Saturday, October 20, 2012

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!