scalpel to dissect pcs initiatives · icd‐10‐cm/pcs trainer mary mcgrady, msn, rn, ccds, crcr...

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Irina Zusman, RHIA, CCS, CCDS, AHIMA‐approved ICD‐10‐CM/PCS trainer

Mary McGrady, MSN, RN, CCDS, CRCR Briggs Strelow, MD, CCDS

NYU Langone Medical Center, New York, NY

Using a Scalpel to Dissect PCS Initiatives

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NYU Langone Medical Center

• Tisch Hospital

– Our flagship acute care facility

– 725 beds, 66 operating rooms

• NYU Lutheran Medical Center

• Rusk Rehabilitation

– Ranked as one of the top 10 rehabilitation programs in the country by U.S. News & World Report since 1989

– Recently awarded a three‐year accreditation from the Commission on Accreditation of Rehabilitation Facilities (CARF)

• Hospital for Joint Diseases

– A dedicated inpatient orthopaedic hospital

• Hassenfeld Children’s Hospital

– Provides comprehensive children's health services across NYU Langone

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NYU Langone Medical Center

• Ranked #1 for quality and safety in the UHC Quality and Accountability Study three years in a row

• Ranked #1 in UHC’s inaugural 2015 Ambulatory Care Quality and Accountability Leadership Award

• Ranked #2 in New York State and #2 in the New York metro area by U.S. News & World Report

• Ranked #15 in the nation on U.S. News & World Report’s “Best Hospitals 2014‐2015” and featured on its distinguished Honor Roll

• The only hospital in New York named among the top 10 in the country for orthopaedics, rheumatology, and rehabilitation programs by U.S. News & World Report

• Received the Gold Seal of Approval from The Joint Commission

• Magnet® recognition for excellence in nursing for the third consecutive time by the American Nurses Credentialing Center

• Received advanced certification in ventricular assist device for advanced heart failure from The Joint Commission

• 390 physicians recognized as leading doctors in the New York metro area

• 13 nationally ranked specialties


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Learning Objectives

• At the completion of this educational activity, the learner will be able to:– Describe NYULMC’s multifaceted approach to improving documentation and decreasing the number of queries

– Identify several initiatives for ICD‐10‐PCS preparation prior to go‐live

– Explain NYULMC’s approach to unforeseen complexities in coding of selected complex procedures discovered after ICD‐10 go‐live

– Define documentation challenges for coding these procedures

– Discuss how physician insight can help to overcome these challenges

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Selected Procedures

Documentation and coding considerations for:

• Contrast‐requiring procedures

• Hip and knee procedures

• Excision of saphenous vein for CABG

• LVAD (left ventricular assist device)

• TAVR (transcatheter aortic valve replacement)

• Mitral valve clips

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ICD‐10 Preparation Prior to Go‐Live


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NYULMC Preparation

NYULMC CDI/coding team approach:

• Physician education

– Creation of job aids and pocket guides

– Updating templates for operative reports

• Coder education

– Extensive course of A&P

– Internal coding guidelines and memos

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Question of the Year: Do We Query Every Time?

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 definitions. 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.

So it is now nationally recognized that coders have brains!

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Proactive Approach: Query Prevention

Selected procedures to demonstrate how up‐front preparation can decrease query volume

• Excision of saphenous vein for CABG

• Contrast‐requiring procedures

• Hip and knee procedures


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Excision of Saphenous Vein for CABG

Coding Clinic, Third Quarter ICD‐10 2014, Page: 8 Effective with discharges: September 15, 2014

Question:Please provide clarification for coding the harvest of the saphenous vein for coronary artery bypass grafting (CABG). In the operative note, the physician documents harvest of left saphenous vein from the leg with no further specificity. Is there any guidance when the documentation does not state upper/greater, or lower/lesser saphenous vein?

Answer:ICD‐10‐PCS does not have an “unspecified” or “not otherwise specified” designation for procedures performed on the saphenous vein. If the documentation does not specify which saphenous vein was harvested, query the physician for clarification so that the appropriate body part may be reported. Facilities may also work with providers to develop facility‐specific coding guidelines, which will establish a default code based on common practice.

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Excision of Saphenous Vein for CABG

Memo Date: 03/05/2015

To: Coding Staff and Clinical Documentation Specialists

Cc: Director of Coding

Director of CDI

From: Director of HIM Coding and CDI Initiatives

RE: Excision of saphenous vein for coronary artery bypass graft

Following AHA Coding Clinic 3rdQ. 2014, p.8 recommendations, the

clarification has been requested from the Department of Cardiothoracic

Surgery. According to this clarification, only greater saphenous veins are

generally harvested for creating a bypass. Harvesting any other vein is

extremely rare and is usually stipulated in the chart. Please use the code for

excision of the greater saphenous vein as default when coding CABG

surgeries.

If laterality of the leg used for harvesting is not specified in the body of the

operative report, please use other documentation (Nursing and OpTime

notes) for gathering this information.

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Contrast‐Requiring Procedures

The seven characters in the imaging section have the following meaning:

• Character 1 = Section

• Character 2 = Body system

• Character 3 = Root type

• Character 4 = Body part

• Character 5 = Contrast

• Character 6 = Qualifier

• Character 7 = Qualifier


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Contrast Material

Imaging root type definitionsRoot type Definition

Plain radiography Planar display of an image developed from the capture of external ionizing radiation on photographic or photoconductive plate

Fluoroscopy Single plane or bi‐plane real‐time display of an image developed from the capture of external ionizing radiation on a fluorescent screen. The image may also be stored by either digital or analog means.

Computerized tomography (CT scan) Computer‐reformatted digital display of multiplanar images developed from the capture of multiple exposures of external ionizing radiation

Magnetic resonance imaging (MRI) Computer reformatted digital display of multiplanar images developed from the capture of radio frequency signals emitted by nuclei in a body site excited within a magnetic field

Ultrasonography Real time display of images of anatomy or flow information developed from the capture of reflected and attenuated high‐frequency sound waves

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Fluoroscopy of Hepatic Artery

© 3M 2015. All rights reserved.

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Coding Tips—Contrast List

BRAND NAME MEDICATION NAMEOsmolarity

Level

Renografin DIATRIZOATE MEGLUMINE & SODIUM HIGH

Cholografin IODIPAMIDE MEGLUMINE HIGH

Visipaque IODIXANOL LOW

Omnipaque IOHEXOL LOW

Isovue IOPAMIDOL LOW

Ultravist IOPROMIDE LOW

Conray IOTHALAMATE MEGLUMINE HIGH

Hexabrix IOXAGLATE LOW

AblavarGADOFOSVESET TRISODIUM

LOW

DefinityPERFLUTREN LIPID MICROSPHERES

Ultrasound

OptisonPERFLUTREN PROTEIN-A MICROSPHR

Ultrasound


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Joint Replacements

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Joint Replacements

Useful tips for coding total joint procedures

Device composition

Ceramics• Alumina – Al2O3 (used for acetabular and femoral components)• Zirconia – ZrO2 (used for acetabular and femoral components)• Hydroxyapatite – Ca10(PO4)6(OH)2 (used for coating stem femoral components)Biolox delta – ceramic (Smith & Nephew)Biolox forte – ceramic (Smith & Nephew)Oxinium – ceramic surface on metal base (often paired with Reflection XLPE; ceramic‐on‐polyethylene)Stryker Trident – ceramic‐on‐ceramic (if with X3 liner, X3 component is poly)

Metals• Low carbon grade austenitic stainless steels

– 316L• Titanium and titanium‐base alloys

– Commercially pure titanium = CP Ti– Ti‐6Al‐4V

• Cobalt alloys– Co‐Cr‐Mo

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Joint Replacements

Quick tips

• Almost all knee replacements are cemented

• Almost all hip replacements are uncemented– Impacted = uncemented

• If you can’t tell from the implants which ones are meant to go in with and without cement …– Check to see if polymethylmethacrylate was used in the case (PMMA or bone

cement)

– If it was used, it was cemented; if it wasn’t, then it wasn’t cemented

More info

• activejoints.com

• totaljoints.info

Computer‐assisted surgery

• Stryker Navigation System


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Query Prevention Means …

• A happy doctor

• A happy coder

• A very happy finance department

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Post Go‐Live Challenges

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More About Hips and Knees: Revision Procedures

There are unintended consequences for a recent change in the grouping logic of ICD‐10 MS‐DRG v33 as it relates to staged knee revision procedures. In summary, when a patient has a surgical procedure where a knee spacer is removed and knee prosthesis reimplanted, this inpatient encounter is being grouped into MS‐DRG 469/470 (primary arthroplasty) rather than MS‐DRG 466/467/468 (revision arthroplasty). In the past, this scenario would result in the patient being assigned appropriately into one of the revision arthroplasty MS‐DRGs.

Reference: Centers for Medicare & Medicaid Services. FY 2015 Final Rule Tables, Table 5 (Final Rule and Correction Notice). Retrieved from https://www.cms.gov/Medicare/Medicare‐Fee‐for‐Service‐Payment/AcuteInpatientPPS/FY2015‐IPPS‐Final‐Rule‐Home‐Page‐Items/FY2015‐Final‐Rule‐Tables.html


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• ICD‐9 – Special codes for joint revision procedures led to assignment of revision DRGs 466, 467, or 468

• ICD‐10 – Revision procedures require multiple code assignment:– Removal of spacer or liner

– Joint replacement

– Supplement

In the 2016 IPPS final rules, it is clear that CMS intended for this scenario to be grouped into a revision arthroplasty MS‐DRG:

We agree that joint revision cases involving the removal of a spacer and subsequent insertion of a new joint prosthesis should be assigned to ICD‐10 MS‐DRGs 466, 467, and 468 as is the case currently with the ICD‐9‐CM based MS‐DRGs Version 32.

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However:

Though all combinations of codes for hip joint are accounted for in the Federal Register, some code combinations for knee joint replacement were omitted.

Principal ICD‐10 diagnosis

ICD‐10 procedures MS‐DRG

Z47.33 – Aftercare following explantation of knee joint prosthesis

0SPD08Z – Removal of spacer from left knee joint, open approach 0SRD0J9 – Replacement of left knee joint with synthetic substitute, cemented, open approach

470

Z47.33 – Aftercare following explantation of knee joint prosthesis

0SRC0J9 – Replacement of right knee joint with synthetic substitute, cemented, open approach 0SPC08Z – Removal of spacer from right knee joint, open approach

470

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LVAD

LVAD – left ventricular assist device

• A life‐saving therapy for patients with decompensating advanced heart failure who fail to improve or stabilize with optimal medical therapy

Indications

• Bridge to transplantation (BTT)

• Bridge to decision (BTD)

• Destination therapy (DT)

• Bridge to recovery (BTR)


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LVAD

Indications

• Bridge to transplantation (BTT)

– Patients with advanced heart failure and deteriorating clinical status

– Patients who may be or are candidates for heart transplantation

– Patients who are too unstable to wait any longer without circulatory support

– Patients with worsening New York Heart Association (NYHA) Class IIIb or IV heart failure (despite inotropic support plus intra‐aortic balloon pump support)

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LVAD

Indications

• Bridge to decision (BTD)– Patients in which mechanical support may be able to reverse contraindications to cardiac transplantation (i.e., secondary end organ dysfunction)

• Destination therapy (DT)– Patients ineligible for transplantation where long‐term use of LVADs is an appropriate alternative

• Bridge to recovery (BTR)– Patients where device implantation and LVAD unloading can promote recovery of myocardial function for eventual explant of the device

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LVAD

Reprinted with the permission of: Thoratec Corporation.


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LVAD

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ICD‐10‐PCS provides the following codes for the implantation and repair of implantable heart assist systems:

• 02HA0QZ Insertion of implantable heart assist system into heart, open approach• 02HA3QZ Insertion of implantable heart assist system into heart, percutaneous approach• 02HA4QZ Insertion of implantable heart assist system into heart, percutaneous endoscopic

approach• 02WA0QZ Revision of implantable heart assist system in heart, open approach• 02WA3QZ Revision of implantable heart assist system in heart, percutaneous approach• 02WA4QZ Revision of implantable heart assist system in heart, percutaneous endoscopic

approach• 02PA0QZ Removal of implantable heart assist system from heart, open approach • 02PA3QZ Removal of implantable heart assist system from heart, percutaneous approach • 02PA4QZ Removal of implantable heart assist system from heart, percutaneous endoscopic

approach

Coding Clinic:

• Currently no coding clinic to assist with accurate capture of these complex procedures

Insertion vs. Revision of LVAD

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Insertion of LVAD—Code Assignment



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Revision of LVAD—Code Assignment


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Insertion vs. Revision of LVAD DRG Considerations – Procedure Code Assignment

Insertion or Replacement of LVAD (coded as Removal and Insertion)

Revision of LVAD

TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS‐RELATED GROUPS (MS‐DRGS), RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY—FY 2016 Final Rule

MS‐DRG

FY 2016 Final Post‐Acute DRG

FY 2016 Final Special Pay DRG

MDC TYPE MS‐DRG Title Weights Geometric mean LOS

Arithmetic mean LOS

001 No No PRE P HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W MCC 26.2466 29.4 38.8

002 No No PRE P HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W/O MCC 14.6448 16.6 20.0


MS‐DRG




Arithmetic mean LOS

215 No No 05 P OTHER HEART ASSIST SYSTEM IMPLANT 15.8738 12.0 18.4


Read operative report carefully in order to determine what has been performed!

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Insertion vs. Revision of LVADDRG Considerations—Principal Diagnosis Dilemma

Principal diagnosis:

I50.33 – Acute on chronic diastolic heart failure

Secondary diagnoses:

I25.5 – Ischemic cardiomyopathy

I25.10 – CAD

Procedure:

02HA0QZ – Insertion of implantable heart assist system, open approach

DRG 002

Principal diagnosis:

I25.5 – Ischemic cardiomyopathy

Secondary diagnoses:

I50.33 – Acute on chronic diastolic heart failure

I25.10 – CAD

Procedure:

02HA0QZ – Insertion of implantable heart assist system, open approach

DRG 001

• 60‐year‐old male awaiting heart transplant due to extreme ischemic cardiomyopathy and CAD admitted in severe acute on chronic diastolic heart failure for LVAD insertion


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Insertion vs. Revision of LVADUsing AHA Coding Clinic for Selection of Principal Diagnosis

Congestive cardiomyopathy and CHF Coding Clinic, Second Quarter 1990, Page: 19 Effective with discharges: April 1, 1990

Question:Define the term "congestive" cardiomyopathy and advise when it is appropriate to code congestive heart failure as the principal diagnosis when both congestive cardiomyopathy and congestive heart failure are listed in the final diagnostic statement.

Answer:Congestive cardiomyopathy, more commonly referred to as "dilated" cardiomyopathy, is a myocardial disease characterized by ventricular dilation, contractile dysfunction, and symptoms of congestive heart failure.In most cases treatment revolves around the management of the congestive heart failure (salt restriction, diuretics, and other drugs) and in those instances the heart failure, 428.0 or 428.1, is the principal diagnosis, with cardiomyopathy, 425.4, assigned as an additional diagnosis.

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TAVR

TAVR – transcatheter aortic valve replacement

• A life‐saving therapy for patients with decompensating advanced heart failure who fail to improve or stabilize with optimal medical therapy

• The mainstay of treatment of symptomatic aortic stenosis (AS)

Image source: “Current Status of Transcatheter Aortic Valve Replacement” Webb, JG, Wood, DA; Journal of the American College of Cardiology, Vol. 60, No. 6, 2012. http://dx.doi.org/10.1016/j.jacc.2012.01.071 accessed March 24, 2016.

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TAVR

Indications

• Patients with severe symptomatic aortic stenosis who have an unacceptably high estimated surgical risk

• Patients considered at extreme risk with severe comorbidities

• Patients whom TAVR is preferred due to technical issues with surgery

– Prior pericardiectomy with dense adhesions

– Prior significant mediastinal radiation

– Prior sternal infection with complex reconstruction

– A patent left internal mammary graft lying beneath the sternum


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TAVR

Indications

• Treatment of failed surgical bioprosthetic valves in the aortic position (valve‐in‐valve procedure), including

– Regurgitation

– Bioprosthetic valve stenosis

– A combination of the two

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TAVR

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TAVR—Code Assignment



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Mitral Clip

Mitral clip

• Transcatheter mitral valve repair (TMVR) is a minimally invasive technique for treatment of chronic mitral regurgitation (MR)

Indications

• Patients with 3 to 4+ primary (degenerative) MR

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Mitral Clip

Guidelines

• TMVR with mitral clip is an option for patients who meet all of the following criteria:– Severely symptomatic (New York Heart Association Class III or IV) heart failure despite medical therapy

– Chronic severe primary MR

– Favorable anatomy for the repair procedure

– Reasonable life expectancy

– Prohibitive surgical risk due to comorbidities

These guidelines are consistent with the 2014 American Heart Association/American College of Cardiology

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Mitral Clip

Contraindications

• Patients who cannot tolerate procedural anticoagulation or antiplatelet agents post‐procedure

• Active endocarditis of the mitral valve

• Rheumatic mitral valve disease

• Thrombus of the femoral vein, inferior vena cava, or intracardiac thrombus


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Mitral Clip

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Mitral Clip—Code Assignment


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TAVR—Code Assignment



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DRG Considerations for TAVR and Mitral Clip

TAVR:

Mitral clip:


MS‐DRG




Arithmetic mean LOS

266 Yes Yes 05 P ENDOVASCULAR CARDIAC VALVE REPLACEMENT W MCC 8.5986 7.3 9.5

267 Yes Yes 05 P ENDOVASCULAR CARDIAC VALVE REPLACEMENT W/O MCC 6.5575 4.4 5.2


MS‐DRG




Arithmetic mean LOS

273 Yes Yes 05 P PERCUTANEOUS INTRACARDIAC PROCEDURES W MCC 3.5499 6.0 8.0

274 Yes Yes 05 P PERCUTANEOUS INTRACARDIAC PROCEDURES W/O MCC 2.4197 2.7 3.4


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DRG Considerations for TAVR and Mitral Clip

• Usually the patients are admitted with acute or chronic heart failure due to valvular insufficiency– Do we assign a code for acute heart failure if medications were not

changed during the admission?

• Repair of valve helps to improve heart failure, so in essence surgery takes care of both conditions– If both valve disease and acute heart failure are coded, what should be

assigned as a principal diagnosis?

• Since treatment is mostly directed to the underlying cause of heart failure, code valvular disease first

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CDI Recap: Pre‐ and Post‐ICD‐10 PCS Takeaways

NYU lessons learned

• More simple documentation and coding questions can be addressed by updating op note templates and defining components needed to complete ICD‐10 coding

• More complex procedures may require CDI to go beyond a typical CDI role

• CDSs are translators between clinical descriptions and coding; we will need to come up with ways to lessen the burden of interpretation for both providers and coders


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CDI Recap:LVAD Takeaways

NYU lessons learned

• Reading entirety of op note, meeting with providers, clarify use of confusing language (e.g., “exchange”)

• Query if the op report isn’t clear

• Meet with the surgeons to understand the operation as it relates to coding terminology

• Provide education for CDI and coding team via videos and case examples

• Establish a relationship with surgeons to be able to review challenging cases

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CDI Recap:TAVR Takeaways

NYU lessons learned

• CDI/coding team collaborates with NYU Langone Structural Heart Program to work through clinical question if it is appropriate to assign a secondary diagnosis of acute heart failure in TAVR cases

• Work on developing a position statement to send to the AHA Coding Clinic to clarify that TAVR is a treatment for acute decompensated HF

• Develop tip sheets for providers on how to clearly document acute HF in the setting of aortic stenosis with plan to treat with TAVR

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Evaluation of Acute HF

“Rule out” Grey zone Confirmatory “rule in”

NT-proBNP cut points for the evaluation of acute HF

NT-proBNP (pg/mL)

300

< 50 years 45050–75 years 900> 75 years 1,800

Sourrce: Januzzi et al., NT-proBNP testing for diagnosis and short-term prognosis in acute destabilized heart failure: an international pooled analysis of 1256 patients. Euro Heart Journal. 2006;27:330-337. NOTE: Such a comprehensive understanding of optimal cut-offs is lacking for BNP use.

In the situation of a “grey zone” result, clinical judgment is necessary to ascertain the correct diagnosis

NOTE: Because NPs are sensitive to factors such as age, sex, BMI, renal

function, and other clinical factors, the use of a one-size-fits all cut point may

not be the best use of the test


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Documenting HF Acuity—NYU Approach

Symptoms:□ New symptoms of dizziness, syncope, angina, or chest pain

Signs:□ Evidence of new volume overload such as jugular venous distension, edema, or ascites□ New sinus tachycardia□ New arrhythmia, especially atrial fibrillation□ Hypotension□ Evidence of oxygen desaturation at rest

Testing:□ Elevated natriuretic peptide□ Elevated cardiac enzymes□ New hyponatremia□ Congestion on chest x-ray□ Cardiomegaly on chest x-ray

Other supportive indicators:□ Need for intravenous diuretics□ Need for unplanned hospitalization

Source: University of Pennsylvania abstract submitted at May 2014 SHVD Scientific conference

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NYU TAVR Sample Query

Documentation clarification is required to meet compliance and accuracy in coding and data reporting. Further specificity in diagnostic terms will reflect the severity of illness of your patient.

Clinical indicators & current documentation:Per Dr. XX, H&P: Patient remains with acute on chronic diastolic heart failure, as evidenced by his grossly elevated BNP (4660) and his persistent NYHA II symptoms3/14 PROCEDURE(S): Transfemoral transcatheter aortic valve replacementEF results 55%

This is the only documentation of heart failure. If patient has "acute on chronic diastolic heart failure” please include this in the progress notes linking diagnosis to treatment, problem list, and discharge summary.Or provide an alternate diagnosis if appropriate:• Chronic diastolic heart failure• Other

Thank you

Documentation added in response to the query: Acute on chronic diastolic HF added to the problem list and discharge summary with note indicating symptomatic severe aortic stenosis and acute on chronic HF with worsening chest pain and SOB on exertion. Plan TAVR.

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Mitral Clip—NYU CDI Lessons Learned Inconsistencies With Diagnostic Code Assignment

• When there is more than one diseased valve involved, the coding pathway leads to the assignment of code for rheumatic heart disease

• A patient with severe mitral valve prolapse and tricuspid regurgitations admitted for mitral clip leads to rheumatic heart disease code; however, this patient’s mitral valve disease is degenerative in nature, so this presents an issue

• This issue has prompted NYU CDI/coding to collaborate with the NYU Structural Heart Program director to write a letter to the AHA to address coding pathway

• If two or more valves are diseased; query for documentation of etiology (Reminder: Mitral clip procedures are contraindicated for patients with rheumatic disease)


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Thank you. Questions?

[email protected]@[email protected]

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide.

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• Averill, RF, et al. Development of the ICD‐10 Procedure Coding System (ICD‐10‐PCS).https://www.cms.gov/medicare/coding/icd10/downloads/2014‐pcs‐procedure‐coding‐system.pdf

• Birks, EJ. Intermediate‐ and long‐term mechanical circulatory support. In: UpToDate, D Mancini (Ed), SA Hunt (Ed), UpToDate, Waltham, MA. (Accessed on January 21, 2016.)

• Brecker, SJD, Gaasch, WH, Aldea, GS. Transcatheter aortic valve replacement: Indications and periprocedural management. In: UpToDate, CM Otto (Ed), D Cutlip (Ed), UpToDate, Waltham, MA. (Accessed on January 21, 2016.)

• Armstrong, EJ, Foster, E. Transcatheter mitral valve repair. In: UpToDate, WH Gaasch (Ed), UpToDate, Waltham, MA. (Accessed on January 21, 2016.)

• 2016 IPPS final rules (https://www.gpo.gov/fdsys/pkg/FR‐2015‐08‐17/pdf/2015‐19049.pdf) Federal Register Vol. 80 No. 158, p. 49390.

• Centers for Medicare & Medicaid Services. FY 2015 Final Rule Tables, Table 5 (Final Rule and Correction Notice). Retrieved from https://www.cms.gov/Medicare/Medicare‐Fee‐for‐Service‐Payment/AcuteInpatientPPS/FY2015‐IPPS‐Final‐Rule‐Home‐Page‐Items/FY2015‐Final‐Rule‐Tables.html

• Centers for Medicare & Medicaid Services. 2016 Official ICD‐10‐PCS Coding Guidelines. Retrieved from https://www.cms.gov/Medicare/Coding/ICD10/2016‐ICD‐10‐PCS‐and‐GEMs.html

References

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Appendix—NYU TAVR Statement

scalpel to dissect pcs initiatives · icd‐10‐cm/pcs trainer mary mcgrady, msn, rn, ccds, crcr...

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