Health Information Management

Those pesky earaches

HIM-HIPAA Insider, January 5, 2015

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Poor Finn. He’s heading for his first birthday, but he may not be in a partying mood. After Finn developed his fifth ear infection in six months, mom Melissa decided it was time to put tubes in his ears. Three days before his birthday. Bummer little dude, but this will be way better in the long run.

 
In the real world, myringotomy is an outpatient procedure. It usually takes 10-15 minutes. However, for instructional purposes, we’re going to admit Finn to the Stitch ‘Em Up Hospital for his myringotomy.
In ICD-9-CM Volume 3, we would report code 20.01 (myringotomy with insertion of tube). What would this look like in ICD-10-PCS?
 
We know our first character will be 0 for the Medical and Surgical section of ICD-10-PCS. The second character is the body system. In this case, we’ll use 9 (ear, nose sinus).
 
Now the fun part—determining the root operation. Coders get to choose the root operation (sorry, docs) based on the intent of the procedure. What is the purpose of putting tubes in Finn’s ears?
 
The idea behind a myringotomy is to drain excess fluid or pus from the middle ear, usually by making a small incision in the ear drum. The tympanostomy tubes keep the middle ear aerated for a few months or years to stop the fluid from building up again.
 
So the physician is putting in a tube to drain fluid. Insertion maybe? That might be your first guess, but ICD-10-PCS defines root operation Insertion as “putting in a nonbiological appliance that monitors, assists, performs, or prevents a biological function, but does not physically take the place of a body part.”
 
That doesn’t really match what our physician is doing. When you look at the root operation definitions, Drainage (taking or letting out fluids and/or gases from a body part) is a better fit.
 
You can save yourself some time and aggravation by simply looking up myringotomy in the ICD-10-PCS Alphabetic Index. The index directs you to see Drainage, Ear, Nose, Sinus. It also helpfully directs us to table 099. And now things get very interesting.
 
Table 099 takes up more than a page in the ICD-10-PCS Manual. That’s a lot of choices. In fact, one crosswalk listed 12 possible code equivalents to 20.01.
 
The first thing we need to do is determine the body part. Is the physician draining the middle ear or the tympanic membrane? Check the documentation. If you aren’t sure, query.
 
If the physician is draining the middle ear, we have two choices (and we’ll report both codes—one for the right ear and one for the left):
  • 099500Z, drainage of right middle ear with drainage device, open approach
  • 099600Z, drainage of left middle ear with drainage device, open approach
Why an open approach? First of all, it’s our only choice. That makes it pretty easy. But if you think about the procedure and the definition of an open approach (cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure), open makes sense. The physician is cutting through the tympanic membrane to drain the middle ear.
 
You do need to be careful with the table. We have two rows for drainage of right and left middle ear. One row has a device character 0 for drainage device (the tubes), the other lists no device. If the physician was simply draining the accumulated fluid without putting in tubes, we would use the codes with no device (09950ZZ, 09960ZZ).
 
Another thing to note is the qualifier. When the physician inserts a drainage device, the qualifier is Z (no qualifier). If the physician is simply draining the fluid, the seventh character can be X (diagnostic) or Z.
 
This is also a good time to stop and think about what ICD-10-PCS means by device. To be a device in ICD-10-PCS, it must remain in the patient after the physician completes the procedure. In Finn’s case, the tubes are staying in. Something like a temporary catheter, which is removed, does not count as a device in ICD-10-PCS.
 
Back to our code possibilities. If the physician is actually draining the tympanic membrane, we have 10 codes to choose from (again, we’ll use two because both ears are getting tubes).
 
The difference between the codes comes down to the approach. We have five possible approaches:
  • Open
  • Percutaneous: entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach the site of the procedure
  • Percutaneous endoscopic: entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach and visualize the site of the procedure
  • Via natural or artificial opening: entry of instrumentation through a natural or artificial external opening to reach the site of the procedure
  • Via natural or artificial opening endoscopic: entry of instrumentation through a natural or artificial external opening to reach and visualize the site of the procedure
Keep in mind the surgeon is probably not going to say, “I used a percutaneous endoscopic approach.” You’ll need to carefully read the operative report and determine which approach the surgeon used.
 
If you commonly code surgery (which most inpatient coders do), you can ask your surgeons to do some short educational sessions to explain how they perform specific procedures. Work with them now so when we get to ICD-10-PCS you won’t query them for information that’s already in the record.
 
This article originally appeared on HCPro’s ICD-10 Trainer blog.



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