Coding Tidbits Written By: Linda Kobayashi
Edited and Posted By: Andrea Wong
The clock is ticking – we are on countdown for ICD-10. Very few of us are ICD-10 coding experts, but with determination and dedication, we will all get there, some of us sooner than later. Several coders intend to retire come October. Please don’t let ICD-10 discourage you. Everyone faces a challenge learning how to code ICD-10 procedures, a complete change from the ICD-9 procedure code set. On a lighter note, the ICD-10-CM diagnostic codes follow similar publication layout/format as ICD-9-CM. There, of course, have been changes to the structure of the ICD-10-CM codes, but none that are all that difficult to learn. Remember this – inch by inch, it’s a cinch. We are all in this together.
There are a few issues we would like to point out for our new readers. Most of you know from previous Tidbits that you are given problems that require assignment of both diagnosis and procedure codes. We will continue to offer this feature for all future Tidbits. The breakdown of diagnostic codes, a relatively new feature, applies only to the PDx. Also, the sequencing of directions for using the tables will now be placed immediately under the principal procedure table rather than placing it as the last item.
Before coding this week’s problem, please note the following: Subsequent encounter for open and closed fractures: used for encounters after active fracture treatment has been completed and the patient is receiving routine care during the healing or recovery period.
Problem for this week:
Several months ago the patient, a 55-year-old woman, fell off a ladder and fractured her left hip. She sustained a closed fracture of the femoral shaft for which she underwent surgery. During her recovery period, she saw her physician complaining of pain in her hip. After x-rays were taken, the physician diagnosed her with non-union of the fracture. Her treatment consisted of a percutaneous insertion of a bone growth stimulator. Do not assign E codes with the exception of the external cause of the fall.
- S72.302K: Unspecified fracture of shaft of left femur, subsequent encounter for closed fracture with non-union
- W11.XXXD: Fall on and from ladder, subsequent encounter
- 0QHY3MZ: Insertion of bone growth stimulator into lower bone, percutaneous approach
Breakdown of S72.302K:
S72 = Fracture of femur
S72.3 = Fracture of shaft of femur
S72.30 = Unspecified fracture of shaft of femur
S72.302 = Unspecified fracture of shaft of left femur
S72.302K = Unspecified fracture of shaft of left femur, subsequent encounter for closed fracture with non-union
To locate S72.302K: Disease Index > Fracture, traumatic > femur, femoral > shaft > S72.30- > Tabular to complete code > left > S72.302 > 7th character required > K > S72.302K
Comments for S72.302K:
- Under S72, Fracture of femur, there is a box containing all the 7th character possibilities.
- K is the 7th character – subsequent encounter for closed fracture with nonunion.
- A dash following a character as in S72.30- indicates that the code is incomplete and you must refer to the Tabular to complete the code.
- Nonunion means the fracture has failed to show evidence of healing and there is still separation of bony structures involved in the fracture.
To locate W11.XXXD: External Causes Index > Fall, falling > from, off, out of > ladder > W11 > go to Tabular to complete the code > see the box immediately below W11 to select the appropriate encounter > D, subsequent encounter for a code of W11.XXXD.
Comments for W11.XXXD:
- This is a subsequent encounter as indicated in the diagnostic statement.
- ICD-10-CM codes are always up to 7 digits in length. How do you account for the 3 Xs? Xs serve as placeholders in ICD-10-CM.
- Certain ICD-10-CM categories have applicable 7th characters and is required for all codes within the category, or as the notes in the Tabular List instruct. If a code that requires a 7th character is not 6 characters, a placeholder X must be used to fill in the empty characters. In our scenario we have 3 Xs to fill in the empty characters.
To locate 0QHY3MZ: PCS Index > Insertion of device in > Bone > Femoral Shaft > Left > 0QHY > locate table 0QH and go across the row to finish building the code:
Insertion of Bone Growth Stimulator into Lower Bone, Percutaneous Approach
- Insertion is defined as “Putting in a non-biological appliance that monitors, assists, performs or prevents a physiological function but does not physically take the place of a body part.”
- This device (BGS) stimulates the natural healing process by sending low-level pulses of electromagnetic energy to the injury or fusion site.
- This problem can be a bit tricky. When indexing Insertion of device in, there is also a subterm for Femoral Shaft (0QH9.) When reviewing the table, Femoral Shaft, Left (9) is not an option for the bone growth stimulator (BGS). In the table row for BGS (M) is the only 6th character device available under the body part for the Lower Bone (Y).
- The diaphragm is used as the frame of reference for body systems classified as upper bones or lower bones. In our scenario, the femur is below the diaphragm and considered to be the part of the Lower Bones.
- If you look at Devices in the 2nd row of table 0QH, it doesn’t include a choice of BGS. The 3rd row of table 0QH does list BGS; therefore, you have no options to use any row in that table except for row #3.
- Guideline B6.1a: A device is coded only if a device remains after the procedure is completed. If no device remains, the device value, No Device, is coded.
Directions for Locating the Codes by Going Directly to the Tables
Insertion of Bone Growth Stimulator
- Step #1 is to locate the correct section in your PCS coding book. You know that surgery was performed, so the most logical selection is the Med/Surg section. The majority of procedures are found here. The first character in the Med/Surg section is always 0.
- Step 2: Determine the correct body system. The body system is Lower Bones. Don’t look for a section entitled Musculoskeletal System. ICD-10-PCS uses Upper Bones and Lower Bones instead of the broader Musculoskeletal System anatomy (muscles, tendons, bursae and ligaments, head and facial bones, upper and lower joints, upper and lower bones, and in our scenario, lower bones.) We have identified the first two characters, 0Q.
- Step 3: Determine the root operation. You know you have to be in a table that starts with 0Q. You should also know that the root operations are listed alphabetically. Simply go through all the tables that start with 0Q and look for the root operation, Insertion. We now have the first three characters, 0QH, which puts us in the correct table. The first 3 character values are always listed for you at the top of the table. It gives the section, Med/Surg; the body system, Lower Bones; the root operation, Insertion.
- Step 4: Identify the body part to determine the 4th character value. The body part, left femoral shaft, should relate to the root operation, Insertion, because it was the femoral shaft that received the Bone Growth Stimulator. However, as we previously discussed, since the device, bone growth stimulator is not an option in row #2, you must use row #3 to capture Bone Growth Stimulator. Row #3 lists only one body part, Lower Bone. We now have 4 character values, 0QHY.
- Step 5: Determine the Approach. No guesswork regarding the approach, as our diagnostic statement clearly states that the procedure was done percutaneously. We should now have 5 characters, 0QHY3.
- Step 6: Determine whether or not a device was left in the patient postoperatively. We know that there was a device left in place, the Bone Growth Stimulator. We should now have 6 characters, 0QHY3M.
- Step 7: There is no qualifier, so we should now have our code, 0QHY3MZ. Z functions as a placeholder in ICD-10-PCS. Z is to PCS what X is to ICD-10-CM.