ortho devices

david.reecerndavid.reecern
in CDI Talk Archive
For those of you doing dual coding or ICD-10 queries, just wondering how you are dealing with ortho devices when the providers are documenting the brand name of an implanted device and not "ceramic, metal..." Our providers are pushing back on getting queries for this. Thanks

Comments

  • tiffany.andrastiffany.andras
    edited April 2016
    Our doc's use a template for the operate reports, I went to them and they have added the type into the template to state metal, ceramic ect.

    If not could you complete a standard keystroke with the dictation that is part of the record, so when they dictate the brand name it populates what is present in the use of this device.

    Tiffany Andras LPN CCS CCDS

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    I have been told that we can use a reference sheet to determine what the device is made of once the brand name is stated in the record.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


  • lsipos@monument.healthlsipos@monument.health
    edited April 2016
    Katy

    Are you taking about a reference sheet you/your institution created from what you see being used by your surgeons?

    Juli

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    Yes. But it is also my understanding that this information could be looked up by coding (for ex: from the manufacturers site). There also is a 'Device Key' in the back of the PCS book for reference that may help in some cases.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


  • ssalinasssalinas
    edited April 2016
    The provider does not have to provide the specifics re surfaces for devices. Any source can be used to obtain this information. Often the implant log provides it. If it does not, the internet will. The same is true for stents, etc.

    Sharon Salinas, CCS
    Health Information Management
    Barlow Respiratory Hospital
    2000 Stadium Way, Los Angeles CA 90026
    Tel: 213-250-4200 ext 3336
    FAX: 213-202-6490
    ssalinas@barlow2000.org

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    Thanks Sharon, Its good to hear that I am not the only one who understood it this way.

    As a side note, I do think this is going to be an important aspect of CDI for those of us who are responsible for all retro queries. We will be the query 'gatekeepers' and that will require a lot of additional knowledge. With duel coding we are running into requests for clarification for I-10 information because specific I-10 language isn’t used. This (of course) is valid in MANY circumstances however, recently we have had questions that really are NOT the responsibility of the physician (at least in my understanding). This is especially true for PCS. For example, the MD's do not use the terms High/low/mid for amputations and we were asked to query for this info. However, my understanding is that this is something coding can determine as long as we have documentation like distal/proximal/etc. The physician doesn’t necessarily have to use the exact term used in I-10, the coder/CDI needs good knowledge of anatomy (as well as their resources) in order to interpret this description into I-10 terminology. The other obvious example is root operations. The physician is unlikely to use excision and resection correctly all the time. Or how about extirpation??? ;-). I am sure we will see this again and again and again.... Coding and CDI needs to brush up on A&P as well as their clinical understanding of procedures in order to accurately account for these procedures. Also, it will take time for coding to become more proficient with resources in the I-10 book (many of us are all too encoder-dependent).
    I think it's very important that we make every effort not to overwhelm providers with queries when we don’t absolutely have to but I can already see that we will be asked to do so. If CDI doesn’t have good understanding of the clinical information as well as what is appropriate for coding to extrapolate from the record, things could get really interesting....

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


  • laura.ringlandlaura.ringland
    edited April 2016
    Speaking of the amputation, I had a AKA and I did query for high/low/mid. There was no documentation regarding the femur and that is a pretty long bone. Do you think I was wrong to ask?


  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    Nope, you do need to query if they don’t say which part. But they don’t have to use the terms high/mid/low

    These definitions of what is high/low/mid are located in the I-10 PCS manual

    Ex:
    Thumb, finger, or toe
    Qualifier 0 Complete: Amputation at the metacarpophalangeal/metatarsal-phalangeal joint
    Qualifier 1 High: Amputation anywhere along the proximal phalanx
    Qualifier 2 Mid: Amputation through the proximal interphalangeal joint or anywhere along the middle phalanx
    Qualifier 3 Low: Amputation through the distal interphalangeal joint or anywhere along the distal phalanx

    Upper arm and upper leg
    Qualifier 1 High: Amputation at the proximal portion of the shaft of the humerus or femur
    Qualifier 2 Mid: Amputation at the middle portion of the shaft of the humerus or femur
    Qualifier 3 Low: Amputation at the distal portion of the shaft of the humerus or femur



    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


  • david.reecerndavid.reecern
    Sharon, is there something from CMS that covers this or a coding guideline/ clinic? Our coding department is the one saying we need to query for specifics if the provider uses the brand name of the device. Thanks


    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Monday, August 10, 2015 12:10 PM
    To: Reece, David
    Subject: RE: [cdi_talk] ortho devices

    The provider does not have to provide the specifics re surfaces for devices. Any source can be used to obtain this information. Often the implant log provides it. If it does not, the internet will. The same is true for stents, etc.

    Sharon Salinas, CCS
    Health Information Management
    Barlow Respiratory Hospital
    2000 Stadium Way, Los Angeles CA 90026
    Tel: 213-250-4200 ext 3336
    FAX: 213-202-6490
    ssalinas@barlow2000.org

    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Friday, August 07, 2015 7:34 AM
    To: Salinas, Sharon
    Subject: [cdi_talk] ortho devices

    For those of you doing dual coding or ICD-10 queries, just wondering how you are dealing with ortho devices when the providers are documenting the brand name of an implanted device and not "ceramic, metal..." Our providers are pushing back on getting queries for this. Thanks
    ---
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  • ssalinasssalinas
    I may be interpreting the CC below too liberally. However the manufacturing sticker should be in the record, so the info can be pulled from that. In I-9, there is no need to query for type if the info is not provided per CC below.

    For I-10, I can find no specific reference regarding where this info can or cannot be obtained. Katy said her PCS book had a listing in it. 3M's Encoder also has a listing available if you click on device at the top of the category so I would assume you can get the info elsewhere as long as the specific name of the device is in the medical record.
    **************************************************************************
    Hip replacement bearing surfaces
    Coding Clinic, Fourth Quarter 2005 Page: 110 to 113 Effective with discharges: October 1, 2005

    The specific code for the type of bearing surface should only be assigned when the information is available in the health record, from either the provider's documentation or the manufacturer's sticker. These codes would not be used, if the information were not available.
    *************************************************************************

    This is how I interpret it anyway.
    Sharon Salinas, CCS
    Health Information Management
    Barlow Respiratory Hospital
    2000 Stadium Way, Los Angeles CA 90026
    Tel: 213-250-4200 ext 3336
    FAX: 213-202-6490
    ssalinas@barlow2000.org


    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Monday, August 10, 2015 1:58 PM
    To: Salinas, Sharon
    Subject: RE: [cdi_talk] ortho devices

    Sharon, is there something from CMS that covers this or a coding guideline/ clinic? Our coding department is the one saying we need to query for specifics if the provider uses the brand name of the device. Thanks


    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Monday, August 10, 2015 12:10 PM
    To: Reece, David
    Subject: RE: [cdi_talk] ortho devices

    The provider does not have to provide the specifics re surfaces for devices. Any source can be used to obtain this information. Often the implant log provides it. If it does not, the internet will. The same is true for stents, etc.

    Sharon Salinas, CCS
    Health Information Management
    Barlow Respiratory Hospital
    2000 Stadium Way, Los Angeles CA 90026
    Tel: 213-250-4200 ext 3336
    FAX: 213-202-6490
    ssalinas@barlow2000.org

    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Friday, August 07, 2015 7:34 AM
    To: Salinas, Sharon
    Subject: [cdi_talk] ortho devices

    For those of you doing dual coding or ICD-10 queries, just wondering how you are dealing with ortho devices when the providers are documenting the brand name of an implanted device and not "ceramic, metal..." Our providers are pushing back on getting queries for this. Thanks
    ---
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    You are receiving this message as a member of CDI Talk as: ssalinas@barlow2000.org If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12538092.1a48df689a710d0d4e067dc4c85563ef@hcprotalk.com
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    HCPro, Inc., 75 Sylvan Street, Danvers MA 01923


    ---
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  • david.reecerndavid.reecern
    Unfortunately we don't have the stickers scanned into our electronic record and what is in the op report device listing doesn't state the material.


    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Tuesday, August 11, 2015 12:49 PM
    To: Reece, David
    Subject: RE: [cdi_talk] ortho devices

    I may be interpreting the CC below too liberally. However the manufacturing sticker should be in the record, so the info can be pulled from that. In I-9, there is no need to query for type if the info is not provided per CC below.

    For I-10, I can find no specific reference regarding where this info can or cannot be obtained. Katy said her PCS book had a listing in it. 3M's Encoder also has a listing available if you click on device at the top of the category so I would assume you can get the info elsewhere as long as the specific name of the device is in the medical record.
    **************************************************************************
    Hip replacement bearing surfaces
    Coding Clinic, Fourth Quarter 2005 Page: 110 to 113 Effective with discharges: October 1, 2005

    The specific code for the type of bearing surface should only be assigned when the information is available in the health record, from either the provider's documentation or the manufacturer's sticker. These codes would not be used, if the information were not available.
    *************************************************************************

    This is how I interpret it anyway.
    Sharon Salinas, CCS
    Health Information Management
    Barlow Respiratory Hospital
    2000 Stadium Way, Los Angeles CA 90026
    Tel: 213-250-4200 ext 3336
    FAX: 213-202-6490
    ssalinas@barlow2000.org


    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Monday, August 10, 2015 1:58 PM
    To: Salinas, Sharon
    Subject: RE: [cdi_talk] ortho devices

    Sharon, is there something from CMS that covers this or a coding guideline/ clinic? Our coding department is the one saying we need to query for specifics if the provider uses the brand name of the device. Thanks


    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Monday, August 10, 2015 12:10 PM
    To: Reece, David
    Subject: RE: [cdi_talk] ortho devices

    The provider does not have to provide the specifics re surfaces for devices. Any source can be used to obtain this information. Often the implant log provides it. If it does not, the internet will. The same is true for stents, etc.

    Sharon Salinas, CCS
    Health Information Management
    Barlow Respiratory Hospital
    2000 Stadium Way, Los Angeles CA 90026
    Tel: 213-250-4200 ext 3336
    FAX: 213-202-6490
    ssalinas@barlow2000.org

    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Friday, August 07, 2015 7:34 AM
    To: Salinas, Sharon
    Subject: [cdi_talk] ortho devices

    For those of you doing dual coding or ICD-10 queries, just wondering how you are dealing with ortho devices when the providers are documenting the brand name of an implanted device and not "ceramic, metal..." Our providers are pushing back on getting queries for this. Thanks
    ---
    CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.

    You are receiving this message as a member of CDI Talk as: ssalinas@barlow2000.org If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12538092.1a48df689a710d0d4e067dc4c85563ef@hcprotalk.com
    ---
    Copyright 2013
    HCPro, Inc., 75 Sylvan Street, Danvers MA 01923


    ---
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    ---
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    ---
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  • katysuegood@gmail.comkatysuegood@gmail.com
    I read it the same Sharon. I also think this is consistent with how coders have always functioned when it comes to PCS coding. The PCS book does have a device key and aggregation table (at least mine does?) but it doesn’t include everything. It does name many device names...
    Ex: "REVERSE " shoulder prosthesis = Synthetic substitute, reverse ball and socket for replacement in upper joints
    "PRESTIGE" cervical disk = synthetic substitute
    "SAPIEN" transcatheter aortic valve = zooplastic tissue in heart and great vessels
    "TRIFECTA" valve (aortic) = zooplastic tissue in heart and great vessels


    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Tuesday, August 11, 2015 10:49 AM
    To: Kathryn Good
    Subject: RE: [cdi_talk] ortho devices

    I may be interpreting the CC below too liberally. However the manufacturing sticker should be in the record, so the info can be pulled from that. In I-9, there is no need to query for type if the info is not provided per CC below.

    For I-10, I can find no specific reference regarding where this info can or cannot be obtained. Katy said her PCS book had a listing in it. 3M's Encoder also has a listing available if you click on device at the top of the category so I would assume you can get the info elsewhere as long as the specific name of the device is in the medical record.
    **************************************************************************
    Hip replacement bearing surfaces
    Coding Clinic, Fourth Quarter 2005 Page: 110 to 113 Effective with discharges: October 1, 2005

    The specific code for the type of bearing surface should only be assigned when the information is available in the health record, from either the provider's documentation or the manufacturer's sticker. These codes would not be used, if the information were not available.
    *************************************************************************

    This is how I interpret it anyway.
    Sharon Salinas, CCS
    Health Information Management
    Barlow Respiratory Hospital
    2000 Stadium Way, Los Angeles CA 90026
    Tel: 213-250-4200 ext 3336
    FAX: 213-202-6490
    ssalinas@barlow2000.org


    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Monday, August 10, 2015 1:58 PM
    To: Salinas, Sharon
    Subject: RE: [cdi_talk] ortho devices

    Sharon, is there something from CMS that covers this or a coding guideline/ clinic? Our coding department is the one saying we need to query for specifics if the provider uses the brand name of the device. Thanks


    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Monday, August 10, 2015 12:10 PM
    To: Reece, David
    Subject: RE: [cdi_talk] ortho devices

    The provider does not have to provide the specifics re surfaces for devices. Any source can be used to obtain this information. Often the implant log provides it. If it does not, the internet will. The same is true for stents, etc.

    Sharon Salinas, CCS
    Health Information Management
    Barlow Respiratory Hospital
    2000 Stadium Way, Los Angeles CA 90026
    Tel: 213-250-4200 ext 3336
    FAX: 213-202-6490
    ssalinas@barlow2000.org

    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Friday, August 07, 2015 7:34 AM
    To: Salinas, Sharon
    Subject: [cdi_talk] ortho devices

    For those of you doing dual coding or ICD-10 queries, just wondering how you are dealing with ortho devices when the providers are documenting the brand name of an implanted device and not "ceramic, metal..." Our providers are pushing back on getting queries for this. Thanks
    ---
    CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.

    You are receiving this message as a member of CDI Talk as: ssalinas@barlow2000.org If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12538092.1a48df689a710d0d4e067dc4c85563ef@hcprotalk.com
    ---
    Copyright 2013
    HCPro, Inc., 75 Sylvan Street, Danvers MA 01923


    ---
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  • katysuegood@gmail.comkatysuegood@gmail.com
    Are they going in a paper record? You may want to consider talking to HIM about scanning this info in. It should be in the record somewhere? Are they including the device name in their documentation? I think you can just look that information up. But I definitely would love to hear more coders speak to this issue.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Tuesday, August 11, 2015 10:59 AM
    To: Kathryn Good
    Subject: RE: [cdi_talk] ortho devices

    Unfortunately we don't have the stickers scanned into our electronic record and what is in the op report device listing doesn't state the material.


    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Tuesday, August 11, 2015 12:49 PM
    To: Reece, David
    Subject: RE: [cdi_talk] ortho devices

    I may be interpreting the CC below too liberally. However the manufacturing sticker should be in the record, so the info can be pulled from that. In I-9, there is no need to query for type if the info is not provided per CC below.

    For I-10, I can find no specific reference regarding where this info can or cannot be obtained. Katy said her PCS book had a listing in it. 3M's Encoder also has a listing available if you click on device at the top of the category so I would assume you can get the info elsewhere as long as the specific name of the device is in the medical record.
    **************************************************************************
    Hip replacement bearing surfaces
    Coding Clinic, Fourth Quarter 2005 Page: 110 to 113 Effective with discharges: October 1, 2005

    The specific code for the type of bearing surface should only be assigned when the information is available in the health record, from either the provider's documentation or the manufacturer's sticker. These codes would not be used, if the information were not available.
    *************************************************************************

    This is how I interpret it anyway.
    Sharon Salinas, CCS
    Health Information Management
    Barlow Respiratory Hospital
    2000 Stadium Way, Los Angeles CA 90026
    Tel: 213-250-4200 ext 3336
    FAX: 213-202-6490
    ssalinas@barlow2000.org


    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Monday, August 10, 2015 1:58 PM
    To: Salinas, Sharon
    Subject: RE: [cdi_talk] ortho devices

    Sharon, is there something from CMS that covers this or a coding guideline/ clinic? Our coding department is the one saying we need to query for specifics if the provider uses the brand name of the device. Thanks


    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Monday, August 10, 2015 12:10 PM
    To: Reece, David
    Subject: RE: [cdi_talk] ortho devices

    The provider does not have to provide the specifics re surfaces for devices. Any source can be used to obtain this information. Often the implant log provides it. If it does not, the internet will. The same is true for stents, etc.

    Sharon Salinas, CCS
    Health Information Management
    Barlow Respiratory Hospital
    2000 Stadium Way, Los Angeles CA 90026
    Tel: 213-250-4200 ext 3336
    FAX: 213-202-6490
    ssalinas@barlow2000.org

    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Friday, August 07, 2015 7:34 AM
    To: Salinas, Sharon
    Subject: [cdi_talk] ortho devices

    For those of you doing dual coding or ICD-10 queries, just wondering how you are dealing with ortho devices when the providers are documenting the brand name of an implanted device and not "ceramic, metal..." Our providers are pushing back on getting queries for this. Thanks
    ---
    CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.

    You are receiving this message as a member of CDI Talk as: ssalinas@barlow2000.org If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12538092.1a48df689a710d0d4e067dc4c85563ef@hcprotalk.com
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    HCPro, Inc., 75 Sylvan Street, Danvers MA 01923


    ---
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    ---
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    HCPro, Inc., 75 Sylvan Street, Danvers MA 01923


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  • ssalinasssalinas
    edited April 2016
    It's me again...

    I have worked at many facilities both as an employee and contract. I think I can safely say all expected coders to get the info somewhere as long as the type was provided somewhere in the record be it the procedure reports, stickers or procedure logs. This also applied to stents and other devices inserted.

    In the past, this could wait until final coding was done. However with I-10, this info is required to assign the procedure code. The stickers should be in the 'hard chart' while the patient is in-house. I agree with Katy that they should be scanned into the EMR but the scanning is often done after discharge so that won't help concurrent CDI/coding. Perhaps this could be discussed with the various department/service heads to require the device name be included in the op report/template?

    Sharon Salinas, CCS
    Health Information Management
    Barlow Respiratory Hospital
    2000 Stadium Way, Los Angeles CA 90026
    Tel: 213-250-4200 ext 3336
    FAX: 213-202-6490
    ssalinas@barlow2000.org


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