肌肉骨骼系統編碼原則分享 - nhi.gov.tw‚Œ肉骨骼... · 髕骨半脫位外側放鬆術lateral release，處置編碼？ A：1.Left Patella lateral tilting 指膝蓋向腿外側傾斜，建議

肌肉骨骼系統編碼原則分享

唐一岑

1050727

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骨折診斷編碼原則

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• 外傷性

• 非外傷性 pathological (due to neoplastic/ osteoporosis/ specified disease)

• 其他

發生

原因

• Displaced or Non-Displaced

• Closed or Open

• Comminuted / transverse…..等type

骨折

類型

• 骨折側性、特殊解剖部位,如: neck、left

• 骨折部位特定分類，如： Neer classifiaction -- Proximal humeral fracture, surgical neck, four-part S42.24-

• Initial / subsequent / sequela (代碼第7碼呈現)

其他

附加外因碼

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https://www.newhealthadvisor.com/Different-Types-of-Fractures.html

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Nontraumatic- see Fracture, pathological

Pathological fracture

-- due to neoplastic

編碼：腫瘤代碼+M84.5-，依入院主因選擇主要診斷。

-- osteoporosis

編碼：依osteoporosis type有合併代碼呈現。

-- specified disease

編碼：M84.6-，Code also underlying condition。

Nontraumatic fracture

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7th character “A” 編碼原則

“A”, initial encounter While the patient is receiving active treatment for the condition.

Examples of active treatment are:

surgical treatment, emergency department encounter, and

evaluation and continuing treatment by the same or a different

physician.

AHA coding clinic 2015 Q1, p.4

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7th character “D” 編碼原則

“D” subsequent encounter is used for encounters after the patient has received active

treatment of the condition and is receiving routine care for the

condition during the healing or recovery phase.

Examples of subsequent care are:

cast change or removal, an x-ray to check healing status of fracture,

removal of external or internal fixation device, medication

adjustment, other aftercare and follow up visits following treatment

of the injury or condition. The aftercare Z codes should not be used

for aftercare for conditions such as injuries or poisonings, where 7th

characters are provided to identify subsequent care. For example,

for aftercare of an injury, assign the acute injury code with the 7th

character “D” (subsequent encounter). AHA coding clinic 2015 Q1, p.4

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7th character “S” 編碼原則

“S”, sequela is for use for complications or conditions that arise as a direct result

of a condition, such as scar formation after a burn. The scars are

sequelae of the burn. When using 7th character “S”, it is necessary

to use both the injury code that precipitated the sequela and the

code for the sequela itself The “S” is added only to the injury code,

not the sequela code. The 7th character “S” identifies the injury

responsible for the sequela. The specific type of sequela (e.g. scar)

is sequenced first, followed by the injury code.


骨折處置編碼注意事項

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移位性骨折(Displaced fracture)

-- Reduction of fracture：手術方式Reposition

非移位性骨折(Nondisplaced fracture)，依實際執行處置

編碼

-- 使用Pin 固定：手術方式Insertion

-- 使用Cast固定：手術方式Immobilization

(外在裝置物置放章節Placement)

guideline B3.16

處置編碼注意事項

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Internal Fixation Device

http://www.mysportphysio.com/Injuries-Conditions/Hip/Hip-

Issues/Adult-Femur-Fractures/a~4388/article.html

• Internal Fixation

Device, Intramedullary

http://www.mysportphysio.com/Injuries-Conditions/Hip/Hip-

Issues/Adult-Femur-Fractures/a~4388/article.html

處置編碼注意事項

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External Fixation Device

• Monoplanar

• Ring

• Hybrid

http://www.mysportphysio.com/Injuries-Conditions/Hip/Hip-Issues/Adult-Femur-

Fractures/a~4388/article.html

Comminuted fracture

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Q：What is the correct diagnosis code assignment for

comminuted fracture of the left distal tibia and fibula?

Would the fracture site or the type of fracture take

precedence?

A：Assign code S82.392-, Other fracture of lower end of left

tibia, for comminuted fracture of distal tibia, and code

S82.832-, Other fracture of upper and lower end of left

fibula, for commmutcd fracture of distal fibula.


Fracture of bimalleolus

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Q：診斷-- Fracture of bimalleolus ankle, right

手術-- open reduction with internal fixation with plate and

screws

請問手術是編0SSF04Z(ankle)? 還是0QSG04Z +

0QSJ04Z ?

A：建議編碼0QSG04Z + 0QSJ04Z。

Fracture of bimalleolus ankle是指

1. medial malleolus fracturetibia

2. lateral malleolus fracturefibula

詳見病管協會諮詢網#1942 http://orthoinfo.aaos.org/topic.cfm?topic=a00391

ORIF of femur, left 0QS906Z

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titanium elastic nails

鈦合金彈性髓內釘

http://www.aaos.org/news/aaosnow/aug09/clinical6.asp

Fracture of femoral neck

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診斷：Left femoral neck fracture with Garden type III

手術：Bipolar hemiarthroplasty with versys bipolar,

Cup 45 mm, neck 28+0, stem : cemented 11 # stem.

ICD-10-CM：S72.002A

ICD-10-PCS：0SRS019

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http://www.nhi.gov.tw/query/Query4_Pic.aspx?No=FBHBA3000TZ1

Joint replacement

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Root operation為“Replacement”

切除關節為關節置換術必經過程，不需分開編碼。

當執行雙側關節時，須編兩個處置代碼(左側+

右側)。

Hip Joint replacement

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詳見健保署網站

Hip Joint replacement

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以第6位碼表示軸承表面所使用替代物的類型材質。

以第7位碼表示是否以骨泥來固定此裝置物。

Revision of hip arthroplasty

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Q：The patient was admitted for revision of right hip arthroplasty.

The right ceramic head and acetabular liner were replaced due to

excessive wear. Is this procedure coded as a revision or

replacement?

A：0SRR03A Replacement of r’t hip, femoral surface with ceramic,

uncemented

0SUA09Z Supplement right hip, acetabular surface with liner, open

0SP90JZ Removal of synthetic substitute from right hip joint, open

0SP909Z Removal of liner from right hip joint, open


Revision of hip arthroplasty續

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When the components of a replaced joint are removed and new

components (i.e., femoral head, acetabular surface, femoral surface,

and liner) are inserted, codes are assigned for the placement of new

components and for the removal of the old components.

A revision should be reported when the objective of the procedure is

to correct the position or function of a previously placed device,

without taking out and putting a whole new device in its place.

Examples of revision surgery include re-cementing of a prosthetic joint

or adjusting a pacemaker lead.

A code for supplement is assigned for placement of the new liner. The

liner is placed to physically reinforce the replaced joint; it is not

functioning as a replaced body part.


Revision of knee arthroplasty

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Q：A patient with painful right total knee arthroplasty presents for

revision of the arthroplasty. The previous components were

removed and new tibial and femoral components were inserted

and cemented into place. Should this be coded as a revision or

replacement procedure?

A：0SRC0J9 Replacement of right knee joint with synthetic

substitute, cemented, open

0SPC0JZ Removal of synthetic substitute from right knee joint,

open


Medial meniscus rupture

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Q：診斷-- Right medial meniscus peripheral tear

手術-- Arthroscopic partial medial menisectomy

A：ICD-10-CM：S83.221A

ICD-10-PCS：0SBC4ZZ

http://www.mendmyknee.com/meniscus-injuries/meniscus-

repair-surgery.php

Patella lateral tilting

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Q：Left Patella lateral tilting 髕骨半脫位外側放鬆術lateral release，處置編碼？

A：1.Left Patella lateral tilting 指膝蓋向腿外側傾斜，建議編碼M25.862(Other specified joint disorders, left knee)

2.此個案手術Arthroscopic lateral release for patella tilting,建議編碼0SND4ZZ(Release Left Knee Joint,

Percutaneous Endoscopic Approach)。

詳見病管協會諮詢網#2187

Core decompression

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Q：Core decompression編碼:0QC60ZZ ，但骨科醫師執行

Core decompression是用電鑽在股骨處打洞減壓讓血管新生，未取出死骨，

A：1.Core decompression建議可參考實際手術的內容，再選取適當的Root operation，例如有些個案的記錄會提及The necortic bone in the cystic lesion was curretage and

removed，此時Root operation 則可選取Extirpation。

2.依據提問，Core decompression手術執行方式若是在股骨上鑽洞減壓讓血管新生，並未將死骨取出，因手術是為了達到減壓目的，故建議Root operation選擇

Release。

詳見病管協會諮詢網#1935 詳見病管協會諮詢網#1892

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Fusion編碼注意事項

融合手術是藉由固定裝置、骨移植或其它方法，將關節部位連結在一起，Body system限定於關節(Upper Joints & Lower Joints) 。

頸椎及胸椎Body system為Upper Joints

腰椎及薦椎Body system為Lower Joints

第7位碼辨識

此融合術是由椎體前側或後側進入

融合處是位於脊柱的前側或後側

Anterior Column

Posterior Column

Fusion編碼注意事項

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第4位碼身體部位(body part)區分頸、胸、

腰椎與薦尾椎關節及單節或多節椎關節及

等等，手術的身體部位不同時要分開編碼。

同一個身體部位有多個脊椎關節做融合術

時，使用不同的裝置物則分開編碼。

例如: Fusion of the C-5/6 and C7-T1

應分別編碼。

第4位碼

身體部位不同

例如: Fusion of C-4/5 with bone graft

and C-5/6 with Interbody cage 應分別編碼

裝置物

不同

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Fusion_Device選擇

Fusion procedures of the spine

同一椎關節使用兩種以上裝置物選取原則。

Interbody

Fusion device

Substitute

Device選取 Autologous

Tissue

Nonautologous

Tissue Synthetic

(+) (+) (+) (+) Interbody

Fusion device

(-) (+) (+) (+) Autologous

Tissue

(-) (-) (+) (+) Nonautologous

Tissue

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Fusion_Qualifier選擇

常見術式 Fusion site Qualifier Values

ALIF Anterior cervical fusion

Vertebral body 0 Anterior Approach,

Anterior Column

Posterior Spinal

fusion

pedicle、lamina、facet、transverse

process, or “gutter”

fusion

1 Posterior Approach,

Posterior Column

PLIF

TLIF Vertebral body J

Posterior Approach,

Anterior Column

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Posterior Lumbar Interbody Fusion with

cage and bone graft

Decompressive laminectomy

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Q：The patient presents for decompressive lumbar laminectomy.

The surgeon performed an open complete decompressive

laminectomy of L3-L4. What is the appropriate root operation,

“Excision” or “Release”?

A：0INB0ZZ, Release lumbar nerve, open approach

Decompressive laminectomy is done to release pressure and

free up the spinal nerve root. The appropriate root operation is

“Release.”


Decompressive foraminotomy/laminectomy

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Q：診斷- lumbar disc herniation, foraminal stenosis and

degenerative scoliosis 手術- lateral microdiscectomy, L2-L3 and L3- L4, using

intraoperative fluoroscopy. During surgery, disc material

displacing the L2-L4 nerve roots was excised. Foraminotomy was

then accomplished by resecting portions of the lamina to

decompress the region. Should the decompressive

foraminotomy/laminectomy be coded along with the discectomy?

A：0SB20ZZ Excision of lumbar vertebral disc, open approach

01NB0ZZ Release lumbar nerve, open approach


PLIF , discectomy

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Q：posterior lumbar interbody fusion with discectomy. Is the

discectomy coded separately or is it considered inherent to the

fusion?

A：Discectomy is almost always performed at the same time as

spinal fusion surgery. Typically, a fusion involves partial removal

of the disc. If the provider performs a discectomy with spinal

fusion, it should be coded as excision of disc. If, however, the

provider documents “total discectomy,” it should be coded as a

disc resection.


Internal fixation used with spinal fusion

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Q：0RG40A0, for interbody fusion of C7 and T1 with placement of Vectra

Synthes plate and screws. (CC, Q1 2013, p.29)

0SG007I and 0SG00AJ for a 360-degree interbody and autologous

bone graft spinal fusion with placement of pedicle screws. (CC, Q3

2013, p.25)

Please clarify whether a separate code is assigned for internal

fixation/instrumentation(rods, screws, plates etc.) used with spinal

fusion.

A：ICD-10-PCS general guideline B3.Ib, clarifies that components of a

procedure specified in the root operation definition and explanation are

not coded separately. The root operation for fusion states “that body

part is joined together by fixation device, bone graft, or other means.”

Therefore, the fixation (rods, plates, screws) is included in the fusion

root operation, and no additional code is assigned.


Percutaneous lumbar vertebroplasty

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Q：Percutaneous lumbar vertebroplasty, is the use of cement

considered a device?

A：0QU03JZ Supplement lumbar vertebra with synthetic

substitute, percutaneous

“cement” is consistent with the definition of device.

The correct root operation for vertebroplasty is supplement


Percutaneous lumbar vertebroplasty

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Percutaneous lumbar kyphoplasty

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http://uspshealthcare.com/services/kyphoplasty/

0QS03ZZ+0QU03JZ

Dynamic pedicle screw system

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http://www.zimmer.com/medical-

professionals/products/spine/dynesys-dynamic-stabilization-

system.html

編碼疑義及案例說明(1)

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回覆：1.同一案例已在疾病分類諮詢網中提出詢問，建議待協會回覆釋義。

2.此個案合併有crush injury，建議可另加編代碼。


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回覆：Z code不應使用在外傷或毒性引起病況的後續照護，應在第

7碼呈現照護時機。

The aftercare Z codes should not be used for aftercare for conditions

such as injuries or poisonings, where 7th characters are provided to

identify subsequent care

參閱 AHA coding clinic 2015 Q1, p.4


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回覆：手術若為Decompressive laminectomy，decompressive

laminectomy is done to release pressure and free up the spinal nerve

root. The appropriate root operation is “Release.”

建議編碼0IN, Release nerve



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回覆：建議編碼

0SUA09Z Supplement right hip, acetabular surface with liner, open


謝謝聆聽敬請指教

Q&A

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Documents

肌肉骨骼系統編碼原則分享 - nhi.gov.tw‚Œ肉骨骼... · 髕骨半脫位外側放鬆術lateral release，處置編碼？ A：1.Left Patella lateral tilting 指膝蓋向腿外側傾斜，建議