Alteration is one of three root operations termed as having “other objectives.” The others are Fusion and Creation. It is identified by using “0” for the third character in a seven character ICD-10 PCS code and denotes the type of procedure performed. The root operation Alteration is defined as modifying the anatomical structure of a body part without affecting the function of the body part (ICD-10 PCS Training Manual, 2013). The procedure can be performed on the entire body part or on a portion of the body part. The primary purpose of an Alteration procedure is to improve the cosmetic appearance of a body part. It is found in the Medical and Surgical Section and is used in the Body Systems: Eye, Ear/Nose/Sinus, Mouth/Throat, Skin/Breast, Subcutaneous Tissue/Fascia, Anatomical Regions, General, and Anatomical Regions, Upper & Lower Extremities. Some of the most common and well-known cosmetic procedures are breast augmentations, facelifts, and liposuctions. The confusion comes into play when the procedure is not easily identified as either “cosmetically” or “medically” necessary.

One of the guidelines for Root Operations state, “In order to determine the appropriate root operation, the full definition of the root operation, as contained in the PCS Tables, must be applied (ICD-10 PCS Training Manual, 2013).” This causes a dilemma in choosing the correct root operation in some cases when it becomes necessary to determine if the procedure is being performed for medical or cosmetic reasons. Sometimes the distinction is difficult to ascertain. The coder must rely upon the diagnostic documentation of the physician and/or surgeon. In order to use the root operation Alteration the documentation must substantiate its use by indicating the procedure is being carried out for cosmetic reasons. Otherwise, one of the other medical root operations, such as, Extraction, Reposition, Resection, Repair, etc. becomes appropriate and must be used instead (ICD-10 PCS Training Manual, 2013).

ALTERATION—ROOT OPERATION “0”

WHAT TO EXPECT

1 Alteration—Root Operation

2 Coding Scenario

3 Spaced Repetition Sign-Up

4 Requests for Coding Topics

“The procedure is not

easily identified as

either cosmetically or

medically necessary.”

APRIL 2014

Volume 1 Issue 4

By Cynthia Brown, MBA, RHIT, CCS

www.cyntcodinghealthinformationservices.com

CCHIS, P.O. Box 3019, Decatur, GA 30031 404-992-8984 http://www.cyntcodinghealth informationserv ices.com Cynth ia@cyntcodinghealthinformat ionserv ices.com [phone ]

CODING YESTERDAY’S NOMENCLATURE TODAY®

When to Use the Root Operation “Alteration”

In ICD-10 PCS Coding

CODING NEWSLETTER FOR HEALTHCARE

CODING PROFESSIONALS

Page 2 Coding Yesterday’s Nomenclature Today

The patient is a 61-year-old female who presents with a complaint of constricted vision in both eyes secondary to drooping eyelids restricting reading and driving. On previous office exam, the patient was noted to have a severe ptosis with absence of lid crease and a poor levator function on both sides in addition to excess and redundant eyelid skin with edema. After discussing these findings with the patient and obtaining visual fields, taped and untaped, and confirming that a significant functional superior field defect was present in both eyes and after obtaining clinical photographs, the patient agreed to have bilateral blepharoptosis repair by external levator resection and bilateral blepharoplasty. The patient’s pre-operative diagnosis is bilateral upper eyelid lateral levator aponeurotic ptosis due to senescence and bilateral upper eyelid functional dermatochalasis. Without going into great detail describing the actual procedure let’s take a look at the selection of the ICD-10 PCS root operation for blepharoplasty. The coder may be tempted to use the root operation Alteration in this coding scenario, because the procedure “modifies the anatomical structure of a body part without affecting the function of the body part.” It does not, however, meet the second criteria for using the root operation; which is to “solely change the appearance of a body part for cosmetic reasons.” The PRINCIPAL purpose in this scenario is not to solely improve the appearance of the patient. The blepharoplasty and brow ptosis is considered MEDICALLY necessary because it is performed for medical reconstructive purposes validated by the documented visual impairment. Notice also, that the procedure is being performed on the upper eyelid. Blepharoplasty on the lower lids is considered COSMETIC and would use the root operation Alteration. Therefore, the correct root operation for the above-mentioned scenario would be repair “restoring to the extent possible, a body part to its normal anatomic structure and function. It is imperative that the coder assigns the appropriate code(s) based upon the diagnostic documentation provided in the health record. If the documentation is unclear or incomplete it is the responsibility of the coder to get clarification. Remember some surgical procedures can be performed for either MEDICAL or COSMETIC reasons and the coder should not make assumptions as to which one applies. Do not hesitate to query the physician.

www.cyntcodinghealthinformationservices.com

Blepharoptosis “drooping eyelids”

“The patient has

constricted vision in

both eyes secondary to

drooping eyelids

restricting reading and

vision.”

Coding Scenario

Coding Yesterday’s Nomenclature Today

SPACED REPETITION The presumption behind spaced repetition is simple. When we first learn a fact, the memory of it is fresh, but subject to change or it simply disappears. Each time we encounter that fact again, however, the memory becomes a more established part of our knowledge, especially if the encounters are spread out over time. In other words, exposing your mind to that same fact multiple times over weeks or months fixes it firmly in your brain. If you or your staff would like to receive facts pertaining to the ICD-10 CM/PCS nomenclature over the next months to assist them in mastering the code set—visit the CCHIS website and sign up. Participation is free. Leave your e-mail address and name. Spaced-out learning sessions will begin 05/01/2014 once a week.

HOW IS YOUR MEMORY?

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Coding

Yesterday’s Nomenclature

Today Coding Health Information Services ®

AHIMA approved ICD-10 CM/PCS

Trainer

“KEEPING THE MOMENTUM GOING” ALL THINGS CODING®

“Accurate and

complete coding is a

must in today’s

economically

challenged healthcare

environment.”

Page 4 Coding Yesterday’s Nomenclature Today

CCHIS Professional Affiliates

AHIMA GHIMA AHIMA approved ICD-10 CM/PCS

Trainer EDWOSB/WOSB VOSB SCORE Atlanta

CyntCoding Health Information Services P.O. BOX 3019 Decatur, GA 30031

Phone: 404-992-8984

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E-mail: cyntcoder@cyntcodinghealthinformationservices.com

Requests for Coding Topics E-mail your coding topics or request your FREE issue of the CCHIS Newsletter by visiting the website and leaving your contact information. You may also contact me at: cyntcoder@cyntcodinghealthinformationservices.com

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