A complete overview of basic Volume 3 procedure coding

1. INPATIENT
ICD-9-CM VOLUME 3

2. FORMAT OF VOLUME 3
 The format of Volume 3, Alphabetic Index and
Tabular List, follows the same format and
conventions that are used in Volume 1, Tabular List
of Diseases and Injuries, and Volume 2, Alphabetic
Index of Disease and Injuries.
 The procedural codes are used to code hospital
inpatient procedures.
 ICD-9-CM procedures codes are not used by
hospital outpatient departments or by physician
practices.
 Physicians and hospital outpatient services are
coded using Current Procedural Terminolgy(CPT)
for procedural coding.

3. FORMAT OF VOLUME 3
 The use of ICD-9-CM procedure codes is restricted
to the reporting of inpatient procedures by
hospitals. (Ref : CC 2008 1Q P.15)
 A hospital may still collect ICD-9-CM procedural
data but only for internal or non-claim-related
purposes.
 Volume 3 consists of 17 chapters. Most of these
chapters are classified by body system.
 It should be noted that Chapter 0 contains
procedures and interventions that represent new
technology.

4. VOLUME 3 TABLE OF CONTENTS
 0. Procedures and Interventions, Not Elsewhere classifiable(00)
 1. Operations on the Nervous System (01-05)
 2. Operations on the Endocrine System (06-07)
 3. Operations on the Eye (08-16)
 4. Operations on the Ear (18-20)
 5. Operations on the Nose, Mouth, and Pharynx (21-29)
 6. Operations on the Respiratory System (30-34)
 7. Operations on the Cardiovascular System (35-39)
 8. Operations on the Hemic and Lymphatic System (40-41)
 9. Operations on the Digestive System (42-54)
 10.Operations on the Urinary System (55-59)
 11.Operations on the Male Genital Organs (60-64)
 12.Operations on the Female Genital Organs (65-71)
 13.Obstetrical Procedures (72-75)
 14.Operations on the Musculoskeletal System (76-84)
 15.Operations on the Integumentary System (85-86)
 16. Miscellaneous Diagnostic and Therapeutic Procedures (87-99)

5. ALPHABETIC INDEX
 The location of procedures in the Alphabetic Index
can be found under the common name of a
procedure (e.g., appendectomy, hysterectomy).
However, procedures may be listed under the
general type of procedure with terminology such as
the following :
Insertion Incision Excision Clipping
Repair Implantation Examination Removal

6. OMIT CODE
 Omit code is an instructional note that is found only
in the Alphabetic Index and Tabular List of Volume3.
 This instruction denotes that no code is to be
assigned.
 The omit code instruction is generally found under
codes that are used for approaches and closures
and therefore may be integral to the operative
procedure.

7. CODE ALSO
 “Code also” is an instructional note found in Volume
3 that directs the coder to code an additional
procedure if it was performed.

8. ADJUNCT CODES
 Adjunct Codes are assigned as add-on codes to a
primary procedure to provide additional information
about the primary procedure performed. These
codes cannot be used alone and are assigned as
secondary procedure code.
 Codes 00.45 and 00.40 are adjunct vascular
system procedure codes. These codes cannot be
used alone and are used only to provide more
information about the procedure that was
performed.

9. UHDDS DEFINITION
Uniform Hospital Discharge Data Set (UHDDS)
definitions are used by acute care, short-term hospitals
to report inpatient data elements in standardized
manner. Definitions that pertain to the assignment of
procedure codes are presented in the following
sections.
PRINCIPAL PROCEDURE
A principal procedure is one that was performed for
definitive treatment rather than for diagnostic or
exploratory purposes or for treatment of a complication.
If two procedures appear to be principal, the one most
related to the principal diagnosis should be selected as
principal procedure.

10. SIGNIFICANT PROCEDURE
 A significant procedure is considered significant if it
 Is surgical in nature
 Carries a procedural risk
 Carries an anesthetic risk
 Requires specialized training
 It should be noted that a significant procedure does not
have to be performed in an Operative Room.
 Procedures can be done in the emergency room (ER)
before admission, at the patient’s bedside, in a
treatment room, or in an interventional radiology
department.
 These procedures can be easily missed because an
operative report describing the procedure may not have
been completed.

11. SIGNIFICANT PROCEDURE
 These procedures are documented with a brief, handwritten
note on the ER record or in a progress note or in a consultation
note.
 Consent for treatment may assist the coder in attempting to
verify a procedure, but not all procedures require consent
forms.
 A signed consent form doesn’t confirm that the procedure was
actually performed.
 A complete review of the entire health record is necessary to
ensure that all completed procedures have been coded.
 Other UHDDS data elements that must be coded include the
date of the procedure and the NPI (National Provider Identifier)
of the person who performed the procedure. It may be the
coder’s responsibility to abstract these data elements.

12. PROCEDURE CODES THAT SHOULD BE REPORTED
 Any procedures that affect payment or reimbursement must be
reported.
 Other procedures may be reported at a hospital’s discretion or in
accordance with hospital policy.
 Encoders(ICD9CM Coding Software) may also have special
popup notices that alert the coder about non-covered or limited
coverage OR procedures.
 After assigning procedure codes, the coder should review the
diagnosis codes to ensure the assignment of diagnosis codes
that support the performance of a procedure.
Example : If It was determined that lysis of peritoneal adhesion was sufficient to
warrant a procedure code in this male patient. It would make sense that a
diagnosis code should be assigned to identify the peritoneal adhesions.
Procedure : Lysis of Peritoneal Adhesions 54.59
Diagnosis : Peritoneal Adhesions 568.0

13. PROCEDURE CODES THAT SHOULD BE REPORTED
 The Centers for Medicare and Medicaid Services (CMS) has
categorized procedures into different classifications through the
Medicare Code Editor (MCE).
 The Medicare Code Editor is software that detects errors in coding on
Medicare Claims. For example, it would identify a male-only procedure
performed on a female patient.
 During a patient’s hospitalization, it may be necessary for a procedure to
be performed at an outside facility. This could be for reasons such as
the service may not be offered at the admitting hospital or equipment
may malfunction. The patient may be transported by ambulance to this
outside facility and after the procedure, returns for continued care at the
admitting hospital. In these cases, the admitting hospital may assign
procedure codes for services performed at the outside facility. The
admitting hospital also would include these charges on the hospital
bill, and the admitting hospital would reimburse the outside facility for
the procedure.

14. VALID OR PROCEDURE
 A Valid OR Procedure is a procedure that may
affect MS-DRG assignment.
 Designation of a procedure as a valid OR
procedure doesn’t mean that it must be performed
in the inpatient setting.
 Many surgical procedures can be safely performed
on an outpatient basis, and many third party payers
and/or insurance companies require that certain
surgical procedures be performed in an outpatient
setting. Repair of direct inguinal hernia is
designated as a valid OR procedure, but this
procedure is usually performed and billed as an
outpatient procedure.

15. NON-OR PROCEDURE AFFECTING MS-DRG ASSIGNMENT
 A procedure designated as “non-OR procedure affecting
MS-DRG assignment” is a procedure that may affect MS-
DRG assignment, even though the procedure is not
routinely performed in the OR.
 In some case, the procedure code 86.07, will make a
difference in MS-DRG assignment; in other cases, it will not.
 The patient was admitted with progressive CKD V. A VAD was implanted for
future hemodialysis. (585.5, 86.07)
In this case, the codes group to surgical MS-DRG:675, Kidney & Urinary
Tract Procedures without CC/MCC
 The Patient was admitted with primary liver cancer. It was decided to
implant a VAD for future chemotherapy (155.0, 86.07)
In this case, the codes group to medical MS-DRG 437, Malignancy of
Hepatobiliary System or Pancreas without CC/MCC.

16. NON-COVERED OR PROCEDURE
 Non-covered OR procedure codes are identified by
the Medicare Code Editor as procedures for which
Medicare does not provide reimbursement.
 Sterilization procedures are identified by the
Medicare. It is possible to assign an MS-DRG but
that does not guarantee payment.

17. LIMITED COVERAGE
 Limited Coverage procedures are identified by the
Medicare Code Editor as procedures covered under
limited circumstances.
 For transplant facility to obtain Medicare coverage
for organ transplantation, it must meet preapproved
guidelines. Criteria are set forth and updated in
Federal Register Notices.

18. SURGICAL HIERARCHY
 The MS-DRG grouper software (computer program
that assigns an MS-DRG), using diagnosis and
procedure codes, identifies whether a particular
patient falls into a medical MS-DRG or a surgical
MS-DRG.
 The MS-DRG grouper is able to determine which
procedure is most resource intensive and assigns
the procedure to that particular surgical MS-DRG.

19. SURGICAL HIERARCHY
In the above case, the patient was admitted and after
study was determined to have breast cancer of the right
upper outer quadrant (174.4). She also has a
comorbidities of congestive heart failure (428.0). The
principal procedure is one that is performed for definitive
treatment; in this case, that would be the modified radical
mastecotmy (85.43). The mastectomy is more resource
intensive than a breast biopsy. It is appropriate to code
the diagnostic breast biopsy (85.12) as an additional
procedure code.

20. SURGICAL HIERARCHY
In the above case, all codes are same, but the breast
biopsy is incorrectly sequenced as the principal
procedure instead of the mastectomy. Because of the
surgical hierarchy within the grouper, it groups to the
mastectomy MS-DRG, so the reimbursement and MS-
DRG assignment would be correct. Even if the grouper
will automatically arrange the codes to fit the surgical
hierarchy, the code should be sequenced as the principal
procedure on the basis of the UHDDS definition.

21. SURGICAL HIERARCHY
In the above case, a data entry error was made and
congestive heart failure was incorrectly sequenced as
the principal diagnosis, resulting in a 983 MS-DRG
assignment. Although MS-DRG 983 may be the correct
assignment in some cases, it is not appropriate in this
case, and the coder should review the entered codes.
In this case, the principal diagnosis combined with the
procedure codes resulted in the MS-DRG assignment.
If the data entry error had not been corrected before
billing, the facility would have been incorrectly
reimbursed.

22. BILATERAL PROCEDURES
 A bilateral procedure occurs when the same procedure
is performed on paired anatomic organs or tissues
(i.e., eyes, ears, joints such as shoulder or knee).
 According to CC 1988 1Q P.9, “when the same
procedures are performed bilaterally and ICD-9-CM
provides a single code that identifies the procedures as
bilateral, assign that code. When the same procedure is
performed bilaterally and ICD-9-CM does not provide a
code to identify that procedure as being performed
bilaterally, record the procedure code twice. When there
is difference in the procedure performed on one side as
opposed to the other side involving different code
assignments, report both codes.”

23. BILATERAL PROCEDURES
 The coding of bilateral procedures should be
addressed by facility policy.
 For major procedures such as joint
replacements, the coder must assign two codes.

24. OPERATIVE APPROACHES & CLOSURES
 An important convention in Volume 3 is the “Omit
code.”
 Main terms in the Alphabetic Index may be used to
identify incisions. If an incision is made only for the
purpose of performing further surgery, the
instruction “omit code” is given.

25. OPERATIVE APPROACHES & CLOSURES
 It is Coder’s responsibility to review the entire
operative report to determine the extent of the
procedure and to decide what should be coded.
 Closure of the operative wound is a routine part of
most surgical procedures, so it is not necessary to
code this separately. In some instances, a surgical
wound is not closed at the time of surgical
operation but is allowed to heal and will be closed
at a later date. In this case, a closure would be
added since it is like a “delayed type closure.”

26. CLOSED SURGICAL PROCEDURES
 As technology has advanced, procedures are
increasingly being performed through scopes
which are less invasive than open procedures.
This has resulted in quicker recoveries, shorter
hospital stays, a fewer complications.
 Common closed surgical approaches include
laparoscopic, thoracoscopic and arthroscopic
procedures.
 Closed procedures may be diagnostic and/or
therapeutic in nature.

27. CONVERSION TO OPEN PROCEDURE
 A surgical procedure may start with a closed
approach that may need to be converted to an open
procedure. V codes describe the conversion from a
closed surgical procedure to an open procedure.
These codes are found in the index under the main
term “Conversion.”
 In the case of conversion from closed to open, only
assign the open procedure code. Some reasons
for conversion to an open procedure include
adhesions, bleeding, technical difficulties due to
anatomic body structure and/or inflammatory
changes, and injury to an organ.

28. CONVERSION TO OPEN PROCEDURE
 “Until specific codes for laparoscopic and
thoracoscopic approaches can be created, the
codes for open approaches must be applied. Do
not assign a separate code for the laparoscopy or
thoracoscopy.” (CC 1992 3Q P.12)
 It may be the policy of some facilities to assign an
additional procedure code for the laparoscopy
(54.21) so that data can be collected on the number
of laparoscopic procedures performed.

29. ENDOSCOPIC APPROACHES
 Endoscopic examinations and procedures are
performed with an instrument that allows
examination of any cavity of the body through a
rigid or flexible scope. The scope usually inserted
into the body through an orifice or stoma. When a
colonoscopy is performed, the anus is the body
orifice that allows entry of the scope.
 As the scope is inserted and various parts of the
body are examined, the coder would not code every
body part that is viewed. The coder would code the
farthest site that was reached. If a procedure such
as a biopsy is performed, only the biopsy code is
assigned.

30. PLANNED & CANCELLED PROCEDURES
 If a patient’s procedure is cancelled prior to the time
that he or she presents to the hospital, no code will
be required because no services were provided, no
bill was generated, and there is no health record.
 If a patient presents to have a procedure
performed, but for some reasons the procedure has
cancelled, the principal diagnosis in this case is the
reason for why the patient was going to have the
procedure performed. If a complication arose that
resulted in the cancellation, a diagnosis code for
that condition would be assigned as a secondary
diagnosis. Also V codes describe the reason for
the cancellation.

31. PLANNED & CANCELLED PROCEDURES
 If a surgical procedure will be started that for
whatever reason cannot be completed. The
surgical procedure should be coded to the extend
that it was performed. These circumstances are
different from those surrounding a procedure that is
cancelled, in that the patient received anesthesia
and surgery was begun. No V codes are available
for these situations.

32. BIOPSY
 Biopsy is a very common diagnostic procedure that
is often performed before more definitive treatment
is provided.
 Biopsy is defined as “the removal of tissue followed
by pathologic examination to establish a precise
diagnosis.”
 Biopsies may be performed in a number of different
ways such as by
aspiration, brush, core, endoscopic, excisional, inci
sional, percutaneous, punch, shave, stereotactic, a
nd washing methods.
 Different codes may be assigned depending on the
biopsy method used.

33. BIOPSY
 Biopsies that are performed by endoscopy or
percutaneous aspiration are coded as “closed”
biopsies. (CC 1984 J-A P.3-4)
 An incisional approach for removal of tissue is
coded as an “open biopsy.” (CC 1984 J-A P.3-4)
 A patient may be undergoing an open abdominal
procedure while a percutaneous biopsy of the liver
is also performed. Biopsy of the liver would be
coded to percutaneous and not to open
biopsy, even though the abdominal cavity was open
at the time per (CC 1988 4Q P.12)

34. ROBOTIC ASSISTED SURGERY
 Robotic-assisted surgery is the most recent development in minimally
invasive surgery. This new technology is designed to enhance surgical
capabilities by facilitating the performance of complex surgery through
small incisions. Robotics requires the use of a surgical robot
(computerized system with a motorized construction, usually an
arm, capable of interacting with the environment).
 Note that although a computer console with 3-D imaging is used with
robotic assisted surgery, it is not the same as computer assisted
surgery (00.31-00.35, 00.39). Computer assisted surgery does not use
robotic arms, devices, or other systems to perform surgical tasks
(e.g., excision or resection.) A key difference of robotic-assisted
surgery over computer-assisted surgery is its ability to repeat identical
motions. Although robotic-assisted surgeries may use computer
assistance, computer-assisted surgeries do not use robots. Computer-
assisted surgery (CAS) is any computer-based procedure that uses
technologies such as 3D imaging and real-time sensing in the
planning, execution and follow-up of surgical procedures. CAS allows
for better visualization and targeting of sites as well as improved
diagnostic abilities.

35. ROBOTIC ASSISTED SURGERY
 Robotic assistance is classified on the basis of the
approach used, such as open (17.41), laparoscopic
(17.42), percutaneous (17.43), endoscopic
(17.44), thoracoscopic (17.45), and other and unspecified
(17.49). Examples of procedures performed with robotic
assistance include prostatectomies, hysterectomies, and
cholecystectomies.

36. Prakash.A. – CPC
Senior Inpatient Medical Coder
RevenueMed India Pvt Ltd
E-mail : prakasha25@gmail.com
THIS PRESENTATION DEDICATED TO
ALL MY IP CODING FRIENDS RMI 