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General Surgery INSTEAD of PLEASE CONSIDER General Surgery INSTEAD OF PLEASE CONSIDER Low or No Severity Diagnosis—NO High Severity Diagnosis---YES ICD 10 Themes: Acuity/Severity/Type/Staging Acute/Chronic/Acute on Chronic e.g. Acute on Chronic Systolic Heart Failure Mild, Moderate, Severe Systolic, Diastolic, Combined Stage I, II, III, IV Anatomy/Site Specificity e.g. Malignant neoplasm of lower lobe right Location of tumor bronchus Bone/Joint/Muscle involved e.g. Decubitus Ulcer, Stage 3, Right Buttocks, Laterality Present on Admission Right/Left/Bilateral/Overlapping (see Neoplasm re overlaps two or more contiguous (next to each other) sites) e.g. Hypertensive heart disease with chronic systolic Manifestations – LINK IT! heart failure Associated or Related Conditions ‘With’/‘Secondary’ to/’Due to’ ‘Evidence of’ and causative organism Use ‘no organism isolated’, instead of ‘negative culture’ e.g. Likely Sepsis secondary to UTI; Etiology – ‘DUE TO’ WhAt? Evidence of Bacterial Pneumonia (‘Evidence of’ in ‘LIKELY’ suspects….Who dun it? outpt setting can be captured as a diagnosis) Possible, Probable, Suspected (Inpt Only) Evidence of, As Evidenced by (Outpt Setting and Inpt Setting) e.g. Drug Poisoning/Adverse Effect Episode of Care/Incidence of Encounter (Trauma/Fractures/Medication.Chemical Event(Drug Poisoning)) Initial/Subsequent/Sequela Intestinal or Peritoneal Adhesions With Obstruction/Without Obstruction Intestinal Obstruction Type/Etiology: Paralytic ileus, Intussusceptions, Volvulus, Gallstone ileus impaction, Adhesions (other). Cholecystitis with or without Cholelithiasis Acuity: Acute/Chronic/Acute on Chronic Anatomical Site: Gallbladder/Bile Duct/Gallbladder & Bile Duct With Obstruction/Without Obstruction 1 | P a g e Rev.9.29.2015 Diverticulitis Anatomical Site: Small, Large or Both Intestines, e.g. sigmoid colon With or Without Bleeding With or Without Hemorrhage With or Without Perforation/Abscess Appendicitis Acuity: Acute/Chronic/Acute on Chronic/Recurrent With or Without Rupture If rupture: With Localized or Generalized Peritonitis With or Without Perforation With or Without (Peritoneal) Abscess Traumatic Pneumothorax/Hemothorax Type: Traumatic, Traumatic Hemothorax, Traumatic Hemopneumothorax, Other (Specify) With or Without Open wound into Thorax; Open; Closed Encounter: Initial/Subsequent/Sequela Neoplasm of Breast Type: Malignant (Primary; Secondary/Metastatic); Benign; In-Situ; Uncertain Behavior (include cell type) (Uncertain behavior is a specific pathologic diagnosis indicating behavior that cannot be predicted, as opposed to a diagnosis of unknown pathology) Morphology: Adenocarcinoma; Sarcoma; Lymphoma etc Note: A primary malignant neoplasm that overlaps Behavior: Primary or Secondary Site; Designate if two or more contiguous (next to each other) sites Overlapping should be classified 'overlapping lesion', unless the combination is specifically indexed elsewhere. For For Secondary Site…document if primary site still exists multiple neoplasms of the same site that are not contiguous, such as tumors in different quadrants of the same breast, codes for each site should be assigned. Gender: Male or Female Laterality: Right; Left; Bilateral Anatomical Site: Breast: Upper-Outer; Upper-Inner; Lower Outer; Lower-Inner; Midline; Central; Nipple; Areola; Axillary tail etc Neoplasm of Colon Type: Malignant; Benign; In-Situ; Metastatic; Distant Metastatic Staging; With invasion or adherence to (other organs/submucosa/muscularis propria/muscularis propria into pericolorectal tissues); Uncertain Behavior (include cell type) 2 | P a g e Rev.9.29.2015 (Uncertain behavior is a specific pathologic diagnosis indicating behavior that cannot be predicted, as opposed to a diagnosis of unknown pathology) Morphology: Adenocarcinoma; Sarcoma; Lymphoma; With or Without BRCA Gene Mutation, etc Note: A primary malignant neoplasm that overlaps Behavior: Primary or Secondary Site; Designate if two or more contiguous (next to each other) sites Overlapping should be classified 'overlapping lesion', unless the combination is specifically indexed elsewhere. For For Secondary Site…document if primary site still exists multiple neoplasms of the same site that are not contiguous, such as tumors in different quadrants of the same breast, codes for each site should be assigned. Laterality: Right; Left; Bilateral Anatomical Site: Ascending; Descending; Sigmoid, Transverse; Cecum; Hepatic Flexure; Splenic Flexure; With Rectum; Regional Lymph Node involvement; etc Spleen Laceration Anatomical Site: Extending into Parenchyma Cavity With or Without Open Wound into Cavity Severity: Major (greater than 3 cm); Moderate (1 to 3 cm); Superficial (less than 1 cm) Encounter: Initial/Subsequent/Sequela Hemorrhage/Infection Complicating Procedure Anatomical Site: i.e. seroma Encounter: Initial/Subsequent/Sequela Volvulus Anatomical Site: Intestinal; Ileal; Jejunal; Ascending Colon; Descending Colon etc With or Without Perforation Abscess Anatomical Site: Abdominal/Lung/Wound/Teeth/Extremity, etc Laterality: Right/Left/Bilateral Manifestations: i.e. Febrile Neutrophilic Dermatosis/Lymphangitis Causative Agent: Viral or Bacterial Causative Organism (if known) Episode of Care: Initial/Subsequent/Sequela (if ‘Wound’ related) Ileus Type: Paralytic; Gallstone; Mechanical; Spastic; Obstructive; Post-operative 3 | P a g e Rev.9.29.2015 Traumatic Fractures (Fracture Clavicle; Tib/Fib, Location: Specific Part of Body - Name of specific bone Femur, Hip) and specific site on bone Laterality Episode of Care/Encounter: Initial (receiving active treatment); Subsequent (encounters AFTER the patient has received active treatment of the condition and is receiving routine care): o Routine Healing or Delayed Healing o Non-Union or Mal-union: . If non union: State if delayed Tx, LEO C. FAUR (it’s Initial Encounter, otherwise it’s ‘Subsequent’) (acronym to remember elements of fracture documentation) Sequela (Use for complications or conditions Zupko and Associates that arise as a direct result of a condition…no time limit….i.e. Neuropathy of lower leg, ankle and foot due to previous crush injury) Open or Closed Classifications: Open use Gustilo Classification: Type I, II, IIIA, IIIB, or IIIC (used for soft tissue classification); Salter; Physeal etc Fracture Pattern/Type/Orientation, i.e.: Greenstick Comminuted Torus Spiral Segmental Transverse Avulsed Oblique Torus Alignment: Displaced or Nondisplaced Underlying Bone Diseases: i.e. Fragility (Pathologic), Stress, Traumatic in healthy etc Results: Routine or Delayed Healing; Non union or Malunion Complications of Surgery Affected Body System Specific Condition Timeframe: Intra operatively or Post operatively (Punctures or lacerations that are unavoidable or Link Complication to Diagnosis: ‘due to’/’secondary to’ inherent to the procedure are not complications. etc… When NOT a complication…include the medical decision making and characterize the event as There is no timeframe/deadline for a Postoperative ‘intentional’, ‘unavoidable’, or ‘inherent’ to the Complication (current condition due to previous 4 | P a g e Rev.9.29.2015 procedure) surgery or procedure) NOT Complications Document: Inherent, Expected, Intended Avoid ‘Accidental/Complication/Unavoidable/Slip/ Additional Terms that suggest non-accidental: to Iatrogenic/Unintended’ etc when it is not a facilitate; necessary; required; intentional; integral; complication. Avoid using ‘Post operative’ when not routinely expected a complication; if used, include that it was ‘intended, expected, inherent’ etc. Procedure Coding System (PCS) – New with ICD 10 Pre-operative/Post Operative Diagnosis State difference b/w pre and post dx, as applicable Link ‘findings’ with post operative diagnosis Procedure Performed Be Explicit, including unplanned Post op drains/tubes – Specify type of drain/tube Be specific re ‘intent’ of surgery i.e. Excision/Biopsy etc Types of Anesthesia/Estimated Blood Loss -Site infused (Central/Peripheral) (EBL)/Transfusions - Type & Volume of Fluid (Fresh/Frozen/Autologous) Procedure – -Intent of the Procedure - Excision (partial removal i.e. biopsy)/Resection (total removal)/Drain fluid/Inspect i.e. Coder needs ALL elements addressed in order to be endoscopy etc. able to assign a code…..physician can use their own language for coder to translate, yet all information -Approach—Specify technique used to reach the site i.e. needs to be available. open, percutaneous, use of scopes etc -Prose for steps and technique, not the name of Coders must have a clear understanding of the procedure ‘intent’ of the procedure..it will help the coder properly assign the appropriate code. -Laterality of incision/Relative Location -Anatomical site – Be specific re site/Body Cavity (instead of quadrants)/How much of body part removed (all, partial, or measurements) - Devices Used Intraoperatively – material or appliance that remains in the body after the procedure is completed. i.e. Biological or synthetic material (i.e. joint prosthesis, intrauterine device; Therapeutic material (i.e. radioactive implant); Mechanical or electronic appliances ( i.e. orthopedic pin, pacemaker) etc. -Intraoperative Grafting – source and destination site -Modality of Guidance 5 | P a g e Rev.9.29.2015 -Specimens – specify if sent to pathology are intended to diagnose and help treatment decisions following the procedure. -Medications applied at Surgical Site -Closure – type/area -Complications Procedure Documentation: Lymph Node Removal Differentiate between removal of: -One or more (portion) lymph nodes Versus
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