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The Administration section consists of infusions, injections and
transfusions, in addition to other interrelated procedures such as irrigation
and tattooing. It is a part of the Medical and Surgical-related Section.
Procedures in this section depict a diagnostic or therapeutic substance
given to the patient and begin with a first character of 3.
Three root operations are used in the Administration section:
0=Introduction which is the putting in or on a therapeutic, diagnostic,
nutritional, physiological, or prophylactic substance except blood or blood
products. The root operation Introduction is used with the Body System
(E) Physiological Systems and Anatomical Regions.
1=Irrigation which is the putting in or on a cleansing substance. The root
operation Irrigation is used with the Body Systems (C) Indwelling Device
and (E) Physiological Systems and Anatomical Regions.
2=Transfusion which is the putting in blood or blood products. The root
operation Transfusion is used with the Body System (0) Circulatory.
A valid code in the Administration section is comprised of seven characters
which include the following:
Section
Body System
Root Operation
Body System/Region
Approach
Substance
Qualifier
THE ADMINISTRATION SECTION
WHAT TO EXPECT
1 The Administration Section
2 Trigger Point Injections
3 Documentation Issues
4 Requests for Coding Topics
January 2016
Volume 3 Issue 1
By Cynthia Brown MBA, RHIT, CCS
Gain Knowledge of Medical Coding Through E-Learning
CCHIS, P.O. Box 3019, Decatur, GA 30031 404-992-8984 Gain Knowledge of Medical Coding Through E -Learning Cynth ia@cyntcodinghealthinformat ionserv ices.com [phone]
CODING YESTERDAY’S NOMENCLATURE TODAY®
CODING TRIGGER POINT INJECTIONS USING
THE ADMINISTRATION SECTION OF ICD-10 PCS
CODING NEWSLETTER FOR HEALTHCARE
CODING PROFESSIONALS
Page 2 Coding Yesterday’s Nomenclature Today
Trigger points are painful areas in muscles, nerves, ligaments, joint
capsules, tendons and related soft tissue. They are typically caused by
injury, inflammation, connective tissue disease, and chronic infection. It
may become medically necessary to relieve spasms and pain through the
use of prophylactic substances. Such substances (6th
character of the
procedure code) may be a (an):
3=Anti-inflammatory
B=Local anesthetic
G=Other Therapeutic Substance
N=Analgesics, Hypnotics, Sedatives
To code trigger point injections, the coder must begin by using the 3E0
characters which represents Administration (3); Physiological Systems and
Anatomical Regions (E); and Introduction (0). Some trigger point injection
procedure codes include:
Soft Tissue
3E0133Z; 3E013BZ; 3E013GC; 3E013NZ
Muscle
3E0233Z; 3E023BZ; 3E023GC; 3E023NZ
Nerve
3E0T33Z; 3E0T3BZ; 3E0T3GC
Joint
3E0U33Z; 3E0U3BZ; 3E0U3GC; 3E0U3NZ
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“Joint Injection”
Trigger Point Injections
Trigger Point Injections
Coding Yesterday’s Nomenclature Today
Documentation Issues Look at the sample procedure for a trigger point injection below. When using
the ICD-10 PCS nomenclature the operative report would be considered
grossly inadequate.
OPERATION: Trigger Point Injection.
ANESTHESIA: Local and sedation.
COMPLICATIONS: None.
DESCRIPTION OF PROCEDURE: The procedure risks, hazards and
alternatives were discussed with the patient and a proper consent was obtained.
The area over the myofascial spasm was prepped with alcohol utilizing sterile
technique. After isolating it between two palpating fingertips a 25-gauge 5"
needle was placed in the center of the myofascial spasms and a negative
aspiration was performed. Then 4 cc of Marcaine 0.5% was injected into each
trigger point. The patient tolerated the procedure well without any apparent
difficulties or complications. They were feeling relief by the block had set.
When using the ICD-10 PCS nomenclature, the physician should clearly
document the following to assist the coder in assigning the most
appropriate/correct procedure code:
Location (body part) of injection(s)
The type of drug (substance & qualifier) injected
Method (approach) of the injection
A specific diagnosis to support “medical necessity” of the injection
AHIMA Approved ICD-10 CM/PCS
Trainer
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
E-Fax: 678-805-4919
E-mail: [email protected]
Requests for coding topics: E-mail your coding topics or view FREE issues of the CCHIS Newsletter by visiting the website. You may also purchase your coding e-books from the site. Contact me at: [email protected].
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CODING YESTERDAY’S NOMENCLATURE TODAY® Gain Knowledge of Medical Coding Through E-Learning
