Author: Linda Kobayashi, BA, RHIT, CCS
Editor: Andrea Wong, BS, RHIT
This week we are going to continue our discussion on orthopedics and hip replacement surgery. How are you coders coping with ICD-10? We’d love to hear from you, as you could benefit from each other as well as us. If we know what is giving you trouble, we could address those issues. Its always comforting to know that other people are facing the same issues you are, whatever they may be.
Problem for this week:
A 75-year-old man, suffering from severe primary osteoarthritis, underwent an open left hip replacement with ceramic on ceramic and no cementing. He also suffers from chronic renal failure, requiring dialysis 3 times per week. His physician stated that the patient’s renal failure is most likely due to hypertension that went undiagnosed for many years. This admission, in fact, is the first time in several years that he has been seen by any physician. According to his physician, “It’s a wonder he’s still alive, especially because of his renal condition. The patient had two hemodialysis treatments during this hospital stay.
- M16.12 = Unilateral primary osteoarthritis, left hip
- I12.0 = Hypertensive chronic kidney disease with stage 5 chronic disease or end-stage renal disease
- N18.6 = End stage renal disease
- Z99.2 = Dependence on renal dialysis
- 0SRB03A = Replacement of left hip joint with ceramic synthetic substitute, un-cemented, open approach
- 5A1D60Z = Hemodialysis
To locate M16.12: Disease Index > Osteoarthritis > primary > hip > M16.1- > Unilateral primary osteoarthritis of hip > Go to the Tabular to replace the dash with the 5th character > Unilateral primary arthritis of the left hip > M16.12
Comments for M16.12:
- The most common reason for hip replacement is osteoarthritis.
- Primary versus secondary arthritis: There’s not much of a difference in the way each type of osteoarthritis arthritis feels, but there is a difference in what causes them. What’s different about the two types is the underlying cause for the cartilage breakdown in the first place.
- Primary osteoarthritis: This is considered “wear and tear” osteoarthritis. This type of arthritis is more commonly diagnosed. It’s associated with aging – the longer you use the joints, the more likely you are to develop this form of osteoarthritis.
- Secondary osteoarthritis: This type of osteoarthritis has a specific cause, such as an injury, obesity, genetics, and inactivity. It tends to strike at an earlier age.
To locate I12.0: Disease Index > Failure, failed > renal > chronic > hypertensive > see Hypertension, kidney > with > stage 5 chronic kidney disease (CKD) or end-stage renal disease (ESRD) > I12.0 > Tabular for further instructions > Hypertensive chronic kidney disease with stage 5 chronic disease or end-stage renal disease > Use additional code to identify the stage of chronic kidney disease (N18.5, N18.6).
To locate N18.6: Disease Index > Disease > end stage renal disease > N18.6 > Verify in the Tabular: chronic kidney disease requiring chronic dialysis > Use additional code to identify dialysis status (Z99.2).
Comments for I12.0 and N18.6:
- It is very important to go to the Tabular; never code from the Index alone because this is where coding guidelines and coding rules are discussed.
- The kidneys filter waste and excess fluid buildup from the blood. As kidneys fail, waste builds up. In later stages, filtering the blood with a dialysis machine may become necessary.
To locate Z99.2: Disease Index > Dialysis > renal (hemodialysis) (peritoneal) > status > Z99.2
To Locate 0SRB03A: PCS Index > Replacement > Joint > Hip > Left > 0SRB > Locate table 0SR and go across the row to complete the code after verifying that the 4th character value of B is correct:
Replacement of Left Hip Joint with Ceramic Synthetic Substitute, Uncemented, Open Approach
- Replacement: Putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part.
- The 6th character identifies the type of material for the bearing surface of the left hip joint replacement procedure; particularly, the surfaces at articulation. In the scenario, the case study stated that the 2 surfaces were both ceramic material. The ICD-10-PCS value descriptor for the correct answer is 3 – “Synthetic substitute, Ceramic” which is the same as Ceramic-on-ceramic, but without the description redundancy.
- Ceramic on ceramic hip replacements are an improvement on traditional hip replacements for a number of reasons. Some of the benefits include:
- Better wear characteristics; life expectancies exceed traditional hip replacements.
- More effective pain relief.
- Lowered chance of breaking because of the material: Ceramic is more durable than the plastics used for other hip replacements.
- Lower joints: The dividing line that separates upper joints from lower joints is the lumbar vertebrae. Your PCS coding book has two sections; one section for upper joints and one section for lower joints.
- Cemented versus uncemented joint prosthesis:
- Cemented: Uses fast-drying bone cement to help affix it to the bone.
- Uncemmented: Specially textured to allow the bone to grow onto the prosthesis and adhere to it over time.
Directions for Locating Procedure Code by Going Directly to the Tables
- Step 1: Determine 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 first character value in this section is always 0.
- Step 2: Determine the Body System. You know that the hip is a lower joint, so simply go to the section entitled Lower Joints which has a character value of S. So far we have 0S.
- Step 3: Determine the Root Operation. Root operations are listed alphabetically. You are already in the Lower Joints section in the PCS tables. Now you need to find Replacement, the root operation, with a value of R. The first 3 characters are easy to find because the format for the PCS tables always lists the Section, Body System and Root Operation immediately above the table. So far we have 3 character values, 0SR.
- Step 4: Determine the Body Part(s). We know that the body part is the left hip joint with a value of B; now we have 4 characters, 0SRB.
- Step 5: Determine the Approach. This is easy because in our scenario, the coding problem states that the approach is open. Open approach always has a character value of 0. We’re up to 5 character values, 0SRB0.
- Step 6: Determine the Device: If there is a device left in place at the end of the procedure, it must be coded. The device is the ceramic used to hold the hip replacement in place, with a value of 3; we now have 6 character values, 0SRB03.
- Step 7: Determine the Qualifier. Qualifiers provide further details about the procedure. In our scenario the character value of A indicates that this procedure was performed without using cement, for a code of 0SRB03A.
We’re not finished yet. We have one more procedure to code, hemodialysis.
To locate 5A1D60Z: PCS Index > Dialysis > Hemodialysis > 5A1D60Z. Locate table 5A1 and then go across the row to verify that the remaining character values are correct:
Performance of Urinary Filtration, Multiple
- Definition of Performance: Completely taking over a physiological function by extracorporeal circulation.
- Note that the 5th and 6th character values, unlike the Med/Surg section, represent Duration and Function, respectively: Duration replaces Approach and Function replaces Device.
- Single versus Multiple: If the patient has more than one dialysis session during a single episode of care, it is coded to multiple. In our scenario, the patient had two dialysis treatments during his hospital stay, coding this to the character value, 6.
- Role of Filtration in the kidneys: Filtrationis the mass movement of water and solutes from plasma to the renal tubule that occurs in the renal corpuscle. About 20% of the plasma volume passing through the glomerulus at any given time is filtered. This means that about 180 liters of fluid are filtered by the kidneysevery day
Directions for Locating Procedure Code by Going Directly to the Tables
- Step 1: Determine the appropriate section. If you aren’t sure which section to use, you can always cheat by going to the Disease Index and referring to the main term, hemodialysis, which gives you the entire code. This automatically puts you in the Extracorporeal Assistance and Performance section.
- Step 2: Determine the Body System: Once you locate table 5A1, the table tells you that is Physiological Systems.
- Step 3: Determine the Root Operation. Root operations are listed alphabetically. You are already in the Extracorporeal section in the PCS tables. Now you need to find Performance, the root operation, with a value of 1. The 1st 3 characters are easy to find because the format for the PCS tables always lists the Section, Body System and Root Operation immediately above the table. So far we have 3 character values, 5A1.
- Step 4: Determine the Body System: Note that Body System replaces Body Part, as found in the Med/Surg section. We know that the Body System is Urinary. Think about it: There’s no way Urinary could be considered a Body Part; now we have 4 characters, 5A1D, with D representing the Body System.
- Step 5: Determine the Duration (Single versus Multiple.) During a single episode of care, if a patient has one dialysis treatment, it is considered a single treatment but if more than one dialysis session occurs during that same episode of care, it is considered multiple, with a character value of 6. We’re up to 5 character values, 5A1D6.
- Step 6: Determine the Function. The function is to clean the blood through the process called filtration, with a character value of 0. We now have 6 character values, 5A1D60.
- Step 7: Determine the Qualifier. Qualifiers provide further details about the procedure. In our scenario the character value of Z indicates that this procedure has no qualifiers. Assign Z, the placeholder for ICD-10-PCS. Z ist to PCS what X is to ICD-10-CM. The hip replacement was performed without using cement, for a code of 5A1D60Z.