Inpatient Facility Coding & Compliance Alert

Heads up: Sketchy details will lead to almost 50 possible code choices.

Physician notes describing a simple red blood cell transfusion might send you to a single diagnosis code under ICD-9, but that will change when you begin using ICD-10-PCS codes in October 2014. If you don’t have sufficient details describing the procedure, you’ll have dozens of potential ICD-10-PCS options.

Step 1: Examine ICD-9 Procedure Codes

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.

The ICD-9 code system lists codes for the transfusion of blood and blood components (99.0 series) based on the type of transfusion (transfusion of packed cells, platelets, coagulation factors, other serum etc.).

Therefore, the documentation in the above scenario supports both the transfusion and clinical indicator as red blood cells. This leads to an accurate code in ICD-9 of 99.04 (Transfusion of packed cells).

Step 2: Translate the Details to PCS Structure

Unfortunately, you cannot properly assign the ICD-10-PCS code based on the scenario’s documentation. Given the information you have, you can assign three components of the code: 

·         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.

Step 3: Find the Missing Pieces for the Complete Code

However, you don’t have enough information to continue narrowing choices for the correct ICD-10-PCS code. You need details regarding the other four digits of the code:

Body Part/Region (refers to specific part of body system on which procedure is being performed):

·         Peripheral

·         Central Vein

·         Peripheral

·         Central artery

Approach (is the technique the provider uses to reach the site of the procedure):

·         Open

·         Percutaneous

Substance:

·         Red Blood Cells

·         Frozen Red Blood Cells

Qualifier (provides additional information about procedure):

·         Autologous

·         Non-Autologous

A bevy of potential diagnosis codes could apply to the situation, if you don’t have the full details. A few possibilities include:

·         30230N0 – Transfusion of autologous red blood cells into peripheral vein, open approach

·         30230N1 – Transfusion of nonautologous red blood cells into peripheral vein, open approach

·         30240N0 – Transfusion of autologous red blood cells into central vein, open approach

·         30240N1 – Transfusion of nonautologous red blood cells into central vein, open approach

·         30250N0 – Transfusion of autologous red blood cells into peripheral artery, open approach

·         30250N1 – Transfusion of nonautologous red blood cells into peripheral artery, open approach.

Resource: For a chart showing the full gamut of choices in this scenario that will help you understand the structure of codes, email editor Leigh DeLozier, CPC (leighd@codinginstitute.us).

Bottom line: Before you can assign the correct ICD-10-PCS code, the provider needs to provide detailed and specific information on the following indicators:

·         Body Part/Region

·         Approach

·         Substance

·         Qualifier.

Next steps: Begin educating providers now about the importance of including details to support every component of ICD-10-PCS codes. Otherwise, you’ll spend unnecessary time asking physicians to amend patient charts before you can submit claims.