Transcription
Optum360 Learning:Coding from the OperativeReport for ICD-10-CM and -PCS2018
ContentsChapter 1: History . 1Early Record Keeping .1Hospital Records .1Record Keeping in America .2Standardized Record Keeping .2The Joint Commission (formerly Joint Commission on Accreditation ofHealthcare Organizations) .3Summary .3Chapter 2: Documentation . 5Content .5Timeliness .6Operative Reports .7Summary .9Chapter 3: Coding .11History of Modifications to ICD . 12Regulatory Process . 14Documentation . 17Documentation Needs . 17Documentation and the Reimbursement Process . 18Advantages of ICD-10 within the Reimbursement Process . 18Chapter 4: Reimbursement .21Medicare . 21Payment Systems . 22Medicare Claims . 25Summary . 25Chapter 5: Fraud and Abuse .27Fraud . 27Abuse . 28Sanctions . 28Compliance . 28Summary . 32Chapter 6: Operative Report Coding .33Names and Terms That Describe Operative Reports . 33Operative Report Coding Guidelines . 36The Operative or Procedure Progress Note . 36Retrieving Information from Documentation in the Operative Report . 38Underdocumented or Incorrect Information . 39Code Selection . 39When to Seek Clarification or Additional Information from the Physician . 40Chapter 7: Operative Reports .43Pre-MDC . 43MDC 1 Diseases and Disorders of the Nervous System . 47MDC 2 Diseases and Disorders of the Eye . 58MDC 3 Diseases and Disorders of the Ear, Nose, Mouth and Throat . 68MDC 4 Diseases and Disorders of the Respiratory System . 80 2017 Optum360, LLCi
Optum360 Learning: Coding from the Operative Report for ICD-10-CM and PCSMDC 5 Diseases and Disorders of the Circulatory System .91MDC 6 Diseases Disorders of the Digestive System . 109MDC 7 Diseases and Disorders of the Hepatobiliary System and Pancreas . 123MDC 8 Diseases and Disorders of the Musculoskeletal System andConnective Tissue . 134MDC 9 Diseases and Disorders of the Skin, Subcutaneous Tissueand Breast . 155MDC 10 Endocrine, Nutritional and Metabolic Diseases and Disorders . 168MDC 11 Diseases and Disorders of the Kidney and Urinary Tract . 179MDC 12 Diseases and Disorders of the Male Reproductive System . 193MDC 13 Diseases and Disorders of the Female Reproductive System . 201MDC 14 Pregnancy, Childbirth and the Puerperium . 209MDC 15 Newborns and Other Neonates with Conditions Originatingin the Perinatal Period . 222MDC 16 Diseases and Disorders of the Blood and Blood-FormingOrgans and Immunological Disorders . 226MDC 17 Myeloproliferative Diseases and Disorders and PoorlyDifferentiated Neoplasms . 231MDC 18 Infectious and Parasitic Diseases . 240MDC 19 Mental Diseases and Disorders . 246MDC 21 Injury, Poisoning and Toxic Effects of Drugs . 250MDC 22 Burns . 256MDC 24 Multiple Significant Trauma . 259Appendix A: Abbreviations .263Appendix B: Glossary .271ii 2017 Optum360, LLC
Chapter 2: Documentation2.If the operative report is not placed in the medical record immediately aftersurgery due to transcription or filing delay, then an operative progress noteshould be entered in the medical record immediately after surgery toprovide pertinent information for anyone required to attend to the patient.This operative progress note should contain at a minimum comparableoperative report information. These elements include; name of primarysurgeon and assistants, findings, technical procedures performed,specimens removed, and postoperative diagnosis as well as estimated bloodloss.3.Immediately after surgery is defined as “upon completion of surgery, beforethe patient is transferred to the next level of care, for example the postanesthesia care unit.” This is to ensure that pertinent information is availableto the next caregiver.OPERATIVE REPORTSA major part of the medical record is the section devoted to the operative report.However, the operative report must do more than contribute to thedevelopment of surgery or provide mortality and morbidity information tostatisticians. An operative report must outline the logic used in treating a patientand document why the particular type of surgery was performed, the stepsinvolved, and the outcome. An adequate operative record provides pre- andpostoperative information, as well as consent to treat forms and status reportswhen additional surgery is required after the initial surgery was performed. Itserves as the basis for reimbursing the surgeon, surgical team, and inpatient oroutpatient facility and as the official record for claims involving malpractice,worker’s compensation, accidental trauma, or medical hardship.Despite regulations, however, operative reports are seldom easy to interpret andcode. Regardless of the physician’s specificity about how a service wasperformed, coders must understand: How operative reports and notes are organized Availability of standard forms for recording information either in a written orelectronic format The documentation required in the health record for each episode of care(e.g., diagnostic or therapeutic surgical care or procedural care)OrganizationOrganization of the health record (including operative reports) is determined bythe hospital unless specified by accrediting agencies. However, the classificationsystem used in organizing data is common among hospitals.Legal and Administrative DataAdministrative data belonging at the front of the health record include billinginformation specifying Medicare, Medicaid, and any supplemental insurance.Legal data generally cover specific patient orders such as signed conditions ofparticipation (CoP), refusals of any specified procedures, living wills, and powerof attorney. 2017 Optum360, LLC*KEY POINTAccording to Medicare’s conditions ofparticipation (CoP), a hospital mustinform each patient, or whenappropriate, the patient’srepresentative (as allowed underHIPAA or state law), of the patient’srights, in advance of furnishing ordiscontinuing patient care wheneverpossible. A signed consent form mustbe in the patient’s record prior toeach surgery. CoP requires hospitalsto develop policies that ensure eachpatient is informed of his or her rightsin language that the patientunderstands (e.g., hospital mustprovide interpretation for those whospeak a language aside from Englishor, for other reasons, requirealternative methods ofcommunication). The policies mustcover any state or federal regulationnotice regarding patient rights,including the right to an advancedirective and notice of noncoverage.7
Chapter 4: ReimbursementThe MS-DRG system relies on accurate diagnosis and procedure codeassignment. Each case is assigned to a DRG. Each DRG has a relative weightassigned to it that is the same for all hospitals throughout the country and isupdated each year. This relative weight is based on the complexity of the servicesexpected to be required to treat that particular case. The DRG’s relative weight ismultiplied by the hospital’s specific base rate, which is calculated based onseveral factors, including the wage index for that geographic area. Thecalculation of DRG relative weight times the hospital base rate determines thespecific reimbursement rate for the case.The DRG is determined by five variables:1. The patient’s principal diagnosis2. The patient’s secondary diagnoses, which includecomplication/comorbidities3. Surgical and other invasive procedures4. Sex of the patient5. Discharge status*KEY POINTMedicare Severity-DRGs, enacted inOctober 2007, improve by 9.41percent the explanation of varianceof hospital resources used over theprevious version of DRGs.A hospital’s Medicare population case complexity is measured by calculating thecase-mix index, which is an average of all MS-DRG relative weights for the facilityduring a given period of time. The higher the case-mix index, the more complexthe patient population and the higher the required level of resources used. Sinceseverity is such an essential component of MS-DRG assignment and case-mixindex calculation, documentation and code assignment to the highest degree ofaccuracy and specificity are of the utmost importance.Review the following steps for accurate MS-DRG assignment:Step 1Assign the principal diagnosis based on the UHDDS definition: “That conditionestablished after study to be chiefly responsible for occasioning the admission ofthe patient to the hospital for care.” If the diagnosis documented at the time ofdischarge is qualified as “possible,” “probable,” “suspected,” “likely,”“questionable,” “still to be ruled out,” or other similar terms indicatinguncertainty, code the condition as if it existed or was established.Step 2Assign diagnosis codes for secondary conditions, defined as those conditionsthat required: clinical evaluation, therapeutic treatment, diagnostic procedures,extended length of hospital stay, or increased nursing care and/or monitoring.Conditions that are designated as MCCs or CCs should be sequenced directlyfollowing the principal diagnosis.Step 3Assign procedure codes for all surgical procedures performed, as well as for otherinvasive procedures that may not have been performed in an operating room.For example, services provided in interventional radiology suites, cardiaccatheterization rooms, or even provided at bedside may be designated as “validnon-OR procedures” and will affect MS-DRG assignment.Step 4Consider all required information (diagnosis and procedure codes, patient sex,and discharge status) when grouping the DRG. Note the medical diagnosticcategory (MDC) and MS-DRG initially grouped. Ensure that the MDC and MS-DRG 2017 Optum360, LLC*KEY POINTUnder the MS-DRG system, physiciandocumentation in the medical recordmust be specific because manychronic conditions are no longerdesignated as CCs. It is only when anacute exacerbation or an acute formof the disease process is documentedand coded that the condition may beconsidered an MCC or CC and affectMS-DRG assignment.23
Chapter 6: Operative Report Coding Other forms or reports filed in separate sections, depending on protocolestablished by the facility or physician’s officeFor example, a pathology report may clarify the type of tumor found in anoperative session (e.g., benign or malignant) or further specify the nature of acondition. Confirm specimens (whether neoplastic tumors or not) excised withthe pathology reports to ensure diagnostic specificity. Many payers take issuewith nonspecific codes. Making diagnostic specificity a standard practice is anexcellent preparation for ICD-10, in which the granularity of data required tocode is further refined.UNDERDOCUMENTED OR INCORRECT INFORMATIONInformation in the medical record can be underdocumented or incorrect asevidenced in a report where the operative report body does not agree with theheading or other chart documentation. Finding underdocumented or incorrectinformation requires the coder to seek information from outside of the operativereport proper whether in an inpatient or outpatient setting.UnderdocumentedExample: The operative progress note states a procedure was performed although theprocedure is not listed in the heading of the operative report but detailed inthe body of the report.IncorrectExample: The operative report heading specifies the patient was a male and ahysterectomy was performed. The operative report states a female had a skiing accident, though the facesheet says a male was admitted to the hospital. The heading of the operative report indicates a procedure was performed onthe left leg and the body of the operative report states the procedure wasperformed on the right leg.*KEY POINTRoom assignment can be used tolook for complications or otherconditions that may affect codeassignment. One should ask, forexample, why a patient was in anintermediate care or intensive careroom. Are these rooms the only onesavailable, or are there otherconditions present?When there are conflicts in thedocumentation that may affectcoding assignment and accuracy ofthe document, ask others in theoffice. Seek information from themedical records director, officemanager, or other entity about whento request additional informationfrom the surgeon. Coders should alsoseek guidance regarding theconditions necessary for anaddendum to the medical record.When conflicts exist in the documentation of a medical record that may affectcoding assignment and accuracy of the document, ask others in the office. Seekinformation from the medical records director, office manager, or other entityabout when to request additional information from the surgeon. Coders shouldalso seek guidance regarding the conditions necessary for an addendum to themedical record.Physician office coders should make sure to receive a copy of any hospital recordaddendum that has been documented. A system must be in place when thedocument is received by the surgeon to prevent important information beingfiled without the coder’s knowledge.CODE SELECTIONAlthough pre- and postoperative diagnoses and procedures are listed in theheading of the operative report, they alone may not contain the information 2017 Optum360, LLC39
Chapter 7: Operative Reports MDC 3OPERATIVE REPORT MDC 3—#4Preoperative diagnosis:Chronic sinusitis. Deviated nasal septum. Turbinate hypertrophy.Postoperative diagnosis:SameProcedure performed:Endoscopic sinus surgery with bilateral total ethmoidectomies, nasal polypectomybilateral nasoantral windows, and partial excision of the middle turbinatesProcedure description:The patient was identified, taken to the operating room, and placed in a neutral position.Smooth endotracheal anesthesia was induced. The patient was prepped and draped inthe standard fashion. 1% lidocaine with 1:100,000 epinephrine was injected into theseptum, uncinate process nasal polyps, and middle turbinates. Visualization with thesinus endoscope revealed a marked spur along the left septum impinging on the leftinferior and the middle turbinate and a marked deviation of the superior septum to theright side precluding adequate visualization of the right middle turbinate. Therefore, aleft hemitransfixation incision was performed, mucoperichondrial flaps elevated, 1.0 cmcaudal and dorsal struts outlined and incised, and a portion of the perpendicular plate ofthe ethmoid, vomer, and quadrangular cartilage as well as a large maxillary crest spurwere resected. The septum was shortened by approximately 1 mm to allow it to return tothe midline, and the incision was closed with 4-0 chromic interrupted simple sutures.Next, the left middle turbinate and middle meatus was identified, and a large polyp wasseen to completely obstruct the middle meatus. The polyp was removed with powerinstrumentation and the insertion of the middle turbinate incised and the anteriortwo-thirds of the middle turbinate resected. The polyp was then further removed via theethmoid sinus. The uncinate process was then infractured and sharply resected, gainingentrance to the maxillary sinus. A large polyp was then noted to almost completely fill themaxillary sinus on the left side, and this was removed with curved power instrumentation.The ethmoid sinus was then entered again, and a marked polypoid and thickenedmucosa was noted throughout. The fovea ethmoidalis and laminal papyracea wereidentified and used as landmarks for the procedure. The basal lamella was entered andthe posterior cells also opened wider. Thicken mucosa was noted in the sinuses as well.The sinoethmoidal recess was evaluated and was seen to be free of polypoid tissue. Theposterior insertion of the turbinate was cauterized with bipolar cautery as was theanterior insertion. The same procedure was performed on the opposite side with similarfindings, except only a small polyp was noted in the right maxillary sinus. Splints coated inointment were sutured to the nasal septum with 3-0 Prolene. The throat pack that wasplaced at the beginning of the case was removed, and the patient was extubated andtransported to the recovery room in good and stable condition.Code all relevant ICD-10-CM diagnosis and ICD-10-PCS procedure codes in accordancewith official guidelines and coding conventions.Diagnosis Codes:Procedure Codes:MS-DRG: 2017 Optum360, LLC77
Chapter 7: Operative Reports MDC 3OPERATIVE REPORT MDC 3—#4Preoperative diagnosis:Chronic sinusitis. Deviated nasal septum. Turbinate hypertrophy.Postoperative diagnosis:SameProcedure performed:Endoscopic sinus surgery with bilateral total ethmoidectomies, nasal polypectomybilateral nasoantral windows, and partial excision of the middle turbinatesProcedure description:The patient was identified, taken to the operating room, and placed in a neutral position.Smooth endotracheal anesthesia was induced. The patient was prepped and draped inthe standard fashion. 1% lidocaine with 1:100,000 epinephrine was injected into theseptum, uncinate process nasal polyps, and middle turbinates. Visualization with thesinus endoscope revealed a marked spur along the left septum impinging on the leftinferior and the middle turbinate and a marked deviation of the superior septum to theright side precluding adequate visualization of the right middle turbinate. Therefore, aleft hemitransfixation incision was performed, mucoperichondrial flaps elevated, 1.0 cmcaudal and dorsal struts outlined and incised, and a portion of the perpendicular plate ofthe ethmoid, vomer, and quadrangular cartilage as well as a large maxillary crest spurwere resected. The septum was shortened by approximately 1 mm to allow it to return tothe midline, and the incision was closed with 4-0 chromic interrupted simple sutures.Next, the left middle turbinate and middle meatus was identified, and a large polyp wasseen to completely obstruct the middle meatus. The polyp was removed with powerinstrumentation and the insertion of the middle turbinate incised and the anteriortwo-thirds of the middle turbinate resected. The polyp was then further removed via theethmoid sinus. The uncinate process was then infractured and sharply resected, gainingentrance to the maxillary sinus. A large polyp was then noted to almost completely fill themaxillary sinus on the left side, and this was removed with curved power instrumentation.The ethmoid sinus was then entered again, and a marked polypoid and thickenedmucosa was noted throughout. The fovea ethmoidalis and laminal papyracea wereidentified and used as landmarks for the procedure. The basal lamella was entered andthe posterior cells also opened wider. Thicken mucosa was noted in the sinuses as well.The sinoethmoidal recess was evaluated and was seen to be free of polypoid tissue. Theposterior insertion of the turbinate was cauterized with bipolar cautery as was theanterior insertion. The same procedure was performed on the opposite side with similarfindings, except only a small polyp was noted in the right maxillary sinus. Splints coated inointment were sutured to the nasal septum with 3-0 Prolene. The throat pack that wasplaced at the beginning of the case was removed, and the patient was extubated andtransported to the recovery room in good and stable condition.Code all relevant ICD-10-CM diagnosis and ICD-10-PCS procedure codes in accordancewith official guidelines and coding conventions.Diagnosis Codes:Procedure Codes:MS-DRG: 2017 Optum360, LLC77
Optum360 Learning: Coding from the Operative Report for ICD-10-CM and PCSOPERATIVE REPORT MDC 8—#7Preoperative diagnosis:Subtalar joint degenerative joint diseasePostoperative diagnosis:SameProcedure performed:Subtalar joint fusion with external fixation deviceProcedure description:The patient was brought in the operating room and placed in a supine position. Generalanesthesia was administered. Once adequate levels of anesthesia had been obtained, atime-out was called with the patient identification and the proposed procedure beingagreed upon by the surgical team and operating room staff. The left foot was preppedand draped in the normal sterile fashion to include a pneumatic tourniquet placed aboutthe left ankle.Attention was directed to the lateral sinus tarsi region, where a 10 cm linear-type incisionwas made and deepened using blunt dissection. Bleeders were cauterized as necessary,and neurovascular structures were retracted medially and laterally as necessary.Dissection was carried out using blunt and sharp technique, revealing the subtalar joint.The capsule was incised, exposing the posterior and middle facets. Using an osteotomeand mallet, the cartilage and subchondral plate was removed adequately to allow foreversion of the calcaneus, once fusion of the talus and calcaneus was achieved. The jointsurfaces were prepared using a smaller osteotome for a shingling effect.At this time, Trinity demineralized bone matrix was introduced into the joint space. AnICOS screw was introduced percutaneously through the dorsal aspect of the talar neck.This was placed through the neck and into the posterior aspect of the calcaneus. Underfluoroscopic guidance, it was noted that adequate compression of the subtalar joint wasachieved. A MiniRail was then placed across the subtalar joint. Two pins were placed inthe calcaneus, and two pins were placed in the body of the talus. Using the MiniRailcompression system, it was noted that the joint was further reduced. Incision was closeddeeply, taking care to reattach the capsular structures, followed by reapproximation ofthe peroneal tendon sheaths, using Vicryl suture. Subcutaneous tissues werereapproximated using simple interrupted Vicryl suturing. The skin was closed using arunning locking Prolene suture. At this time, the surgical site was dressed with Xeroform,4x4 gauze, Kling, Coban, and an Ace wrap.The patient was taken to the postoperative care unit where vital signs were stable andintact. It was noted that neurovascular status of the left foot remained intact. Patient wasdischarged to home once he emerged successfully, without incident, from generalanesthesia.Code all relevant ICD-10-CM diagnosis and ICD-10-PCS procedure codes in accordancewith official guidelines and coding conventions.Diagnosis Codes:Procedure Codes:MS-DRG:148 2017 Optum360, LLC
Optum360 Learning: Coding from the Operative Report for ICD-10-CM and PCSAnswers and Rationale DEFINITIONScul-de-sac. Blind pouch, or cavity,such as the pouch of Douglas (retrouterine) or the conjunctival fornix,which is the loose pocket ofconjunctiva between the eyelid andthe eyeball that permits the eyeballto rotate freely. CODING AXIOMICD-10-CM Official Guidelines forCoding and Reporting SectionI.C.6.b.1:A code from category G89 (Pain, notelsewhere classified) should not beassigned if the underlying (definitive)diagnosis is known, unless the reasonfor the encounter is pain control/management and not managementof the underlying condition.Preoperative diagnoses:Chronic pelvic pain, dysmenorrheaPostoperative diagnoses:Endometriosis of the posterior cul-de-sac and ovary,1,2 chronic pelvic pain, dysmenorrheaProcedure description:Patient was taken to the operating room; prepped and draped in normal sterile fashion.Attention was turned to the abdomen. A 5 mm skin incision was made in the patient’sumbilicus with scalpel. Veress needle was inserted and pneumoperitoneum wasachieved. A 5 mm trocar and the laparoscope3,4 were inserted. A separate 7-8 mmincision was made in the lower abdomen, ad a 7-8 mm trocar was inserted through theincision. A probe was inserted, and the pelvic cavity was explored. The anterior cul-de-sacwas normal. The posterior cul-de-sac showed 2 areas of endometriosis close to theuterosacral ligaments on both sides, which were cauterized with the bipolar cautery.2,4Another area of endometriosis was noted on the patient’s left ovary, and this wascauterized as well.1,3 All instruments were removed from the abdomen. Excellenthemostasis was noted. Sponge, lap, and needle counts were correct. The patienttolerated the procedure well and was taken to the recovery room in stable condition.Diagnosis CodesN80.1Endometriosis of ovary1N80.3Endometriosis of pelvic peritoneum 2Rationale for Diagnosis CodesThe operative note specifies that the endometriosis discovered is in the posteriorcul-de-sac and on the left ovary. According to the index for ICD-10-CM, the posteriorcul-de-sac is coded to pelvic peritoneum. The chronic pelvic pain is not reported,according to guidelines section I.C.6.b.1, which states that codes from the G89 category(Pain, not elsewhere classified) should not be reported if the definitive diagnosis isknown. It is also inappropriate to report the dysmenorrhea as this is routinely associatedwith endometriosis (section I.B.6).Procedure Codes0U514ZZ Destruction of Left Ovary, Percutaneous Endoscopic Approach30U5F4ZZ Destruction of Cul-de-sac, Percutaneous Endoscopic Approach4Rationale for Procedure CodesThe procedures were performed using a laparoscope, making the approach charactervalue 4. Two codes are necessary to report the cauterization of the endometriosis becausetwo separate anatomical sites were treated. In the index, “Cauterization” refers toDestruction or “physical eradication of all or a portion of a body part by direct use ofenergy, force or a destructive
MDC 12 Diseases and Disorders of the Male Reproductive System . 193 MDC 13 Diseases and Disorders of the Female Reproductive System . 201 MDC 14 Pregnancy, Childbirth and the Puerperium . 209 MDC 1
