Surgery Documentation Specificity Key to Proper CodingDr. Erica Remer, MD, FACEP, CCDS People often ask me questions about fascinating CDI topics which spawn ICD10monitor articles, Talk Ten Tuesday TalkBacks, and newsletter articles. These topics that they broach usually come from some condition which has been difficult to understand, to reconcile the coding-clinical disconnect, or which the CDIS or PA has been tasked with formulating materials to teach their colleagues or medical staff. One of our ACPA CDI Committee members just sent me this: CDI team just emailed me that they are always confused about “procedure specificity not only with debridement type and depth, but also laceration repair depth, abscess drainage depth, etc.” This intrigued me because it illustrates how you must understand WHY the question is being asked to be able to give a cogent answer or effective assistance. A provider has to repair a laceration, or an abscess needs to be drained. What’s the difference how deep the injury or abscess extends?! You debride until you are done removing icky tissue, so why do I need to be so specific? First, as the PA, you need to understand that there are two different coding systems which are utilized to code procedures. For outpatient procedures facility fee billing and coding for the professional fee, the Current Procedural Terminology system (CPT) is used. Inpatient procedures are codified with ICD-10-PCS (PCS = Procedure Coding System). CPT has codes with precise definitions, and clinicians are more accustomed to providing those terms. ICD-10-PCS requires the coder to understand what was accomplished by the procedure and to pick the correct root operation/s and the correct body part/s. This is why the operative note is so important – if the coder can’t tell what was done to what part, they can’t derive an accurate code. The codes for laceration repairs and abscess drainage vary for both CPT and ICD-10-PCS depending on certain factors, which might include depth. Let’s explore which specific factors affect the codes for these procedures. For CPT, the determinants of the Incision and Drainage code set (10040-10180) are:
I&Ds can also be found elsewhere in CPT, for instance, intraoral, perianal, and vulvovaginal abscess I&Ds. In ICD-10-PCS, the first decision point is which body system is involved. The deepest layer involved establishes the body system. Skin has a second character of H, subcutaneous tissue and fascia are designated with J; muscles, tendons, and ligaments have their own characters. Once the body system is selected, the fourth character is for the body part, e.g., scalp, face, right or left neck, chest, back, right upper arm, left lower leg, right or left foot. Additionally, the coder needs to be able to ascertain if the procedure was done open or percutaneously and whether a drain was placed. Similarly, laceration repairs require specificity for both CPT and ICD-10-PCS. CPT:
ICD-10-PCS This one flummoxed me for a bit. If the laceration depth is only skin and superficial subcutaneous tissue and a single-layer repair is done, the approach (for the body system of Skin) is external. However, if the body system is subcutaneous tissue and fascia or deeper, the choices for approach were open and percutaneous. It took me a while to comprehend the concept of percutaneous laceration repair, because intuitively, a laceration seemed like it was by definition “open.” The essence is the same for any distinction between open and percutaneous – is the part being operated on directly visualized or not? Percutaneous either means through the skin or through a small skin incision where the deeper part is accessed but is not directly visualized. If the fascia or muscle is exposed (often requiring undermining), approximated, and repaired, that is open. If big, deep bites of suture material involve deeper tissues which are not directly visualized, that is percutaneous, even if there is a skin incision. Examples would be fascial plication sutures or galeal repair in scalp laceration when it is done as a single layer (skin, subcutaneous, and galea). I can definitely see where a query might be needed to sort this out. Finally, debridement. For CPT:
For ICD-10-PCS, the CDI Committee has devoted a whole set of materials for the PA on the ACPA website CDI Resource Page. The essential question is whether the procedure involves excision which is the removal of a portion of a body part (e.g., a hunk of skin and subcutaneous fat). An excisional debridement takes the Diagnosis Related Group (DRG) from a medical to a surgical grouping which reimburses higher due to increased resource consumption. In comparing all of these different procedures, we can see that the elements required to assign an accurate CPT code may not be exactly the same as those needed for the ICD-10-PCS code. The provider may be more focused on the CPT selection because that determines their professional fee, and the CDIS or coder may be more interested in the ICD-10-PCS constituents. The practitioner may be documenting everything they need to support their CPT and may need education as to what is needed for a correct ICD-10-PCS code. Depth and size are critical components. The bottom line for the PA is that you need to impress upon your medical and surgical colleagues that the CDI team is not asking for gratuitous information, and that it is to everyone’s benefit for them to answer queries accurately and specifically. Understanding the provider’s WHY can help the PA figure out the HOW to close queries. If you have a CDI situation that arises in your institution or system that you think would be excellent fodder for materials out of our CDI Committee, please send them to [email protected]. We are always looking for topics that will help our membership. |