Question

Case 2

This 78-year-old male is status post hip replacement 6 days ago. He is now at the Sunny Hill Rehabilitation Center, where we are currently working on physical and occupational therapy so that he will be able to live at home and function normally.

This patient is working on being able to groom and dress himself. He is very anxious to able to use the shower but would be unable to get into his tub unassisted. today we worked on walking to the closet/dresser, walking back to bed and getting his clothes on assisted. He did very well, though he tired easily and we did not get to the bathroom to brush teeth or wash up. The assessment took 60 minutes.

ICD 10 PCS Code assignment:

Answer 1

ICD 10 is the 10th revision of the international classification of the diseases where there will be a list of medical problem which are given by World Health Organisation.

PCS is the procedure classification system where there will be a list of in patient procedure will be coded and maintained by the medicaid and medicare services along with 3M information management.

The purpose of this ICD 10 PCS to make easier in collecting the data about the procedure,for the payment,to support the electronic health for the patients.

Structure of ICD 10 PCS

This ICD 10 PCS will have some coding for the all inpatient procedure with seven alphanumeric characters.

1.Section: this deals with the body of the procedure or the category.For example medical surgical,obstetrics,placement,administration,osteopathic,physical rehabilitation,mental health,substance abuse etc.

2.Body system: This involves the anatomical region or the physiological system that is involved in the procedure.For example: nose,mouth,throat,heart,bones etc.

3.Root operation: This is how the procedure is done or the main aim of the procedure.For example: drainage,abortion,excision etc.

4.Body part: This is the specific part of the body where the procedure is involved.For example: lower arm,upper leg,right breast etc.

5.Approach: The technique used in the procedure or the technique used to relieve the discomfort.For example:endoscopic,percutaneous etc.

6.Device: This is the equipment or the instrument use or left the body to remove the discomfort.For example:prosthesis,grafts etc.

7.Qualifier: This is an additional attribute to the procedure which can be specified if they are using.

Coming to the present case the patient is now taking the physical and occupational rehabilitation after the hip replacement,so the ICD 10 PCS for this case is

Z96.64 for hip replacement

Y80.1 for physical rehabilitation

Z57.0 for occupational rehabilitation