Check out how many PCS options you have without detailed information.
Notes describing the simple transfusion of red blood cells might direct you to an ICD-9 procedure code right now, but without details, you'll have dozens of potential ICD-10-PCS codes in 2014.
Here's what your provider's documentation needs.
Scenario: The physician notes "Transfusion of Red Blood Cells, Leukocyte Reduced."
The medical record indicates the patient has received treatment for myelodysplastic syndrome pancytopenia secondary to anemia. The discharge summary and progress notes document the transfusion of blood.
First, Examine ICD-9 Procedure Codes
The ICD-9 Code system provides codes for Transfusion of Blood and Blood Components (99.0 Series) with respect to type of transfusion (e.g. transfusion of packed cells, platelets, coagulation factors, other serum etc.).
Therefore, the existing clinical documentation supports both the transfusion and clinical indicator as red blood cells, which leads to accurate code in ICD-9 as:
Here's What Information You Do Have
Unfortunately, you cannot properly assign the ICD-10-PCS code. Given the documentation you have, you have enough for the following three
Section (relates to type of procedure): Administration
Body System (refers to general body system): Circulatory
Root Operation (specifies objective of procedure): Transfusion: Putting in blood or blood products
Pick Apart What's Missing For ICD-10-PCS Coding
However, you don't have enough to continue on with your ICD-10-PCS code. Here's where your code gets muddled:
Body Part/Region (refers to specific part of body system on which procedure is being performed):
Approach (is the technique the provider uses to reach the site of the procedure):
Substance:
Qualifier (provides additional information about procedure):
Check out the potential codes you can use:
Therefore, for you to provide the correct ICD-10-PCS code, the provider needs to provide detailed and specific information on the following indicators:
