General coding standards Flashcards
How should endoscopic and minimal access operations that do not have a specific code be coded?
When an endoscopic or minimally invasive procedure is undertaken but no specific code exists to capture this type of approach, dual coding is required.
The following codes and sequencing are required:
* Open procedure code
* Minimal access approach code (Y74 -Y77)
* Y code (if required)
* Z site code
* Z94.- laterality (if applicable)
If more than one minimally invasive procedure has been undertaken, assign an approach code after each open procedure code.
Describe the diagnostic versus therapeutic procedures general coding standard.
If a diagnostic procedure proceeds to, or is performed at the same time as, a therapeutic procedure on the same site then only the code for the therapeutic procedure is required.
This includes:
* diagnostic endoscopies performed prior to an open procedure
* diagnostic endoscopies performed prior to a therapeutic endoscopic procedure
How must abandoned, failed or incomplete procedures be coded?
To the stage reached at the abandonment of the procedure; the intention must not be coded.
If the intervention/procedure reaches the final stage and has been unsuccessful, it must be coded as if the whole procedure has been carried out.
Exception to this is ERCP - must always be coded to J43.9
How should failed minimal access and percutaneous transluminal procedures converted to open be coded?
- Open procedure code
- Y71.4 Failed minimal access approach converted to open NEC or Y71.5 Failed percutaneous transluminal approach converted to open or Y72.1 Failed robotic minimal access approach converted to open or Y72.2 Failed video-assisted minimal access approach converted to open
Describe the unintentional procedures general coding standard.
Where an unintentional action occurs during a procedure, this unintentional action must not be recorded using OPCS-4 codes.
Any surgical procedures performed to correct the unintentional action, must be recorded using the appropriate OPCS-4 code(s).
What must coders take into account when coding a ‘radical’ operation?
- Code assignment must fully reflect the procedure(s) performed during the radical operation
- Instructional Notes must be applied in order to fully reflect all procedures performed
- Any uncertainty as to what procedures were performed during the radical operation must be clarified with the responsible consultant in order to ensure correct code assignment
Describe PGCS9: Excision and biopsy procedures.
When an excision and biopsy is performed on the same site during the same theatre visit, only assign a code(s) for the excision, as a biopsy is an integral part of the excision.
Describe how diagnostic endoscopic procedures should be coded according to PGCS10: Coding endoscopic procedures.
- If multiple sites are examined during a diagnostic endoscopy, only a Z site code for the furthest site examined is assigned.
- If a biopsy is taken at the same time that multiple sites are examined, only the Z site code for the biopsy is required, as the biopsy is considered of greater importance. This includes where the biopsy os not the furthest site examined.
- If multiple biopsies are taken, only assign a site code for the furthest point biopsied.
Describe how therapeutic endoscopic procedures should be coded according to PGCS10: Coding endoscopic procedures.
When a therapeutic endoscopic procedure is performed and a biopsy is taken at the same time, the following codes and sequencing must be applied:
* Therapeutic body system endoscopy code
* Z site code (if not stated in the endoscopy code and site of biopsy is different to the therapeutic endoscopy)
* Y20 Biopsy of organ
* Z site code for biopsy site
When must a biopsy be coded when taken at the same time as an endoscopic excision?
Only when the biopsy is taken from a different site to the excision.
How must multiple endoscopic excisions be coded when the same method has been used?
Site codes for each site of excision must be assigned following the code for the endoscopic excision.
How should multiple simultaneous therapeutic endoscopic procedures be coded according to PGCS10: Coding endoscopic procedures.
- If multiple therapeutic methods/techniques are used during an endoscopic procedure, a body system code for each method must be assigned followed by the relevant site code(s)
- Additional codes from Chapter Y may be assigned if it adds further information
- A biopsy taken at the same time as multiple therapeutic endoscopic procedures should be coded to Y20 Biopsy of organ following any of the body system codes
When are codes from Chapter X used when associated with congenital deformities?
If the Chapter X code can be directly index trailed from the OPCS-4 Alphabetical Index, then the Chapter X code must be used.
Describe PGCS11: Coding procedures for the correction of congenital deformities.
- If the Chapter X code can be directly index trailed, use the Chapter X code.
- If a body sytem code more accurately reflects the procedure, use the code from the body system chapter, unless there is specific instruction to do otherwise.
- Ensure the codes assigned fully and accurately describe the procedure(s) performed, may need to seek advice from the responsible clinician.
How must autografts (other than skin grafts) be coded?
- Body system code classifying the organ/site being grafted
- Y36.5/Y36.6/Y36.7 (if scaffold was used)
- Z site code for site being grafted (if not already identified in the body system code)
- Z94.- laterality (if applicable)
- Y code identifying type of tissue harvested and site of harvest (unless identified in the body system code)
- Z site code for site of harvest (if not already identified in Y harvest code)
- Z94.- laterality (if applicable)
How must other types of graft (not autografts) of sites other than skin be coded?
(grafts using material not harvested from patient, including allograft, xenograft and prosthetic graft)
- Body system code classifying the organ/site being grafted
- Y27.- Graft of organ NOC (if not identified in the body system code)
- Y36.5/Y36.6/Y36.7 (if scaffold was used)
- Z site code for specific site/organ being grafted (if not already identified in the body system code)
- Z94.- laterality (if applicable)
What are the sequencing rules when codes from both Chapters Y and Z are assigned?
Y code must precede Z code
How does the coder determine whether a procedure is an ‘emergency’?
The nature of the procedure not the nature of the admission must be taken into account.
The term emergency pertains to the use of operating theatre time that has not been pre-scheduled (including operations added to a pre-scheduled list).
How should conversion procedures be coded?
- ‘Conversion to’ codes should always precede ‘conversion from’ codes
- ‘Conversion to’ and ‘conversion from’ codes should always be used together (unless there is a note indicating that a code not specifically described as ‘conversion to’ or ‘conversion from’ can be used)
- They should always be assigned from different three-character categories
In which chapters can conversion procedures be found?
G and W
What is meant by a conversion procedure?
The dismantling of a particular type of operation and introduction of a new and different procedure on the same site.
What can be added to maintenance/attention to codes?
A supplementary code from Chapter Y if it provides additional information.
How should staged procedures be coded?
If a specific code decribing the staged procedure is not available one of the following codes must be added to indicate the stage:
* Y70.3 First stage of staged operations NOC
* Y71.1 Subsequent stage of staged operations NOC
How should temporary operations be coded?
If a specific temporary operation code does not exist, code Y70.5 Temporary operations must be assigned in a secondary position.
If the organ is temporarily occluded, Y44.3 Temporary occlusion of organ NOC should be used in preference.
Describe PGCS20: Procedures performed for haemostasis.
When coagulation/cauterisation is performed as a means of haemostasis following the extirpation of a lesion, the coagulation/cauterisation must not be coded in addition.
