Health Information Management

Sleuthing for documentation details

HIM-HIPAA Insider, August 4, 2014

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Put on your deerstalker hat and grab your magnifying glass. It’s time to do our best Sherlock Holmes impersonation.
 
We just received a chart from Dr. Doolittle and we need to code the procedure. However, some of Dr. Doolittle’s documentation went astray (such as the clinical indications, diagnosis, and history), and this is all the information we have:
Confirmed identity of patient Jill, who was satisfactorily sedated. I used the MFL 1,000 for extracorporeal shock wave lithotripsy, delivering 1,000 shocks to the stone in the lower pole of the right kidney, and 800 shocks to the stone in the upper pole of the same, with change in shape and density of the stone indicating fragmentation. The patient tolerated the procedure well.
 
Which ICD-10-PCS code would we report?
 
Let’s start by determining what we know. Well, we’re in the Medical and Surgical section, which means our first character is 0.
 
The procedure involves the kidneys, which makes our body system the urinary system (second character T).
 
For the root operation, we need to figure out what Dr. Doolittle did. He documented “extracorporeal shock wave lithotripsy” as the procedure. When we look up lithotripsy in the ICD-10-CM, we find two possible root operations:
  • With removal of fragments, see Extirpation (taking or cutting out solid matter from a body part)
  • See Fragmentation (breaking solid matter in a body part into pieces)
Dr. Doolittle didn’t mention removing fragments, so it’s probably not Extirpation.
 
If you look up extracorporeal shock wave lithotripsy, ICD-10-PCS directs you to Fragmentation. So Fragmentation it is.
 
That gives us 0TF as our table. When we get to the table, we notice that the right kidney and the left kidney have their own body part values. We don’t have a bilateral kidney choice, so we’ll be reporting two codes, one for each kidney.
 
On to the approach. We have six choices in this table and no indication of an approach in the documentation, right? Actually wrong.
 
An extracorporeal medical procedure is one that is performed outside the body. That makes the approach external.
 
The table includes only one choice for a device and one for a qualifier, so the little grey cells get a break on the last two characters of our codes. Based on Dr. Doolittle’s documentation and our own sleuthing abilities, we would report:
  • 0TF3XZZ, fragmentation in right kidney pelvis, external approach
Now let’s go see if we can find the rest of Jill’s record.
 
This article originally appeared on HCPro’s ICD-10 Trainer blog.



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