Code for the Day: Getting Through the Operative Report without Crying Part 2 (R45.83)

Every once in awhile I get a complimentary email or message about a blog posting from a couple of years ago, "Getting Through an Operative Report - Without Crying."  It's always great to hear that people are reading my blog.  It's even better when people cite a particular posting and tell me how very helpful it was for them. This posting has been speaking to me lately too as I move beyond the shallow end of the ICD-10 coding pool and immerse myself neck deep in this new and strange coding world.  I'm not sure if this will make people feel better or if I risk losing part of my audience with this admission, but I've been crying a lot lately when it comes to ICD-10-PCS coding.

And thus, the code for the day:

• R45.83, Excessive crying of child, adolescent or adult

To say that ICD-10-PCS coding is foreign is an understatement.  My favorite statement about it - which I'm sure I've already blogged about before - is that ICD-10-PCS is like CPT on steroids.  Even the most experienced coders struggle with it and I've had my share of debates with colleagues about how to code something. And yes, there have been tears.

But the tears have not overshadowed the sheer excitement of learning this new coding system.  I find that I'm learning more about how procedures are performed and it's honing my coding skills further.  But there are a few things I really have a hard time with.

• The concept of root operation is a tough one.  Trying to determine the intent of a procedure is harder than it seems.  So many things we take for granted in ICD-9-CM will be so different in ICD-10-PCS.  Case in point: when you replace a device in ICD-9-CM, you will likely find that procedure indexed under the main term "Replacement."  In ICD-10-PCS, the root operation Replacement is only used to describe replacing a body part with a device.  When a device is replaced, it's usually two separate root operations: Removal and Insertion.
• Determining the approach is not something to take for granted.  How a physician approaches a procedure is easy, right?   We know laparoscopic versus open.  We understand that that there are certain body parts you can get to through an orifice while others can be access percutaneously by puncture.  But approach is more complex than you think.  For a transbronchial biopsy, the scope is placed through a natural orifice, but once inside the bronchus, a percutaneous puncture is made to obtain the biopsy, so the approach is percutaneous endoscopic.  The really unfortunate thing here is that many coders don't realize they are making mistakes with approach because it seems so darn easy!
• There's no such thing as unbundling in PCS.  Having coded both ICD-9-CM and CPT procedures, I strongly believe that CPT coding is a great prep for learning PCS.  The level of detail needed to code CPT is much greater than that needed for ICD-9-CM procedural coding.  But there are times when I initially miss PCS codes because I am applying CPT bundling rules to PCS.  In short, you can't do that.  We have specific PCS coding guidelines - if you have procedures that have more than one approach, root operation, or body part as defined in the PCS table, you code multiple codes.  And for a CPT coder, that's sometimes hard.  A specific example - we have a PCS guideline that says if they biopsy a structure and then remove it, you code two procedures since it is two root operations: Excision and Resection.  Weird, huh?!
• Where is the class on procedures?  We've been hearing for years that coders need to bone up on the biomedical sciences including medical terminology and anatomy and physiology, but I'm finding that many coders can't figure out the root operation because they don't understand the procedures themselves.  And while the training I've been working on does go into detail about how procedures are performed, I find there isn't really a college course you can take on procedures.  But YouTube has some great videos if you want to self study.

Okay, so that's the bad news.  PCS is hard.  Really hard.  The good news is this.  It's fun.  Super fun!  And it's opened up dialogue with other coders I haven't had the chance to have in a long time and I miss that.  So if you're starting to learn PCS and you're struggling -maybe even crying - you aren't alone.  And the best news of all is that they make some really cute tissue boxes these days!

Code for the Day: Lack of Awareness (R41.9)

Some day I intend to write a book about airline travel.  Not the usual fun and informative here-are-my-best-tips-and-tricks type of book, but a real, this-is-what-it's-really-like-and-can-you-believe-people type of book.  You see, for an avid people watcher, airports are the mother lode.  And what strikes me most about airline travel is how completely clueless people can be when they're using airplanes to get from point A to point B.

If you've traveled a lot, you've seen it too.  The woman with 5 bags (how did she get them all through security?!) who can't manage them all, so she stops in the middle of a busy airport concourse to reorganize herself but fails to see the traffic accident she caused behind her.  The young, able bodied person who takes a seat on the rental car shuttle while a elderly woman with obvious difficulty balancing stands and hangs onto the roof strap for dear life.  The person in the middle seat sitting next to you on the plane, who decided taking the armrest wasn't enough and now has his elbow in your side.  Or how about the guy who took my carry-on and walked off the plane and was at the parking garage before he realized he had the wrong bag? 

I just finished a couple months of more travel than I've done for quite some time.  I used to travel every week and I think you become immune to it after awhile, but after my brief return to airline flight, upon my arrival home, I happily posted on Facebook that I was glad to be done with my weekly dose of invasion of personal space (AKA airline travel). 

And while I don't think people are purposefully annoying, I do think it boils down to one thing: lack of awareness.  I've talked before about addiction to smart phones, but seriously - people are so dialed in that they've lost touch with reality.  It reminds me of the movie WALL-E, where the humans have left earth and spent countless years floating around on hovercraft and talking to their friends on little computer screens. And of course, the friends they are talking to are sitting right next to them!  One day the little robot WALL-E knocks a couple of them out of their little machines and they not only discover each other, but that the spaceship has a pool!

I know I am guilty of being ultra-plugged in, so I try to make an extra effort to unplug when I'm in a busy airport.  Unless of course, I am waiting at my gate and need something to pass the time.  The payoff is immense - watching other people can be quite entertaining!  One of my favorite people watching stories happened at baggage claim.  It was a late Monday evening and I was at an airport that I traveled to weekly and I knew it took about 30 minutes for bags to start arriving.  I also knew that the airport was terrible about marking which carousel would have your flight's bags.  On this Monday evening, I sat on the edge of an empty baggage carousel and watched the madness unfold.  It wasn't long before my attention locked on a short, balding, middle-aged man who bore a striking resemblance to the lead character from that cartoon, The Critic.  He bounced around from carousel to carousel looking for his bag.  When he saw one that was red (this appeared to be his only criteria - not size or other appearance), he pulled it off, looked at the tag, and heaved the suitcase back on the carousel with a heavy sigh.  I was momentarily put off when he grabbed my bag, but as I watched him struggle with my huge bag, which was more than half his height (and full of code books!), I suppressed a giggle.  Karma!

So this week as I am now happily grounded and working on some education material, I ran across this little gem of a code.  It's not the code description that captured my interest, but the index entry.  I found the code for the day under the main term "Lack of" and the subterm "awareness"

• R41.9, Unspecified symptoms and signs involving cognitive functions and awareness

 And just for good measure, let's add this one too:

• Y92.520, Airport as the place of occurrence of the external cause

If you're heading to the airport any time soon, happy aware travels!

Presidential Debate = Total Coronary Occlusion (I25.82)

Topping news headlines in Denver this morning is tonight's presidential debate.  I know what you're thinking - it's a big topic everywhere.  But here the focus is not on the candidates or their platforms - yet.  The focus is on what it will do to Denver traffic for the evening commute as our own University of Denver (DU) plays host to the candidates. 

If you're not familiar with the geography of Denver - besides the whole mile-high thing - we have one major interstate that runs north and south, connecting the northern community of Fort Collins to the southern city of Colorado Springs.  That is Interstate 25.  And right smack dab in the middle is Denver.  I think Denver is quite unique in that the downtown area is not the only major business area.  Just a little to the south is the Denver Technological Center (DTC) - the Silicone Valley of Colorado, if you will - which is filled with office parks.  To say that I-25 is a busy thoroughfare during rush hour is an understatement.  It's the heart of the city's traffic structure.  And DU is situated right in the middle of downtown Denver and the DTC - just off the I-25 corridor.  And for this evening's presidential debate, a significant portion of I-25 near DU will be closed off.  And this leads me to today's code for the day:

• I25.82, Chronic total occlusion of coronary artery

Of course, I suppose this closure would be more of an acute total occlusion, but I just loved the wording so much, I took a liberty or two with my blog today.  I think it's hysterical that coronary artery disease codes to category I25.  It tickles my twisted coder funny bone to realize that the code for clogged heart arteries is the namesake of the frequently clogged interstate that runs through my home town.  I believe I even snickered out loud in class when I made this discovery.  To add to my joy, arteriosclerosis of the peripheral arteries is classified to category I70, which happens to be our major east/west artery through Colorado and the gateway to the mountains.  On a Sunday afternoon, eastbound I-70 traffic coming into Denver is more backed up than I-25's morning rush hour as people erase their peaceful mountain weekend bliss and cuss at each other on their way down the mountain.  But I digress!

Category I25 is filled with all kinds of codes covering the gamut of coronary artery disease, including CAD of the native arteries as well as CAD of the bypass grafts or vessels of a transplanted heart.  It also has codes for chronic total occlusion of the coronary artery (as already mentioned), old MI, and coronary atherosclerosis due to lipid rich plaque, which always brings to mind a quote from a movie I can't quite place right now: "Your cholesterol is so high, you're practically a solid!"

So to all my blog followers who live in the Denver area, best of luck with your evening commute.  Hopefully you have a nice boss who either let you work from home today or will let you leave early!

Code for the Day: I Saved the Article on Procrastination for Last (Z73.89 )

Whew, it's over!  That's really all I can say about September - it's over!  It  was a very busy month both professionally and on a personal level and as I organize my to do list this week, I realize just how much I put off.  Busy people understand that you can't get it all done, so it's all about prioritizing and since I am a very ambitious person, my to do list is usually pretty huge and I know going into it that something is going to get cut.  The opposite of this process, in my mind, is doing absolutely nothing!

One of my to do stacks.  I'll get to it one of these days...

The other day during a little down time (I do have some!), I decided to start in on a series of articles my mom clipped for me.  I usually don't have time to read the articles she sends me, but as I flipped through the pages, with topics ranging from saving for retirement to time management, I thought perhaps I should take the time.  I read the article on why you should break certain time management rules first.  Then I moved onto the icky articles on retirement planning - good information, but not my favorite topic.  I saved the article on procrastination for last.

Oh, procrastination, you are my friend!  I am a master procrastinator, although it has backfired on me in the past.  I don't enjoy the last minute scramble to get a project done, it's just that I often so tightly manage my time (not a good thing according to the first article), that it's all about priorities.  And ever since high school, I have done some of my best work at the eleventh hour.  The tricky part is making sure you're not extending that into the twelfth hour!

And, of course, I had to see if there was a code for procrastination, and I do believe I found one:

• Z73.89, Other problems related to life management difficulty

I suppose you would only really consider this code if you thought procrastination was a bad thing.  Category Z73 also includes codes for type A behavior (Z73.1), lack of relaxation and leisure (Z73.2), and stress, not otherwise classified (Z73.3).  So I suppose if you aren't careful, a Z73.1 lifestyle along with Z73.89 can lead to Z73.2 and ultimately, Z73.3.  But I still think there is such a thing as a healthy amount of procrastination.

Now, to get back to that to do list.  I can check one thing off for today, but I'm sure there's something else I can put off until tomorrow...