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ICD-10 PCS CODING PROCEDURES COMMON TO ALL FACILITIES Presented by AHIMA-Approved ICD-10-CM/PCS Trainers : Deb Selland, RHIT, CCS Sue Roehl, RHIT, CCS

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Page 1: ICD-10 PCS CODING PROCEDURES COMMON TO ALL FACILITIES Presented by AHIMA-Approved ICD-10-CM/PCS Trainers : Deb Selland, RHIT, CCS Sue Roehl, RHIT, CCS

ICD-10 PCSCODING PROCEDURES COMMON TO ALL FACILITIES

Presented by

AHIMA-Approved ICD-10-CM/PCS Trainers :Deb Selland, RHIT, CCS

Sue Roehl, RHIT, CCS

Page 2: ICD-10 PCS CODING PROCEDURES COMMON TO ALL FACILITIES Presented by AHIMA-Approved ICD-10-CM/PCS Trainers : Deb Selland, RHIT, CCS Sue Roehl, RHIT, CCS

Instructors • Sue Roehl, RHIT, CCS

Sue is a Manager and Health Care Consultant with Eide Bailly LLP in Fargo, ND. She has more than thirty years of health care experience, with an emphasis in coding, health information and quality management. She provides ICD-9-CM and CPT coding, documentation, and compliance reviews for hospitals throughout the country. She also provides coding support for inpatient and outpatient accounts.

Sue specializes in assisting hospital medical records coding staff, physicians, business services and ancillary departments with appropriate reimbursement. In addition, Sue offers onsite educational sessions and coding validation studies to determine if providers are assigning correct diagnosis and procedure codes for reimbursement and compliance.

Sue completed the AHIMA ICD-10-CM/PCS training in 2009. She has twice served as President for the North Dakota Health Information Management Association, along with various other Board offices.

 

• Deb Selland, RHIT, CCS

Deb is employed by Blue Cross Blue Shield of North Dakota as the Reimbursement Coding Coordinator and is responsible for performing DRG Validation coding audits on all North Dakota participating facilities. She has been employed in the Health Information industry for over thirty years.

Deb completed the AHIMA ICD-10 CM/PCS Academy certification in 2010. She has formerly served as President and Education Director for NDHIMA.

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Disclaimer• The presenters have made every reasonable effort to

ensure accuracy of the information provided in this material.

• The presenters make no guarantee the information compiled or presented is error-free.

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Objectives• Review structure of PCS codes• Code common procedures from various sections of

ICD-10-PCS

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ICD-10-PCS

Procedure Classification System

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ICD-10-PCS

(Procedures)Used in inpatient hospital setting

Replaces Volume 3

Maintained by CMS

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Structures and Features Comparison

ICD-9-CM Volume 3

Procedures

ICD-10-PCS

Procedures-3 or 4 characters (numeric)

-Always 7 characters per procedure (alphanumeric)

-Digits 0-9 used

-Letters A-H, J-N, P-Z

(no I or O because of confusion with numbers 1 and 0)

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*Documentation Alert

• ICD-10-PCS Coding Guideline:• A8: All seven characters must be specified to be a valid code. If the

documentation is incomplete for coding purposes, the physician should be queried for the necessary information.

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*Documentation Alert• ICD-10-PCS Coding Guideline:

• A11: Many of the terms used to construct PCS codes are defined within the system. It is the coder’s responsibility to determine what the documentation in the medical record equates to in the PCS definition. The physician is not expected to use the terms used in PCS code descriptions, nor is the coder required to query the physician when the correlation between the documentation and the defined PCS terms is clear. Example: When the physician documents “partial resection” the coder can independently correlate “partial resection” to the root operation Excision without querying the physician for clarification.

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Structures and Features Comparison

ICD-9-CM Volume 3

(Procedures)

ICD-10-PCS

(Procedures)

Consists of:

-Index

-Tabular

Consists of:-Index

Provides first 3 or 4 values of the code

- Tables

Must be used to build complete code

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Structure and Features of ICD-10-PCS 

Character Meanings 

1 2 3 4 5 6 7

Section            

  

Sections (#16)0 Medical & Surgical ·        For procedures in the Medical & Surgical section the first character will always be zero (0).

Sections 1-9 comprise the Medical & Surgical-related sections such as obstetrical procedures and extracorporeal therapies, while sections B-D and F-H contain the Ancillary sections including procedures such as imaging and nuclear medicine.

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1 2 3 4 5 6 7

Section Body System          

 

2nd Character Body Systems (#31)

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1 2 3 4 5 6 7

Section Body System  Root

Operation

       

 3rd CharacterRoot Operation

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ICD-10 PCS CODING GUIDELINES

B3.1a In order to determine the appropriate root operation, the full definition of the root operation as contained in the PCS Tables must be applied.

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ICD-10 Procedure Coding SystemGlobal Root Operations (Section 0-9)

Alteration Definition-Modifying the anatomic structure of a body part without affecting the function of the body part

Explanation-Principal purpose is to improve appearance

Examples-Face lift, breast augmentation

Bypass Definition-Altering the route of passage of the contents of a tubular body part

Explanation-Rerouting contents around an area of a body part to another distal (downstream) area in the normal route; rerouting the contents to another different but similar route and body part; or to an abnormal route and another dissimilar body part. It includes one or more concurrent anastomoses with or without the use of a device such as autografts, tissue substitutes and synthetic substitutes.

Examples-Coronary artery bypass, colostomy formation

Change Definition-Taking out or off a device from a body part and putting back an identical or similar device in or on the same body part without cutting or puncturing the skin or a mucous membrane.

Explanation- All Change procedures are coded using the approach External

Examples-Urinary catheter change, gastrostomy tube change

Control Definition-Stopping, or attempting to stop, postprocedure bleeding

Explanation-The site of the bleeding is coded as an anatomical region and not to a specific body part.

Examples-Control of post-prostatectomy hemorrhage, control of post-tonsillectomy hemorrhage 16

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Global Root Operations (Section 0-9)

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Creation Definition-Making a new genital structure that does not take over the function of a body part

Explanation-Used only for sex change operations

Examples-Creation of vagina in a male, creation of penis in a female

Destruction Definition-Physical eradicating all or a portion of a body part by the direct use of energy, force or a destructive agent

Explanation- None of the body part is physically taken out.

Examples-Fulguration of rectal polyp, cautery of skin lesion

Detachment Definition-Cutting off all or a portion of an upper or lower extremity

Explanation-The body part value is the site of the detachment, with a qualifier if applicable to further specify the level where the extremity was detached

Examples-Below knee amputation, disarticulation of shoulder

Dilation Definition-Expanding an orifice or the lumen of a tubular body part

Explanation-The orifice can be a natural orifice or an artificially created orifice. Accomplished by stretching a tubular body part using intraluminal pressure or by cutting part of the orifice or wall of the tubular body part.

Examples-Percutaneous transluminal angioplasty, pyloromyotomy

Division Definition-Cutting into a body part without draining fluids and/or gases from the body part in order to separate or transect a body part

Explanation-All or a portion of the body part is separated into two or more portions

Examples-Spinal cordotomy, osteotomy

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ICD-10 Procedure Coding SystemGlobal Root Operations (Section 0-9)

Drainage Definition-Taking or letting out fluids and/or gases from a body part

Explanation-The qualifier DIAGNOSTIC is used to identify drainage procedures that are biopsies.

Examples-Thoracentesis, incision and drainage

Excision Definition-Cutting out or off, without replacement, a portion of a body part

Explanation-The qualifier DIAGNOSTIC is used to identify excision procedures that are biopsies

Examples-partial nephrectomy, liver biopsy

Extirpation Definition-Taking or cutting out solid matter from a body part

Explanation-The solid matter may be an abnormal byproduct of a biological function or a foreign body. The solid matter is imbedded in a body part, or is in the lumen of a tubular body part. The solid matter may or may not have been previously broken into pieces. No appreciable amount of the body part is taken out.

Examples-Thrombectomy, choledocholithotomy

Extraction Definition-Pulling or stripping out or off all or a portion of a body part

Explanation-The body part is pulled or stripped from its location by the use of force (e.g., manual, suction). The qualifier DIAGNOSTIC is used to identify extraction procedures that are biopsies.

Examples-Dilation and curettage, vein stripping

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Global Root Operations (Section 0-9)

Fragmentation Definition-Breaking solid matter in a body part into pieces.

Explanation-The solid matter may be an abnormal byproduct of a biological function or a foreign body. Physical force (e.g., manual, ultrasonic) applied directly or indirectly through intervening body parts is used to break the solid matter into pieces. The pieces of solid matter are not taken out, but are eliminated or absorbed through normal biological functions.

Examples-Extracorporeal shockwave lithotripsy, transurethral lithotripsy

Fusion Definition-Joining together portions of an articular body part rendering the articular body part immobile.

Explanation-The body part is joined together by fixation device, bone graft, or other means.

Examples-Spinal fusion, ankle arthrodesis

Insertion Definition-Putting in a non-biological appliance that monitors, assists, performs or prevents a physiological function but does not physically take the place of a body part.

Explanation- None

Examples-Insertion of radioactive implant, insertion of central venous catheter

Inspection Definition-Visually and/or manually exploring a body part.

Explanation-Visual exploration may be performed with or without optical instrumentation. Manual exploration may be performed directly or through intervening body layers.

Examples-Diagnostic arthroscopy, exploratory laparotomy19

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ICD-10 Procedure Coding SystemGlobal Root Operations (Section 0-9)

Map Definition-Locating the route of passage of electrical impulses and/or locating functional areas in a body part

Explanation-Applicable only to the cardiac conduction mechanism and the central nervous system

Examples-Cardiac mapping, cortical mapping

Occlusion Definition-Completely closing an orifice or the lumen of a tubular body part

Explanation-The orifice can be a natural orifice or an artificially created orifice

Examples-Fallopian tube ligation, ligation of inferior vena cava

Reattachment Definition-Putting back in or on all or a portion of a separated body part to its normal location or other suitable location

Explanation-Vascular circulation and nervous pathways may or may not be reestablished

Examples-Reattachment of hand, reattachment of avulsed kidney

Release Definition-Freeing a body part from an abnormal physical constraint by cutting or by use of force

Explanation- Some of the restraining tissue may be taken out but none of the body part is taken out

Examples-Adhesiolysis, carpal tunnel release

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ICD-10 Procedure Coding SystemGlobal Root Operations (Section 0-9)

Removal Definition-Taking out or off a device from a body part

Explanation-If the device is taken out and a similar device is put in without cutting or puncturing the skin or mucous membrane, the procedure is coded to the root operation CHANGE. Otherwise, the procedure for taking out the device is coded to the root operation REMOVAL and the procedure for putting in the new device is coded to the root operation performed.

Examples-Drainage tube removal, cardiac pacemaker removal

Repair Definition-Restoring, to the extent possible, a body part to its normal anatomic structure and function

Explanation-Used only when the method to accomplish the repair is not one of the other root operations

Examples-Herniorrhaphy, suture of laceration

Replacement Definition-Putting in or on biological or synthetic material that physically takes the place of all or a portion of a body part

Explanation-The biological material is non-living, or the biological material is living and from the same individual. The body part may have been previously taken out, previously replaced, or may be taken out concomitantly with the Replacement procedure. If the body part has been previously replaced, a separate Removal procedure is coded for taking out the device used in the previous replacement.

Examples-Total hip replacement, free skin graft21

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ICD-10 Procedure Coding SystemGlobal Root Operations (Section 0-9)

Reposition Definition-Moving to its normal location or other suitable location all or a portion of a body part

Explanation-The body part is moved to a new location from an abnormal location, or from a normal location where it is not functioning correctly. The body part may or may not be cut out or off to be moved to the new location.

Examples-Reposition of undescended testicle, fracture reduction

Resection Definition-Cutting out or off, without replacement, all of a body part.

Explanation-None

Examples-Total nephrectomy, total lobectomy of lung

Restriction Definition-Partially closing an orifice or the lumen of a tubular body part

Explanation-The orifice can be a natural orifice or an artificially created orifice.

Examples-Esophagogastric fundoplication, cervical cerclage

Revision Definition-Correcting to the extent possible a malfunctioning or displaced device

Explanation-Revision can include correcting a malfunctioning or displaced device by taking out or putting in components of the device such as a screw.

Examples-Adjustment of pacemaker lead, adjustment of hip prosthesis 22

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ICD-10 Procedure Coding SystemGlobal Root Operations (Section 0-9)

Supplement Definition-Putting in or on biological or synthetic material that physically reinforces or augments the function of a body part

Explanation-The biological material is non-living, or living and from the same individual. The body part may have been previously replaced. If the body part has been previously replaced, the Supplement procedure is performed to physically reinforce and/or augment the function of the replaced body part

Examples-Herniorrhaphy using mesh, free nerve mitral valve ring annuloplasty, put a new acetabular liner in a previous hip replacement

Transfer Definition-Moving, without taking out, all or a portion of a body part to another location take over the function of all or a portion of a body part

Explanation-The body part transferred remains connected to its vascular and nervous supply.

Examples-Tendon transfer, skin pedicle flap transfer

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ICD-10 Procedure Coding SystemGlobal Root Operations (Section 0-9)

Transplantation Definition-Putting in or on all or a portion of a living body part taken from another individual or animal to physically take the place and/or function of all or a portion of a similar body part

Explanation-The native body part may or may not be taken out, and the transplanted body part may take over all or a portion of its function

Examples-Kidney transplant, heart transplant

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4th CharacterBody Part

1 2 3 4 5 6 7

Section Body System Root Operation

Body Part      

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Comparing ICD-9-CM and ICD-10-PCS:Release Carpal Tunnel Release, Percutaneous

In the ICD-9-CM Alphabetic Index locate the main term “release,” followed by subterm “carpal tunnel (for nerve decompression)” which identifies code 04.43, Release of carpal tunnel.

In ICD-10-PCS, the main term entry of “release” requires the coder to select the body part being released. It is necessary to know that the median nerve is released during a carpal tunnel release. The body part value assigned is the structure released (median nerve) and not the structure cut (carpal ligament) to obtain the release. The subterm “nerve, median” below the main term “release” leads to 01N5. The 01N table is then accessed to construct the remainder of the code. The code assigned for a percutaneous release of the median nerve is 01N53ZZ.

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Approach

1 2 3 4 5 6 7

Section Body System Root Operation

Body Part    

5th CharacterApproach (7 Options)

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ICD-10 Procedure Coding SystemMedical and Surgical Approaches

1 Open Cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure Example: Abdominal hysterectomy

2 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 Example: Needle biopsy of liver

3 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 Example: Arthroscopy

4 Via natural or artificial opening

Entry of instrumentation through a natural or artificial external opening to reach the site of the procedure Example: Endotracheal intubation

5 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 Example: Sigmoidoscopy

6 Via natural or artificial opening endoscopic with percutaneous endoscopic assistance

Entry of instrumentation through a natural or artificial external opening and entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to aid in the performance of the procedure Example: Laparoscopic-assisted vaginal hysterectomy

7 External Procedures performed directly on the skin or mucous membrane and procedures performed indirectly by the application of external force through the skin or mucous membrane Example: Closed fracture reduction

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Device

1 2 3 4 5 6 7

Section Body System Root Operation

Body Part Approach  

 6th CharacterDevice

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Types of DevicesDevices that remain after the procedure is completed

• 4 general types of devices:• Biological or synthetic material that takes the place of all or a portion of

a body part (i.e., skin graft, joint prosthesis)• Biological or synthetic material that assists or prevents a physiological

function (i.e., IUD)• Therapeutic material that is not absorbed by, eliminated by, or

incorporated into a body part (i.e., radioactive implant)• Mechanical or electronic appliances used to assist, monitor, take the

place of, or prevent a physiological function (i.e., cardiac defibrillator, orthopedic pin)

• Materials such as sutures, ligatures, radiological markers, and temporary post-operative wound drains are considered integral to the procedure and

are not coded as devices.

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1 2 3 4 5 6 7

Section Body System Root Operation

Body Part Approach Device

  

7th Character - Qualifier-Defines an additional attribute of the procedure performed, if applicable.

Qualifier

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Medical and Surgical Section (0)

ICD-9 Volume 3 ICD-10-PCS

81.91 Arthrocentesis Arthrocentesis, right knee, diagnostic, no device0S9C3ZX

51.23 Laparoscopic cholecystectomy 0FT44ZZ

51.22 Open cholecystectomy 0FT40ZZ

54.91 Percutaneous abdominal drainage Not diagnostic, no device0W9F3ZZ

03.31 Spinal tap Diagnostic009U3ZX (spinal canal) 009Y3ZX (lumbar spinal cord)_Spinal canal appears more appropriate

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Medical and Surgical Section (0)

ICD-9 Volume 3 ICD-10-PCS

86.04 Incision and drainage skin Left upper arm, diagnostic0H9CXZX

54.51 Laparoscopic lysis of peritoneal adhesions

0DNW4ZZ

54.59 Open lysis of adhesions Greater omentumADN50ZZ

34.04 Insertion chest tube Left, percutaneous with device0W9B30Z

64.0 Circumcision 0VTTXZZ

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Obstetric Section

• The obstetric section includes procedures performed on the products of conception only. Procedures on the pregnant female are coded in the Medical & Surgical section (e.g., episiotomy).

• The term “products of conception” refers to all physical components of a pregnancy, including the fetus, amnion, umbilical cord, and placenta. There is no differentiation based on gestational age.

• The specification of the products of conception as a zygote, embryo or fetus, or the trimester of the pregnancy is not part of the procedure code but can be found in the diagnosis code.

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Obstetric Section

• Character 1 - Section - always 1• Character 2 - Body System - Pregnancy

• Character 3 - Root Operation• Vaginal Delivery and Cesarean are both Extraction

• Character 4 - Body Part • Products of Conception• Products of Conception, retained• Products of Conception, ectopic

• Character 5 - Approach• Character 6 - Device (Fetal Monitor electrodes)

• Character 7 - Qualifier (type of extraction, type of Cesarean Section, or type of fluid taken out)

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Medical and Surgical Section (0)Obstetrics Section (1)

ICD-9 Volume 3 ICD-10-PCS

73.6 Episiotomy 0W8NXZZ Episiotomy10E0XZZ Delivery

74.1 Low cervical cesarean section 10D00Z1

73.09 AROM 10907ZC (Amniotic fluid is considered a product of conception)

75.4 Manual removal placenta 10D17ZZ

72.79 Vacuum extraction 10D07Z6 (Extraction – vacuum is the qualifier)

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Obstetric Section

• Vaginal delivery, vacuum:• Extraction: Extraction of Products of Conception, Vacuum, Via

Natural or Artificial Opening

• Vaginal delivery with episiotomy:• Extraction: Delivery of Products of Conception, External Approach • Division of Female Perineum, External Approach

• Cesarean Section• Extraction: Extraction of products of conception, low cervical, open

approach (Low cervical Cesarean section)

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Placement (2)

• Character 1 – Section Always 2• Character 2 – Anatomical Region

• Anatomical Region or:• Anatomical Orifices

• Character 3 – Root Operation• No incision or puncture• Compression ;Dressing: Immobilization; Packing; and Traction are

root operations in the Placement Section

• Character 4 – Body Region/Orifice• Character 5 – Approach - Always External• Character 6 – Device – almost always a device• Character 7 – Qualifier - always No Qualifier

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Placement

• Packing of external ear canal: 2Y42X5Z

• Splinting of right ankle: 2W3LX1Z

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Administration (3)

• Administration section codes represent procedures for putting in or on a therapeutic, prophylactic, protective, diagnostic, nutritional, or physiological substance. The section includes transfusions, infusions, and injections, along with other similar services such as irrigation and tattooing.

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Administration Section (3)

• Character 1 - Section - always 3• Character 2 - Body System

• Indwelling Device• Physiological System and Anatomical Regions• Circulatory System (transfusion procedures)

• Character 3 - Root Operation• Introduction• Irrigation• Transfusion

• Character 4 - Body System/Region• Character 5 - Approach

• Percutaneous injection, insertion of catheter to introduce contrast

• Character 6 - Substance• Character 7 - Qualifier

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ICD-9 Volume 3 ICD-10-PCS

96.04 Endotracheal intubation Not endoscopic0BH17EZ

96.71 Mechanical ventilation <96 consecutive hours

Less than 24 hours5A1935Z

99.15 TPN 2 codes (upper vein)05HY33Z3E0336Z

73.4 Medical induction labor (IV Oxytocin)

3E033VJ (intro, peripheral vein, hormone)

99.04 Packed cell transfusion 30233N1

75.34 External fetal monitoring 4A1HXCZ

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Extracorporeal Assistance and Performance Section (5)• In Extracorporeal Assistance and Performance

procedures, equipment outside the body is used to assist or perform a physiological function. The section includes procedures performed in a critical care setting, such as mechanical ventilation and cardioversion; it also includes other services such as hyperbaric oxygen treatment and hemodialysis.

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Resources:Comprehensive Anatomy and Physiology for ICD-10-CM and -PCS Coding (Softbound) - www.optumcoding.com($149.95)

http://www.freebookcentre.net/medical_books_download/Gray's-Anatomy.html

http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/icd10

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