG), electrophysiology (EPS) study, exercise stress test, rhythm EKG, tilt table, and vectorcardiogram. 

1)  In which medical record document can the placement/insertion of this device be found?

  • Procedure/operative report
  • Progress note
  • Other (specify)

2)  Which function(s) does this document list?*

  • Action currents
  • Electrical activity
  • Output
  • Rate
  • Rhythm
  • Sampling and pressure
  • Sound
  • Total activity

3)  Does the medical record document specify the approach used to place the device? If so, which approach is appropriate?

  • External
  • Open
  • Percutaneous

*In ICD-10-PCS, measurement is defined as the determination of the level of physiological or physical function at a point in time; monitoringis defined as the determination of the level of physiological or physical function over a period of time.

Cardiac extracorporeal assistance device documentation checklist: Examples of cardiac extracorporeal assistance devices include the balloon pump, pulsatile compression, and impellar pump.

1)  In which medical record document can the placement/insertion of this device be found?

  • Procedure/operative report
  • Progress note
  • Other (specify)

2)  Does the documentation specify the duration of the pump output? If so, what is it?

  • Intermittent
  • Continuous

Cardiac extracorporeal performance documentation checklist: Examples of cardiac extracorporeal performance include the cardiopulmonary bypass and external cardiac massage.

1)  In which medical record document can the performance of this procedure/service be found?

  • Procedure/operative report
  • Progress note
  • Other (specify)

2)  What function is being performed?

  • Output (e.g., cardiopulmonary bypass, external cardiac massage)
  • Pacing

3)  Does the document specify the duration? If so, what duration?

  • Single (e.g., external cardiac massage)
  • Intermittent
  • Continuous (e.g., cardiopulmonary bypass)

Cardiac extracorporeal therapy documentation checklist: Examples of cardiac extracorporeal therapy include extracorporeal cardiac shock wave therapy. 

1)  In which medical record document can this therapy be found?

  • Procedure/operative report
  • Progress note
  • Other (specify)

2)  Which vessel is treated?

  • Heart
  • Other vessel (specify) 

3)  Does the document specify the duration? If so, what is it?

  • Single therapy
  • Multiple therapies

Cardiac rehabilitation documentation checklist:Examples of cardiac rehabilitation therapies include aerobic capacity and endurance; ventilation, respiration and circulation; and therapeutic exercise.

1)  In which medical record document can this therapy be found?

  • Therapy visit note
  • Progress note
  • Other (specify)

2)  Which body part(s) are receiving therapy?      

  • Circulatory system – Head
  • Circulatory system – Neck
  • Circulatory system – Upper back
  • Circulatory system – Upper extremity
  • Circulatory system – Lower back
  • Circulatory system – Lower extremity
  • Circulatory system – Whole body

3)  Does the document specify the type of equipment used? If so, what type? 

  • Aerobic endurance and conditioning
  • Assistive, adaptive, supportive, or protective
  • Electromechanical
  • Electrotherapeutic
  • Mechanical
  • Orthosis
  • Physical agents
  • Prosthesis
  • Other equipment (specify)
  • No equipment

About the Author

Lolita M. Jones, RHIA, CCS is an AHIMA-Approved ICD-10-CM/PCS trainer who writes the monthly newsletter titled ICD-10-PCS Solutions(published by MedLearn).

Contact the Author

www.EZMedEd.com.

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Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.