HIM1103_Module04.LiveLecture

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Rasmussen College, Florida *

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1103

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Dec 6, 2023

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HIM1103 Coding Foundations Module 4 ICD-10-PCS Coding Welcome to an In-Depth Look at How to Code for Inpatient Procedural Coding The Clintegrity Encoder will be introduced in this module.

12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential 2 • ICD-10-PCS coding is very different from ICD-10-CM and CPT coding. With ICD-10-PCS, you are building the individual characters of the code based on coding guidelines, definitions, and in alignment with the provider documentation. • All codes have 7 characters • The physician is not expected to use PCS terms. It is the coder’s responsibility to determine how the documentation equates to PCS definitions Overview of ICD 10 PCS Coding

Medical and Surgical Section ( pg. 42) Largest section in the ICD-10- PCS Code Book. The first character of a code indicates the section. For the Medical and Surgical Section the character value is “0”. Most ICD-10-PCS procedure codes come from this section . Medical and Surgical Related Sections: Includes: 9 sections e.g. Obstetrics, Placement, Measurement & Monitoring etc. First characters are 1 - 9 Ancillary Sections: Includes: 7 sections e.g. Imaging, Nuclear Medicine, Radiation Therapy etc. First characters: B – D, F – H. New Technology is an “X”. 3 ICD-10-PCS: 3 Main Sections of Code Tables 12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential

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4 • This week it will be important to do your reading assignment from the code book and the information in the course under “Lesson Content”. • Listen to the Live Classroom session before doing any of the assignments. • The reading in the code book is critical in helping you to understand how the code book is structured and the coding guidelines are organized as well as how to apply them to the procedural statements. • It is not intended for you to memorize all of the information. It is important, however, to become familiar with the guidelines and definitions to be able to find the information when needed to code correctly and code according to guidelines. Module 4 Reading Assignment

12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential 5 • Live Classroom Assessment Code/Questions – Your Instructor will provide the required response during the live classroom session . • Assignment: Coding Principles and Code Build Process – Enhance your understanding and application of the coding guidelines and definitions in the code build process. – Three Part Assignment. • Lab Activity: ICD-10-PCS Coding – Practice identifying the Main Term/Root Operation – Build the code using the ICD-10-PCS Code Book Alphabetic Index and Code Tables • Quiz: Test Your Knowledge of ICD-10-PCS Concepts Module 4 Assignments

12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential 6 • There are basic concepts and rules that a coder must understand and apply when assigning ICD-10 PCS codes in order to be ethical, compliant, and accurate for reporting purposes. (Schraffenberger & Palkie, 2020). • For ICD-10-PCS there are conventions and guidelines for individual characters of the Medical and Surgical PCS Code Structure. • Additional guidelines are available for Obstetrics, Radiation Therapy and New Technology. • Review the guidelines in the front of the ICD-10-PCS code book. Official ICD-10-PCS Coding Guidelines

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12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential 7 • Examples… • A1. Seven character PCS Codes • A2. Alphanumeric codes; 0 – 9 and all letters with the exception of O and I • A6. Purpose of the Alphabetic Index • A7. Intent of Code Tables • A8. All seven characters must be specified • A9. All combinations of characters must come from the same row in the Code Table • A11. The physician is not expected to use PCS terms. It is the coder’s responsibility to determine how the documentation equates to PCS definitions Coding Conventions

12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential 8 • Medical and Surgical Guidelines address… • Multiple Procedures • Discontinued and Incomplete Procedures • Biopsy Procedures • Bypass Procedures • Fusion Procedures • Inspection Procedures • Occlusion vs Restriction Procedures • Release vs Division Procedures • Fracture Procedures • Bilateral Body Parts • External Approach • Device Guidelines Coding Guidelines

9 Read and follow the specific steps given in Lesson Content. In general… 1. Read the documentation thoroughly 2. Determine the intent or objective of the procedure 3. Locate the Main Term or Root Operation in the Alphabetic Index of the PCS Code Book 4. Locate the Body Part under the Root Operation in the Alphabetic Index 5. Use the first 3 characters of the code from the Index to locate the Code Table 6. Determine the remaining characters (4 th – 7 th ) based on the documentation and definitions. 7. Check the code against the documentation ICD-10-PCS Coding Building Steps

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12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential 10 Procedure: Colonoscopy with biopsy of the cecum Identify the Main Term : Main Term : Biopsy Why not Colonoscopy??? CG: B3.11a Inspection of a body part performed in order to achieve the objective of a procedure is not coded separately. Lookup Main Term in the Alphabetic Index: Biopsy- See: Excision with Qualifier Diagnostic See: Extraction with Qualifier Diagnostic See: Drainage with Qualifier Diagnostic Determine the appropriate Root Operation based on documentation, definitions and any corresponding coding guidelines: Root Operation Definitions- 1. Excision: cutting off or out without replacement a portion of a body part 2. Extraction: pulling or stripping out or off a portion of a body part by the use of force 3. Drainage: Taking or letting out fluids and/or gases from a body part Reference medical terminology and other resources to further your understanding of the clinical terms used by the providers. Let’s Practice Determining the Root Operation ICD -10-PCS

12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential 11 Procedure: Reduction of displaced fracture Identify the Main Term: Lookup Main Term in the Alphabetic Index: Determine the appropriate Root Operation based on documentation, definitions and coding guidelines: Root Operation Definition – CG - Your Turn to Practice Determining the Root Operation ICD-10-PCS

12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential 12 ANSWERS Procedure: Reduction of displaced fracture Identify the Main Term : Main Term : Reduction Lookup Main Term in the Alphabetic Index: Reduction – Fracture, see Reposition Determine the appropriate Root Operation based on documentation, definitions and coding guidelines: Root Operation Definition – Reposition: Moving to its normal location or a more suitable location all or a portion of a body part . CG- B3.15 Reduction of a displaced fracture is coded to the root operation Reposition and the application of a cast or splint in conjunction with the Reposition procedure is not coded separately. Treatment of a non-displaced fracture is coded to the procedure performed. Your Turn to Practice Determining the Root Operation ICD-10-PCS

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Introduction to the Clintegrity Encoder for ICD-10-PCS coding: An encoder is coding software used to locate codes and is used by a coder. The Clintegrity is a book based encoder. The coding pathway is very similar to coding directly from a physical code book.

12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential 14 • The Rasmussen College Clintegrity Encoder is accessed via the website: http://quantim.ahima.org:8080/topaz/main.do • The encoder is made available through the national AHIMA organization. • The User Name is RAS001 (zeroes) • The Password will be provided by your instructor. – The password changes on January 1 and July 1 each year. • It is very important that the password is never changed by students. Changing the password will lock out the entire college and prevent anyone…including yourself…from using the encoder. • If you experience problems getting in, try the following: – Try another browser – Enter the website address manually into the browser – Turn off pop up blockers – Sundays tend to have heavy use which may cause problems. Wait 15 minutes and try again. – If problems still occur, contact the AHIMA Help Desk or your instructor-DO NOT contact PSC as they are not familiar with the encoders. How To Access the Clintegrity Encoder

12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential 15 • A link to the Clintegrity Encoder Demo is embedded in the Course Content for Module 4 and available under the Resource Guides . • The demo provides a brief walk-through demonstrating how to access and utilize the encoder. • Use the encoder only as instructed in the course. Clintegrity Encoder Demonstration

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12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential 1. Follow the instructions for the Lab Activity regarding when to use the ICD-10-PCS Code Book for a portion of the assignment and when to utilize the encoder. 2. Screen shots will be required for that portion of the Lab Activity requiring the encoder. 3. Instructions for taking “screen shots” is available in the course content View the Clintegrity Encoder Demonstration and review the accompanying power point for instructions on determining the ICD-10-PCS codes using the encoder application. 16 Using the Clintegrity Encoder this Week

Any Questions? For the Live Session attendees, please ask your Instructor any questions now. For the Recorded Session, please ask your Instructor questions via Course Email or General Course Questions. 17

Submission of the Assessment Responses Indicates you….. - Listened to the recorded lecture or participated in the live classroom session -Are accountable for the information contained in the lecture materials Responses to the Assessment Questions need to come from the information presented in lecture . Remember your Assessment Response! November 9, 2023 Copyright Rasmussen College, 2012. Proprietary and Confidential. 18

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12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential 19 • Schraffenberg, L.A., & Palkie, B.N.(2020). Basic ICD-10-CM and ICD-10- • PCS Coding. Retrieved from URL for publisher home page. References