Welcome to TCAA's webinar, Root Operations and Coding Procedures for Trauma Patients, presented by Pumphrey Consulting. I'm Michelle Pumphrey, President of Pumphrey Consulting, and I will be your moderator today. We're going to hold all questions to the end, and we will address those questions at the end of the presentation. If we do not have ample time to answer all questions, we will get those from TCAA and have a follow-up document that will go out to everyone in which we answer those questions. It is my pleasure to introduce you to Marcella Juarez. She is a content expert for Pumphrey Consulting. She has her MBA and her BS in Health Informatics. She has her RHIT, CCS, and CAISS certifications. She is a Data Management Analysis at a Level 2 Trauma Center, and she has been working as a trauma registrar for eight years. Marcella? Thank you for the introduction, and welcome everyone. So, we have a lot of information to cover, so I'm just going to get started. Okay, so my objective for this course is to better help you understand your data, and also to identify coding resources and to grasp the ICD-10-PCS coding structure. We're also going to cover and define and apply root operations and their categories, as well as to properly select codes for root plating procedures and CTAs. Okay, so throughout the webinar, you'll see some polling questions. I have an easy one for you. It's just to get to know a little bit more about you, and how long have you been a registrar? I'll allow a little more time. Okay, wow, so we have a very wide variety of experience on the line, and again, thank you for joining. So, hopefully, as a new registrar, you take away some knowledge to help build that skill that you have, and for more experienced registrars, hopefully, this just confirms what you already put into practice, and just helps to build that confidence. So, let's get started here. Okay, so first, I want to highlight a few things. So, during the course, we'll discuss and apply the ICD-10-PCS coding guidelines, and these guidelines are more in line with reimbursement, and in the trauma registry, we don't have to be concerned with certain aspects of billing, such as unbundling procedures. So, we do have a little bit more freedom in the registry. What's important to remember is to understand the purpose of the data that we are capturing. So, we need to be able to create a timeline for the patient's care to support the performance improvement program for the center, and this means that we are documenting all of the procedures that are essential to the diagnosis, stabilization, and treatment of the patient's specific injuries and complications. So, my goal for you today is to ensure that you understand how to select these corrective operations. So, we'll be reviewing them as they relate to trauma. Your center may or may not use all of these codes. It will depend on what your patient population is, how your reports are built, and what your center captures, as well as how it uses its data. But, at the minimum, we want to make sure that you meet the NTDB inclusion criteria. So, always refer to your data dictionary for the complete list of procedures that you're supposed to be capturing. So, all of these procedure codes are submitted to the Trauma Quality Improvement Program, or what we know as TQIP, and in turn, we get a risk-adjusted benchmark report that allows our center to track its outcomes and to improve patient care. So, just make sure that you keep that in mind when you're coding and selecting these root operations. Also, make sure that you're collaborating with your team and other registrars to ensure consistency. That's important. Okay, I've also provided a list of resources that can help you when you're trying to select your root operations. Our primary resource is always the ICD-10 PCS coding book. There are many publishers out there to choose from. What I suggest is to get an expert edition, since it includes the guidelines and the root operations and their definitions, and some additional information that's useful. There are several websites out there. A popular one is the ICD10data.com. I would also suggest getting anatomy books to help you identify body parts, as well as the vessels in the cardiovascular system. And finally, the NTDB Google group. This was created by the ACS, and it's an email community that allows you to reach out and collaborate with other centers and our peers. Okay, our most valuable resource again is our ICD-10 PCS coding book, and here's an example of what the index and the PCS table look like. So our first step, if you're using the book, is to choose the main term from the index. You can search for it by name, or you can search by the procedure name, or by the root operation. And then if you know what section to go to, you can go directly to the table and start building your code from there. But if you are using the index, it usually will provide you with the first three to four characters in the PCS section. The subterms in the index correspond to the body parts, and then these characters will be used to select your table. So once you've located your table, your final step is to complete the code. What you have to remember is that once you have chosen your body part value, you need to select the characters in that same row. So do not cross rows, because this can result in creating an incorrect code. Okay, so another polling question. How many characters make up an ICD-10 PCS code? Very good, and seven is correct. Okay, so correct. All PCS codes consist of seven characters. The letters L and O are not going to be used. Instead, you're going to see the numbers 1 and 0. And so each character in the code represents a different aspect of the procedure. So our first character represents the section. There are 17 sections that can be separated into three main groups. We have the medical surgical, medical and surgical related, and the ancillary section. Our second character represents one of the 31 available body systems in the medical and surgical section. Character 3 represents our root operations. So there are 31 root operations, and they can be divided into nine categories. So our fourth character represents the body part, and there are 34 possible body part values per body system. There are seven approaches, which are represented by the fifth character. The sixth character represents the device, and so this is applicable to certain procedures. This would include grafts, prosthetics, implants, and things like that. And then our final seventh character represents the qualifier that provides additional information for certain types of procedures. So again, we're going to focus on the root operation and discuss how to define and apply the guidelines for these procedures as they relate to trauma. Okay, please also keep in mind as we're reviewing these root operations that it is the coder's responsibility to figure out how the documentation in the medical record aligns with these PCS definitions. So our physicians are not expected to use the PCS terms. The coder should ask to match that documentation to these definitions. So a good example would be if your physician is documenting a partial resection is performed. So us as the coders can independently correlate partial resection to the root operation excision without having to clarify this information with the physician. So I'll explain this concept a little more in detail as we move along the sections. So I do want to talk about the approaches first before we move into the root operation. So this is our fifth character and that code represents the approach that we're using to perform the procedure. So the values for each approach will remain consistent throughout each of the PCS tables in each of the sections. So zero will always be open, three will always be percutaneous. And so when determining your approach, don't focus too much on the instrument that's being used. Instead, define the technique used to reach that procedure site. So there are seven options to choose from as you can see here. And they can be placed in two different categories. So our first one is procedures that are performed through the skin or mucous membrane. And then there are procedures that are performed through an orifice. So a frequently asked question in most of our classes is how to differentiate between an open and a percutaneous approach. And our key is in the documentation. So our open approach will require sutures for the entry point to heal. So the surgeon will cut through skin, mucous membrane, and any other body layers necessary to access that site. And a percutaneous procedure will be more of a minor puncture or an incision and it will only require a bandaid or a steristrip to heal. Normally you'll see needles and catheters used for these procedures. And always look at your documentation. It will be found in your procedure or operative work. Okay, so how many root operations will you find in the medical and surgical section? All right, if you said 31 then you are correct. So there are 31 root operations in the medical and surgical section. So instead of trying to memorize all 31 definitions, focus on learning these nine categories that you see here. So it helps to locate the category that best describes the purpose of your procedure first and then select one of the root operations that falls into the category. So moving forward we'll start going through these nine categories and then discuss the root operations associated with each one. But of course I will focus on the ones related to trauma. Okay, so our first group of procedures that take, these are procedures that take out some or all of a body part. And so the first column you see is the root operation and its corresponding value in the PCS table. And again they'll remain consistent throughout each of the tables. So procedures for specific injuries depend on the factors such as the severity, the affected body part, and the patient's condition. And it's important to understand the medical terminology that you're reading in order to select the correct root operation. So our first one is excision. This is the cutting out a portion of a body part without replacement. And it involves the surgical removal of growths, tissues, organs, or bones using a scalpel, laser, or any other cutting tool. So an example to look for in documentation would be a 20 centimeter small bowel resection was performed or skin, muscle, bone, tissue were debrided using a sharp tool. Our next one is resection. And this is the cutting out or off all of the body part without replacement. So sometimes the entire body part or organ needs to be completely resected due to the nature of the injury. So these procedures include lobectomies, splenectomies, hemicolectoms. So resection and excision are very similar to each other. So the difference is that resection includes all of the body part or any subdivision of a body part that has its own body part value in the ICD-10-PCS table. And excision is only removing a portion of this body part. What you will find is that excision and resection are used interchangeably in our documentation. So it is up to you to make sure that you're reading the documentation carefully before selecting the root operation. So we'll use this example again. A 20 centimeter small bowel resection was performed, but our root operation is still going to be excision because only a portion of that small bowel is being removed. An example of a resection is when you see the term hemicolectomy. So a right hemicolectomy is removing the entire ascending colon, or a left hemicolectomy is removing the entire descending colon. And the reason this is resection is because they have their own body part value in that PCS table. And that's where the index refers you to is to resection. Okay, so our next root operation is a detachment, and it's specifically used for amputations for the upper and lower extremities. And this includes any amputations of the hands, fingers, toes, and you see below and above the knee amputations, or any disarticulation at the joint. And in this case, the seven character qualifier is used for additional documentation. So in our long bones, in the arm and leg, it describes the level of detachment, whether it is high or at the proximal portion of the bone, mid or at the middle part of the shaft or low or at the distal portion of the bone. This applies to thumbs, fingers, and toes as well. They can be complete, high, mid, or low. Amputations of the foot or the carpal metacarpal joint can be complete, partial, and it also describes at which bone or ray is being amputated. Our next one is destruction. This is the physical eradication of a body part by the direct use of energy, force, or a destructive agent. So none of the body part will be removed in this instance because it's being destroyed. So you'll see the terms fulguration or ablation commonly documented in these procedures. And then we have extraction. This is the pulling or stripping a body part by the use of force. So we'll see these in tooth extraction, dilation and curettage, vein stripping, or also a non-excisional debridement. So this would be documented as a brushing or a scraping of devitalized or necrotic tissue. The difference between an excisional debridement is the use of the cutting tool. So if they're using any kind of tool to debride this tissue, then you're going to use the root operation excision. Okay, so before we move to the next group, you have an opportunity to test your knowledge. So what root operation is used for cutting out or off without replacement all of a body part? Not sure if I'm seeing the results here. Okay, well, um, oh, there we go. Okay, if you chose resection, then you're correct. We're removing all of the body part. Okay, let's try another one. Okay, so what root operation would you use to code a 20 centimeter small bowel resection performed during an operative report or operative procedure? And excision is for a partial resection. So try asking yourself questions like these as you're trying to select your root operation. What is the purpose of this procedure? That always helps me to kind of talk myself through that, or maybe talk to your colleagues. That also helps. All right, let's move on to our next group. And this involves taking out solids, fluids or gases from a body part. And the most commonly used root operation and trauma is drainage and extirpation. Fragmentation also falls into this category, but we normally don't use it for trauma. So I added the definition here, but we'll stick to reviewing the other two. Okay, so drainage takes out fluids or gases from a body part. And this is where you would code Foley catheters to drain the bladder, chest tube insertions for pneumothorax or hemothorax, a thoracentesis, this is where a needle is used to drain excess liquid from the pleural space, or paracentesis, where they're draining fluid from the abdomen. Okay, we have extirpation, and this takes out or cut solid matter from a body part. And this can be an abnormal byproduct of a biological function, or it can be a foreign body. So procedures here range from splinter removals to hematoma evacuations, either in the skin or even in the intracranial cavity. Group three involves cutting or separation only. And the difference between these two procedures is that one is performed within the body part, and then the other one frees around the body part. So let's take a look at each one. So in division, the procedure involves separating all or a portion of a body part into two parts. So in this case, we're going to look at the spine. So in division, the procedure involves separating all or a portion of a body part into two different sections. So procedures that you'll see here are a spinal chordotomy for pain, or an osteotomy to change or to realign a bone. So common procedure used for trauma is release. So the point of the procedure is to free the body part from an abnormal physical constraint. And so some of the restraining tissue may be taken out, but the body part itself will be left in place. So an example here would be a distortion of the anatomy due to trauma causing displacement. Ligaments and connective tissue are cut to release that body part from its constraint. A good example would be a fasciotomy for compartment syndrome. The fascia is cut to relieve pressure to the underlying tissue and muscle. So that's where you would use this one. So another opportunity to test your knowledge. A chest tube is placed in the left chest due to a hemothorax. What is your correct root operation for this procedure? And if you chose drainage, then you are correct. Good job on that one. All right, we have one more. So what root operation is used to free a body part from abnormal physical constraint by cutting or using force? Very good. I think we all got released there. All right, good job. Okay, let's keep moving. So group four involves the putting in or back all or some of the body part. So these root operations all will involve moving a body part in some way. And it's up to the coder to determine the intent of the procedure. So let's take a closer look at each one. So first we have transplantation. So this involves putting in all or some of a body part taken from another individual or animal to physically take the place or function of that body part. So these procedures include transplanting organs or other tissue. Unfortunately, in the case of our trauma patients, they are usually the donors of these organs when life saving measures fail. So we hopefully are not using these often. Okay, next we have reattachment. And this involves putting back in some or all of a separated body part to its normal location. So this can be the reattachment of an extremity, or a solid organ. And in the case of an extremity, so all efforts will be made to repair the fractures by the use of pins, wires or plates. We're repairing the nerves, muscles and any other connective tissue that's going to regain the use of that extremity. We also have transfer, and it involves moving without taking out all or a portion of a body part to another location to function for a similar body part. So these are transfer procedures, they can be done with tendons, ligaments and muscle and even skin. So the donor site remains connected to the body and including its blood supply, and then it is transferred to the recipient site. So common procedures for traumatic injuries would be a skin flap transfer. So this is where that skin is taken and moved to where there's skin breakdown in a traumatized area. Okay, next we have reposition, which is moving a body part back to its normal location or to another suitable location. And I think we're all pretty familiar with fracture reductions and internal fixations. So I did want to cover a newer procedure that we're seeing more often in trauma. And that would be rib plating. So studies have shown that using rib stabilization techniques reduce immediate and long term complications associated with rib fractures. Rib plating is an open reduction that stabilizes fractured ribs with titanium plates and screws. An incision will be made near the fracture, the muscles surrounding the rib are split, the rib is then realigned and the titanium plates and screws are placed to stabilize that fractured rib. So you can see an example here in these diagrams. Okay, and just like other bones, we code rib plating to the root operation reposition. So the surgeon is reducing or repositioning the rib back to its normal location and stabilizing it with an internal fixation device. So here's an example of what the table is going to look like in your ICD-10 PCS book. So our body part character depends on how many ribs are being plated. So we can either have one or two, or three or more. Our approach is going to be open since the incision is cutting through the skin, connective tissue and the muscle. And then our device character would be four to represent the internal fixation device, or in this case, the titanium plate. And then here are the two codes that we can build from this table. So make sure that you're reading your operative report carefully to make sure that you're capturing the correct number of ribs here. So I'll just pause a little bit so it gives you some time to read through through these procedure codes. Okay, let's move on to our next group. These are procedures that alter the diameter of or the route of a tubular body part. And these can be found in the cardiovascular, gastrointestinal and even the respiratory system. So our first route operation is restriction. It partially closes an orifice or the lumen of the tubular body part. And this can be done with an intraluminal device or an extraluminal device. So similar to restriction is occlusion. The purpose of this procedure is to completely close the body part. And this can also be done with an intraluminal or extraluminal device. And this is more common in traumatic injuries. So an example of this would be embolization to stop bleeding in a severely injured patient. So substance is placed into the vessel to prevent blood flow from going through it. You can have balloons, gel foam, coils, and those types of devices to stop the blood. We also have bypass, and this alters the route of passage of the content of the tubular body part. So we do see these commonly in our severely injured patients. So injuries to the intestine require excision or resection of that damaged area. And this requires the surgeon to either reconnect the intestine through anastomosis, or to create a colostomy, which is an opening from the colon to the abdomen. So both of these will alter the original route of passage of that intestine. And you can also use these for vessels as well. We have dilation, and this is when the orifice is expanded through the lumen or through the tubular body part. And this can be intraluminal or extraluminal device as well. Group six is a much larger section, and it always involves a device. So our first column here is the intraluminal or extraluminal device. And this is where So our first column here includes our root operation and its corresponding character, just like all the rest. And so the root operation selected will depend on the function of the device that's being placed. So let's take a look at each one. So we have insertion, and this is putting in a non-biological device in or on a body part. And this device should monitor, assist, perform, or prevent, but it will not physically take the place of that body part. So the main objective of the procedure is to insert the device into the body part without performing any additional procedures. So if you do have a procedure and more is performed, then you would code to that root operation. So an example here would be a central venous catheter, which gives a more reliable vascular access, or intubation of a patient. This is when a tube is inserted into the trachea via natural or artificial opening, and this is performed to protect the airway. Okay, we have replacement, and it involves putting in or on a biological or synthetic material that physically takes the place or function of that body part. So we commonly see these procedures in our elderly population, especially our isolated hip fractures. So damaged cartilage and bone is removed and replaced with a metallic, ceramic, or a plastic implant, and that restores the function of that hip. So when the procedure is performed or referred to as a total hip replacement, the body part is coded to the joint, and a partial hip replacement is when the body part is the upper portion of that femur. So make sure that you're reading your operative report carefully to make sure that you're selecting that correct body part value. So our next route operation is supplement. It's used when a device that reinforces or augments the body part is placed. So an example would be a hernia repair using a mesh implant. So this mesh is used to patch the abdominal wall, and so it's reinforcing that weakened muscle. We can use it for free nerve grafts as well. If there's a damaged nerve, it's used to bridge a gap between the two ends of that damaged nerve. Tissue can be autologous, which is taken from within the body, or it can be an allograft taken from, for instance, a cadaver. So then we have change. This is when the device is taken out or off from the body part and then replaced with an identical or a similar device. Procedures performed will be without cutting or puncturing the skin. So change procedures will always be an external approach. We also have removal. So this is when the device itself is taken out without being replaced. This will be the removal of a drain, a chest tube, a Foley catheter, or even when our patients are extubated. And then finally, we have revision. So this is correcting, to the extent possible, a portion of a malfunctioning device or a reposition of a displaced device. This can be the revision of a hip prosthetic or readjusting of a previously placed fixator pin. So we have another opportunity to test your knowledge. So what is the root operation used to correct a portion of a malfunctioning device or a reposition of a malfunctioning device or the position of a displaced device? Let's see here. Oh, coming up. All right, if you chose revision then you're correct. Okay, let's try one more. Okay. Okay, so due to an injury, the extensor tendon of the hand, the physician transferred the EIP tendon to the extensor mechanism of that small finger. So what root operation would you use for this procedure? This one's a little more difficult. All right, just waiting for results to come through. And if you chose replacement, then that is the correct answer. And this is because that EIP tendon is being taken and then replacing that extensor mechanism that was damaged, so it's actually taking over that body part. Okay, our next group is pretty straightforward. So this would be procedures that require examination only, and that would be inspection and map. So inspection, the objective of this route operation is to inspect or visually and manually explore a body part, and no other procedure will be performed. So this is a good example in the registry where we differ a little bit from the guidelines. Normally you wouldn't code a procedure together with this one, but for us we can use it to capture a certain patient population for data tracking and reporting purposes. And that's okay if your center uses it or doesn't, but just make sure that it's being coded consistently, so make sure that you're collaborating with your team to make sure that you have quality data. Okay, so then mapping is locating the route of passage of electrical impulses or locating functional areas in a body part. These would be things such as cardiac mapping or cortical mapping. Okay, so we have group eight. I know I'm throwing a lot of information at you, but we're almost to the end here. And then these are route operations that include repair and control. The repair we're constantly using in trauma, and this definition is to restore to the extent possible a body part to its normal anatomical structure and function. And it's used only when the method to accomplish the repair is not one of the other route operations. And then depending on the injury, the repair can be to skin, muscle, nerve, solid organs, and even vessels, or any other body part that's located on that body part character in your PCS-2. So our other route operation is control. So the procedure is performed to stop or attempt to stop post-procedural bleeding or any other acute bleeding. So our site will be coded to the anatomical region and not to a specific body part. This includes, of course, post-operative bleeding, this includes, of course, post-operative bleeding, control of intracranial subdural hemorrhage, control of a bleeding of a duodenal ulcer, or retroperitoneum hemorrhage. Okay, and our final group is other objectives, and our list is fusions, alteration, and creation. So we'll focus on fusion since we don't use alteration and creation in trauma. Okay, so route operation fusion renders a joint immobile. So the procedure fuses two bones at their joint for stability after an injury, and the sixth character describes the device in the procedure. It can be autologous, a synthetic substitute, non-autologous, or an intrabody fusion when it's related to the spine. So we'll take a closer look at that. So in our spinal fusions, the seventh character qualifier provides additional information for our procedure. It describes from what position the area was accessed and what portion of the spine is being fused. So if the patient is documented as supine, they are in the face up position, and an incision is made on the front side of the body or the anterior approach. If the patient is in a prone position, they are laying flat with the chest down and the back in the up position, and then the incisions are made on the back side of the body or the posterior approach. Your qualifier will also describe which portion of the spine is being fused. If the vertebral body is fused, then it's the anterior column, and then if the posterior sides are fused, then it's the posterior approach. Okay, so here's a list of common abbreviations that you'll see in your operative report for anterior column fusions. But just make sure that you're reading your entire report and not just the listed procedures at the top. Many times the physician will find additional injuries, or they can change their approach due to a complication or the inability to access the site. So sometimes these additional procedures won't make it to the top of the list. Make sure that you're reading it in its entirety. Okay, our next section is pretty straightforward. Those sections are one through nine. These codes are easily found in the index. They normally will give you the full code, so I won't break these down for you, but you'll find cast applications, mechanical ventilations, cardiac monitoring, and CPR in this section. Okay, and then we have our ancillary section. So there are no root operations here. The characters represent the types of procedures. We'll find MRIs, x-rays, PET scans, wound care, detoxification therapies. So of course, as we all know, this is common in the registry, and we code a lot of imaging procedures here. So we're going to have a few coding examples and break down the CTAs for you. So we have another polling question here. So what is the main purpose of a CT angiogram in a severely injured patient? Is it to create a cross-sectional image, to diagnose and evaluate blood vessels, create a two-sectional image to detect fractures, or to serve as a screening tool? Well, I'll wait a little bit, and if you guessed to diagnose and evaluate blood vessels, then you're correct. Okay, so a computed tomography angiography, also known as a CTA or a CT angio, is a technique used to enhance the anatomic structure of the veins and arteries throughout the human body. So we frequently see these CTs and CTAs performed in trauma patients, and a CT is the imaging technique that takes cross-sectional images of soft tissues and bones and in traumas used to detect internal injury and bleeding. Now a CTA will combine the CT scan with the use of contrast injected into the bloodstream, and it's used to create a 3D image to evaluate the solid organs and its vasculature structures for injury. So it's important to read your entire report to make sure that you're capturing this procedure correctly. So during abstraction, you'll see the documentation that can kind of flag you to look for a CTA. During a primary survey, your physician may document seat belt signs, which would be cuts, bruising, or pain where the seat belt crosses the neck and the torso. Abdominal distension can indicate air-free fluid, pulseless extremities, or even more obvious signs like active pulsatile bleeding. You can have a positive FAST scan. A patient may arrive hypotensive, tachycardic, have cold extremities. So these would be signs of hemorrhage in the setting of trauma. Also in the CT scanner, the radiologist may document findings such as a blush, active extravasation, or mention a solid organ injury with vascular involvement. So these would be things to look for in your documentation. A couple of things before we get into our guidelines. So when you're selecting your code, make sure that you're in the correct body system and also that you're selecting the correct body part. So we have to remember our aorta, for example, runs through the thoracic and the abdominal cavity, and it's separated by the diaphragm. So pay attention to what section you're in before selecting your body part value. And then also get familiar with your contrast. The contrast that's used in your center, it's also a part of your code. So make sure that you're reading through your report to make sure that you're selecting the correct one. A common contrast is omni-peg 350, and it's a low osmolar contrast. Okay, so now let's look at our guidelines. So we have two important guidelines that we need to follow as registrars. So that is our ICD-10 PCS coding guidelines and also our NTDB data dictionary. So first, coding guideline state, multiple procedures are coded if the same root operation is performed on different body parts with distinct values in the PCS table, or if the same root operation is repeated multiple times on separate and distinct body parts classified to a single ICD-10 PCS body part value. So basically what this is saying is that we need to make sure that we're capturing all the body parts being imaged. And our NTDB data dictionary also follows the same logic. Procedures are coded when they are essential to diagnose, stabilize, or treat a patient with traumatic injuries. And so for trauma patients, certain procedures are performed multiple times during the course of care. And according to our NTDB, angiographies are reported per event, even when there are more than one. So just make sure that you're capturing all of them. And also refer to your data dictionary for a complete list of procedures that also follow this logic. Okay, so these two guidelines focus on selecting the correct body part character. So guideline B4.1 states when the body part does not have a separate body part value, then you can code it to the whole body part. Our guideline B4.2 applies more specifically when coding vessels. So when a specific branch of a body part does not have its own body part value in the PCS, then you would code it to the closest proximal branch that has that specific body part value. And if that proximal branch would require assigning a code in a different body system, then the procedure is coded to the general body part. So this is important to remember since not all vessels will have a body part value in the PCS table. So you're either going to select the branch or a general body part where the vessel is located. Okay, let's move on to our coding examples. So also just get into the habit of reading your entire report and not just the results section. I know it's tempting to just to go directly to it, but the majority of your information will be found in that long narrative. So just make sure that you're reading all of it and capturing everything. Okay, so let's get to our first coding example. So this is a patient with traumatic injury struck by a car and CT images of the head and neck were performed using OmniPAG-350 and images of the vessels were obtained. So there is a mild narrowing of the supraclinoid portion of the internal carotid artery. So this is where the vessel moves into the intracranial cavity. Mild stenosis of the bilateral vertebral arteries, left and right middle cerebral artery and anterior cerebral artery are visualized, no occlusion or dissection. So the visualized segments of the great vessels in the neck are pain. So that would be the common carotid arteries that branch from the aorta and then they eventually divide into the neck, into the external and internal carotid arteries. And so those were also normal no stenosis, the extracranial segments of the vertebral arteries are patent, no dissection. So we're going to select procedure codes from the upper body, upper artery body system. And our procedure codes include CTAs of the intracranial arteries. Next we have the greater vessels of the neck, which include the bilateral common carotid arteries. We also have a bilateral code for the internal carotid arteries and then a code for the bilateral vertebral arteries. So that covers the head and neck. So we'll move down the line. So we're going to use our same scenario from the previous slide, patient struck by a car and then a CTA of the chest was performed using OmniPay 350. So chest images were generated of the thoracic aorta, supra aortic branches, the pulmonary arteries, pulmonary veins, and coronary arteries. All vessels were patent, normal in size and without injury. So the supra aortic vessels branch from that aorta, and then they travel towards the neck. Then these are the ones that eventually split into the internal and external carotid arteries, which are the ones we spoke about in the previous slide. And then these will supply blood to the brain as well as to the head, face, and scalp. So since our body part being images the chest, our codes will be from the upper artery and veins also. And so our first code includes the thoracic aorta and all of its branches that do not have their own body part value in the PCS table. The pulmonary artery does not have a bilateral code, so we have to choose left and right. Our next code is a bilateral code for the pulmonary veins. And then our last code includes the coronary arteries. And moving further down the line, still the same patient. And so now we're imaging abdomen, pelvis, and lower extremities with low osmolar contrast. So a CTA of the abdomen, pelvis, and lower extremity were performed. Findings of the abdominal aorta, celiac artery, SMA, renal arteries, and bilateral lower extremity arteries are all normal and without injury. So you can see the list here of all everything that was imaged. So we're going to select procedure codes from the lower artery body system. And these procedures include CTA for the abdominal aorta and its branches. So this includes the common external and internal iliac arteries. Then the inguinal ligament separates them at the femoral artery. And so then we use the one code to capture the remaining arteries of the bilateral lower extremities. All right, and that's your examples there. All right, so that wraps up the presentation for today. I know this was a lot of information that we covered, but the key takeaway here is use your references. If you can, get a copy of your ICD-10 PCS coding book or at least a copy of your coding guidelines to keep handy. Collaborate with your team or even with other centers. Consistent coding is the key to obtaining quality data. Also get familiar with your root operation categories. And you're not expected to have all 31 definitions memorized, but if you learn the nine categories, it can help to narrow down these choices. For rib plating procedures, make sure that you're reading the operative report in its entirety before selecting your code. And remember that rib fractures are treated like other fractures and they code to the root operation reposition. And same goes for the CTAs. Read the narrative to ensure that you're capturing all of the vessels being imaged and refer to your body part key. And also get familiar with the anatomy. Use your resources. Get a copy of an anatomy book. That's very helpful. I know I keep one at my desk. And that's it. I guess we'll open up for questions. Do you have anything to add, Michelle? Yes. Great presentation, Marcella. And the comments are amazing. And I have a great list of questions here. The one thing as we get started with the questions, we've got about 10 minutes. And anything we don't get covered, we will cover in a document that will go out to everyone. First of all, there are going to be some questions that some centers code and other centers don't. As Marcella said, be very clear on that. My suggestion would be to include all of these caveats in your internal data dictionary. Yes. So the first question is amputation. Traumatic amputation happens on the scene and in the op, they clean out and maybe just clean up the amputation. Do you still use amputation as the root operation or excision code for the cleanup or revision? Okay. So you would use excision or repairs or anything that they're, so you're, whatever they're performing at the center. So the amputation is used when the physician is actually amputating this extremity. So once it's already amputated, then they're just cleaning it up, excisional debriefments, washouts, repairs, things like that. That's what you would code at your center. If this happened at the scene, what was the resection qualifier for a body part such as hemicolectomy? Can you repeat that? What was the qualifier? What was the resection qualifier for a body part? And the example was the hemicolectomy. I would have to go through and see what qualifiers mean that I'm, I don't know that off the top of my head, so we can add that to the list of questions. Okay, perfect. Coding Foley catheters, is this an insertion? So it depends on what are the purpose of your procedure, right, is to drain the bladder. So if you're just inserting the Foley catheter, then it would be insertion, but if the, we're draining this bladder for a specific purpose, so then you would use drainage. So it just depends on your purpose for that procedure for that specific patient. Wound vac, is that coded as drainage? Wound vac, I think that one is in the medical and surgical related. I would have to look, I don't know that one off the top of my head, but I believe it's a wound therapy procedure code, so we can add that to our list. Can reattachment be used in lieu of coding out all the other specific operations, such as bone nerve vascular, on a partial or complete amputation? Yes, that would be the purpose of the reattachment code is, it's basically including all of this work that's being done to repair every single portion of the body part to regain the use of that extremity. That's actually the definition of reattachment. All right, would you use extraction when a VersaJet is used in the OR as a debridement, especially for use in open fractures? When a what? I'm sorry, what was the? Would you use extraction when a VersaJet is used in the OR as a debridement, especially for an open fracture? I would think not. I would like to look up some more information on that one, but I would think that we're using excision on that one, because that's the purpose, right? We're debriding that wound, but let me, let me follow up on that one just to make sure I'm giving the correct information. Perfect. Would a gel foam used for an arterial embolization be considered restriction as it is not permanent and will be discontinued or will dissolve? Well, in that moment, we are occluding the artery, right? We're stopping the blood flow to stop bleeding. So the purpose of your procedure is to occlude that artery. So it stops blood flow. So I would go with occlusion. So speaking, speaking of blood flow, where are tourniquets coated? Controlled by the anatomical area or compression? I think that one's compression. If I'm, if I'm thinking of this as off the top of my head, I believe it is compression and it's interbent, but I can clarify that one, but I'm 90% sure it's compression. Okay. Can inspection be used in cases of bronchoscopy or endoscopy or any other procedure when no injury is found repaired at the same time? So yes, if you're just inspecting and you're doing nothing else, yes, we're using that root operation inspection. All right, let's see. Is it safe to say that most CTAs will get coated to with or without contrast or applicable by coding operations, by coding options? Sorry. I'm not sure I understand that question. So CTAs will be coated with or without contrast where applicable by coding operations. So I think that's true because every CTA is going to tell us with or without contrast, correct? Correct. Yes. All right. There are a lot of questions popping up in the chat. Let's see. Oh my. Oh, so someone just commented, just read the VersaJet yesterday in a coding textbook. This is a non-excisional debridement and coded as extraction. Okay. Well, thank you for that information. Let's see. We've got time for just a couple more. Okay. And there are a lot. How would you code a CTA of the upper right extremity? The upper right extremity, then you would code that to the whole body part. If you don't, if you have specific arteries and vessels being mentioned, then you would use those. If not, then you would code to the body part. Okay. There were a lot of questions related to coding of a CTA of an upper extremity. Okay. So we can, I can go back through and have my homework cut out for me, it sounds like. Well, no, I meant, no, that was a general question. What should we code for CTA of upper extremity? How do we code the CTA of an upper right extremity? So there were just a lot of upper extremity CTA, which I think you just covered. Yeah. How do you choose a code for a vascular injury like repair for suturing, the broken vein or occlusion or control of bleeding? Okay. So that's, again, it's the purpose of your procedure, right? So if it's a transected vessel and they're repairing it, then that's what would, that would be your root operation is repair. Now, if they're using an embolization or a extraluminal device, then you would just go down the line and, and, you know, read your operative report and select the root operation according to what they're performing. So it's always the purpose of your procedure. Is there a length of incision that would determine if the approach was percutaneous or open? There is no specific length that I am aware of, but usually it just always go back to, are these body layers being accessed? Are they suturing? So when they're closing, are they going back and suturing all of these body layers to heal this site? That's, that's basically we're going to look at is in your operative report. Does it need repair or was it just a quick closure, like the insertion of a catheter or, you know, a needle, that kind of thing. So you're just reading your operative report would help you answer that question. Yeah. I loved what you said in the beginning, open requires sutures, percutaneous requires a band-aid. Yeah. I love that. That's pretty much it. Yeah. Cause there is no real like, oh, it has to be, you know, this amount of, you know, lacerate or, you know, incision. It's just read your operative report. Let's see. It is after one. So we're going to end here. Again, thank you for attending the TCAA's webinar on root operations presented by Pumphrey Consulting. Marcella Juarez is our speaker today and expert content for Pumphrey Consulting. Any questions that we've not addressed in the chat we will receive from TCAA and Marcella will research them and give a descriptive answer that will go out to all of the participants. But thank you for your time and attention today. I hope everyone enjoys the rest of their day.

Root Operations

ICD-10-PCS Coding

Trauma Patients

Coding Procedures

Data Understanding

Rib Plating

CT Angiograms

Coding Guidelines

Upper Extremities