Healthcare Solutions ICD-10-PCS ExpressLearn … · ICD-10-PCS Physical Rehabilitation © 2015 Anthelio Healthcare Solutions Inc. Proprietary and confidential. All Rights Reserved

ICD-10-PCSPhysical Rehabilitation

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The ICD-10-PCS Official Guidelines for Coding and Reporting 2016 do not provide us with any specific direction when coding physical rehabilitation cases. Knowing this, we then must use the information found in the introduction to the Guidelines which states, “The instructions and conventions of the classification take precedence over guidelines.”

When looking up the term “Rehabilitation” in the index of ICD-10-PCS we find the following:

Rehabilitation see Speech Assessment, Rehabilitation F00

see Motor Function Assessment, Rehabilitation F01

see Activities of Daily Living Assessment, Rehabilitation F02

see Speech Treatment, Rehabilitation F06

see Motor Treatment, Rehabilitation F07

see Activities of Daily Living Treatment, Rehabilitation F08

see Hearing Treatment, Rehabilitation F09

see Cochlear Implant Treatment, Rehabilitation F0B

see Vestibular Treatment, Rehabilitation F0C

see Device Fitting, Rehabilitation F0D

see Caregiver Training, Rehabilitation F0F

All the codes are in Section F, Physical Rehabilitation and Diagnostic Audiology, so let’s take a look at the characters.

Character 1, Section: F is the value that represents Physical Rehabilitation and Diagnostic Audiology as the first character. Physical Rehabilitation and Diagnostic Audiology contains character definitions for characters 2-6 which are unlike the other sections in ICD-10-PCS.

Character 2, Section Qualifier: Specifies whether the procedure is a rehabilitation or diagnostic audiology procedure.

Character 3, Root Type: Defines the general procedure root type. There are currently fourteen (14) root types in the Physical Rehabilitation and Diagnostic Audiology Section. The Root Types will fit into one of four broad categories:

1. Treatment: Use of specific activities or methods to develop, improve and/or restore the performance of necessary functions, compensate for dysfunction and/or minimize debilitation 2. Assessment: Includes a determination of the patient’s diagnosis when appropriate, need for treatment, planning for treatment, periodic assessment and documentation related to these activities 3. Fitting(s): Design, fabrication, modification, selection and/or application of splint, orthosis, prosthesis, hearing aids and/or rehabilitation device 4. Caregiver Training: Educating caregiver with the skills and knowledge used to interact with and assist the patient

Character 4, Body System and Region: Defines the body system or body region studied, which may be combined, where applicable.

Character 5, Type Qualifier: This character further specifies the procedure type.

Character 6, Equipment: This character specifies the equipment used, if any. This is an exception to the rule that in ICD-10-PCS, equipment used to assist in the performance of the procedure is not coded.

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Character 7, No Qualifier: This character is a qualifier, and is not specified in the Physical Rehabilitation and Diagnostic Audiology Section. Currently the only value choice available for this character is: Z – None.

Let’s work with a scenario that would fall under category Treatment.

Scenario: Inpatient rehabilitation, patient receiving wound care treatment of left calf ulcer, down to the muscle, using pulsatile lavage. F08L5BZ

Let’s break down the character selections as we build our code.


ICD-10-PCS Table

Section F Physical Rehabilitation and Diagnostic Audiology

Section Qualifier 0 Rehabilitation

Type 8 Activities of Daily Living Treatment: Exercise or activities to facilitate functional competence for activities of

daily living

Body System / Region Type Qualifier Equipment Qualifier

D Integumentary System –

Head and Neck

F Integumentary System –

Upper Back / Upper Extremity

G Integumentary System –

Lower Back / Lower Extremit y

H Integumentary System –

Whole Body

J Musculoskeletal System –

Head and Neck

K Musculoskeletal System –

Upper Back / Upper Extremity

L Musculoskeletal System –

Lower Back / Lower Extremity

M Musculoskeletal System –

Whole Body

B Physical Agents

C Mechanical

D Electrotherapeutic

E Orthosis

F Assistive, Adaptive

Supportive or Protective

U Prosthesis Y Other Equipment Z None

Z None5 Wound Management

ICD-10-PCS Index

Activities of Daily Living Treatment, Rehabilitation F08



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Character 1, Section: F Physical Rehabilitation and Diagnostic Audiology

Character 2, Section Qualifier: 0 Rehabilitation

Character 3, Root Type: 8 Activities of Daily Living Treatment: Exercise or activities to facilitate functional competence for activities of daily living

Character 4, Body System and Region: L Musculoskeletal System -Lower Back / Lower Extremity - This was a calf ulcer down to muscle tissue, and is therefore deeper than the Integumentary System

Character 5, Type Qualifier: 5 Wound Management – Treatment of the calf ulcer

Character 6, Equipment: B Physical Agents – The wound is being treated by the lavage liquid, a physical agent, not by mechanical means such as debridement

Character 7, No Qualifier: Z None

Let’s work with a scenario that would fall under category Assessment.

Scenario: Inpatient rehabilitation, patient receiving articulation and phonology assessment using spectrograph F00Z9QZ

Again, let’s break down the character selections as we build our code.


The first three characters given to the coder in the ICD-10-PCS Index

{

ICD-10-PCS Index

Assessment Speech see Speech Assessment, Rehabilitation F00

Speech Assessment F00



Type 0 Speech Assessment: Measurement of speech and related functions


Z None K Audiovisual

P Computer

Q Speech Analysis

Y Other Equipment

Z None

Z None9 Articulation/Phonology

ICD-10-PCS Table



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Character 3, Root Type: 0 Speech Assessment: Measurement of speech and related functions

Character 4, Body System and Region: Z None - None are applicable

Character 5, Type Qualifier: 9 Articulation/Phonology – The definition found in the Definitions section of the ICD-10-PCS Codebook is, “Measures speech production.”

Character 6, Equipment: Q Speech Analysis - To understand why this selection is made we need to understand what a spectrograph is, “A sound spectrograph is a laboratory instrument that displays a graphical representation of the strengths of the various component frequencies of a sound as time passes.”


Next, let’s work with a scenario that would fall under category Fitting(s).

Scenario: Inpatient rehabilitation, patient receiving individual fitting of moveable brace, right knee. F0DZ6EZ

ICD-10-PCS Table

Once more, let’s break down the character selections as we build our code.

The first three characters given to the coder in the ICD-10-PCS Index

{

ICD-10-PCS Index

Device Fitting F0DZ



Type D Device Fitting: Fitting of a device designed to facilitate or support achievement of a higher level


Z None E Orthosis

F Assistive, Adaptive,


U Prosthesis

Z None

Z None6 Dynamic Orthosis

7 Static Orthosis

8 Prosthesis

9 Assistive, Adaptive,


Devices



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Finally, let’s work with a scenario that would fall under category Caregiver Training.

Scenario: Caregiver training in feeding, no special equipment used F0FZ2ZZ




Character 3, Root Type: D Device Fitting: Fitting of a device designed to facilitate or support achievement of a higher level of function Character 4, Body System and Region: Z None - None are applicable

Character 5, Type Qualifier: 6 - Dynamic Orthosis The information found in the Definitions section of the ICD-10-PCS Codebook is, “Includes/Examples: Includes customized and prefabricated splints, inhibitory casts, spinal and other braces, and protective devices allows motion through transfer of movement from other body parts or by use of outside forces.”

Character 6, Equipment: E - Orthosis An “orthosis” is an orthopedic appliance or apparatus, such as a brace, used to support or assist movement of a weak or injured part of the body; or to align, prevent, or correct deformities; or to improve function of movable parts of the body.


The first four characters given to the coder in the ICD-10-PCS Index {

ICD-10-PCS Index

Caregiver Training F0FZ



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Type F Caregiver Training: Training in activities to support patient’s optimal level of function


Z None E Orthosis

F Assistive, Adaptive,


U Prosthesis

Z None

Z None0 Bathing/Showering Technique

1 Dressing

2 Feeding and Eating

3 Grooming/Personal Hygiene

4 Bed Mobility

5 Transfer

6 Wheelchair Mobility

7 Therapeutic Exercise

8 Airway Clerance Techniques

9 Wound Management

B Vocational Activities and

Functional Community or

Work Reintegration Skills

C Gait Training/Functional Ambulation

D Application, Proper Use and Care of

Devices

F Application, Proper Use and Care of

Orthoses

G Application, Proper Use and Care of

Prosthesis

H Home Management

ICD-10-PCS Table

For a final time, let’s break down the character selections as we build our code.



Character 3, Root Type: F Caregiver Training: Training in activities to support patient's optimal level of function Character 4, Body System and Region: Z None - None are applicable

Character 5, Type Qualifier: 2 Feeding and Eating ICD-10-PCS Definition: Exercise or activities to facilitate setting up food, selecting and using utensils and tableware, bringing food or drink to mouth, cleaning face, hands, and clothing, and management of alternative methods of nourishment

Character 6, Equipment: Z None


Note: The coder must be guided by documentation in the medical record of each individual case to make the correct code selections.

The first four characters given to the coder in the ICD-10-PCS Index {


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Healthcare Solutions ICD-10-PCS ExpressLearn … · ICD-10-PCS Physical Rehabilitation © 2015 Anthelio Healthcare Solutions Inc. Proprietary and confidential. All Rights Reserved