codificação em oftalmologia congresso...- restritas as possibilidades para o 4º caractere (body...

Codificação em Oftalmologia

Lara Queirós

3 de Março de 20179º Congresso da A.M.A.C.C. - Santiago do Cacém

- Restritas as possibilidades para o 4º caractere (body part) nos slides 48-51, uma vez que os procedimentos envolvem as pálpebras superiores. 21Mar2017

- Corrigido código encurtamento (gralha)

- Revisto código injecção intravítrea ocriplasmina/outras substâncias - exemplo do conflito frequente entre a descrição do método/objectivo do procedimento: codificar ambos? A clarificar em sede própria.

- Para efeitos de simplificação e sistematização, os procedimentos foram dissecados em elementos que, não raramente, se realizam concomitantemente na cirurgia (ex: facotrabeculectomia, vitrectomia com injecção de óleo de silicone).

- Dado estarmos no início de um percurso, é de esperar que haja omissões e incorrecções. São bem-vindos todos os comentários para a melhoria da codificação.

[email protected]

ICD-10-PCSICD-10-CM

ICD-10-PCS

Section 0 Medical and Surgical

Body System

Root Operation

Body Part

Approach

Device

Qualifier

ICD-10-PCS

Section 0 Medical and Surgical

Body System 8 Eye

Root Operation

Body Part

Approach

Device

Qualifier

ICD-10-PCS

Section

Body System

Root Operation - O PROBLEMA DO DIA-A-DIA

Body Part

Approach

Device

Qualifier

Root OperationsDestruction

Physical eradication of all or a portion of a body part by the direct use of energy, force, or a destructive agent.

None of the body part is physically taken out.

Root OperationsDestruction

Root OperationsExcision | Resection | Extraction

Excision Cutting out or off, without replacement, a portion of a body part.

The qualifier DIAGNOSTIC is used to identify excision procedures that are biopsies.

Resection Cutting out or off, without replacement, all of a body part

Extraction Pulling or stripping out or off all or a portion of a body part by the use of force

The qualifier DIAGNOSTIC is used to identify extraction procedures that are biopsies

Root OperationsDrainage | Extirpation

Drainage Taking or letting out fluids and/or gases from a body part.

The qualifier DIAGNOSTIC is used to identify drainage procedures that are biopsies.

Extirpation Taking or cutting out solid matter from a body part

The solid matter may be an abnormal byproduct of a biological function or a foreign body; it may be imbedded in a body part or in the lumen of a tubular body part. The solid matter may or may not have been previously broken into pieces

Root OperationsFragmentation

Breaking solid matter in a body part into pieces.

Physical force (e.g., manual, ultrasonic) applied directly or indirectly is used to break the solid matter into pieces. The solid matter may be an abnormal byproduct of a biological function or a foreign body. The pieces of solid matter are not taken out.

Root OperationsBypass | Dilation | Occlusion | Restriction

Altering the route of passage of the contents of a tubular body part.

Rerouting contents of a body part to a downstream area of the normal route, to a similar route and body part, or to an abnormal route and dissimilar body part. Includes one or more anastomoses, with or without the use of a device

Root OperationsBypass | Dilation | Occlusion | Restriction

Dilation Expanding an orifice or the lumen of a tubular body part

The orifice can be a natural orifice or an artificially created orifice. Accomplished by stretching a tubular body part using intraluminal pressure or by cutting part of the orifice or wall of the tubular body part

Occlusion Completely closing an orifice or the lumen of a tubular body part Explanation: The orifice can be a natural orifice or an artificially created orifice

Restriction Partially closing an orifice or the lumen of a tubular body part Explanation: The orifice can be a natural orifice or an artificially created orifice

Root Operation

Putting in or on biological or synthetic material that physically reinforces and/or augments the function of a portion of a body part.

The biological material is non-living, or is living and from the same individual. The body part may have been previously replaced, and the Supplement procedure is performed to physically reinforce and/or augment the function of the replaced body part.

Supplement | Replacement | Insertion | Change | Removal | Revision

Root Operation

Intracorneal Ring Segments (ICRS)

L.I.O. fáquica Artisan® Artiflex® L.I.O. fáquica ICL™

L.I.O. fáquica Acrysof® Cachet®


Root Operation

Putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part

The body part may have been taken out or replaced, or may be taken out, physically eradicated, or rendered nonfunctional during the Replacement procedure. A REMOVAL procedure is coded for taking out the device used in a previous replacement procedure


Root Operation

Insertion Putting in a nonbiological appliance that monitors, assists, performs, or prevents a physiological function but does not physically take the place of a body part

Change Taking out or off a device from a body part and putting back an identical or similar device in or on the same body part without cutting or puncturing the skin or a mucous membrane

All CHANGE procedures are coded using the approach EXTERNAL

Removal Taking out or off a device from a body part

If a device is taken out and a similar device put in without cutting or puncturing the skin or mucous membrane, the procedure is coded to the root operation CHANGE. Otherwise, the procedure for taking out a device is coded to the root operation REMOVAL

Revision Correcting, to the extent possible, a portion of a malfunctioning device or the position of a displaced device

Revision can include correcting a malfunctioning or displaced device by taking out or putting in components of the device such as a screw or pin


Root OperationAlteration

Modifying the anatomic structure of a body part without affecting the function of the body part.

Principal purpose is to improve appearance.

Root OperationInspection

Visually and/or manually exploring a body part

Visual exploration may be performed with or without optical instrumentation. Manual exploration may be performed directly or through intervening body layers

Root OperationRelease

Freeing a body part from an abnormal physical constraint by cutting or by the use of force.

Some of the restraining tissue may be taken out but none of the body part is taken out.

Root OperationTransfer

Moving, without taking out, all or a portion of a body part to another location to take over the function of all or a portion of a body part

The body part transferred remains connected to its vascular and nervous supply

Root OperationReposition

Moving to its normal location, or other suitable location, all or a portion of a body part

The body part is moved to a new location from an abnormal location, or from a normal location where it is not functioning correctly. The body part may or may not be cut out or off to be moved to the new location

Root OperationReattachment

Putting back in or on all or a portion of a separated body part to its normal location or other suitable location.

Vascular circulation and nervous pathways may or may not be reestablished.

Root OperationRepair

Restoring, to the extent possible, a body part to its normal anatomic structure and function.

Used only when the method to accomplish the repair is not one of the other root operations.

ICD-10-PCS

Section

Body System

Root Operation

Body Part

Approach

Device

Qualifier

Body Part

Right upper eyelid Left upper eyelid

Right lower eyelid Left lower eyelid

Body Part

Right upper eyelid Left upper eyelid

Right lower eyelid Left lower eyelid

Levator palpebrae superioris muscleSuperior tarsal plate

Orbicularis oculi muscleLateral canthus

Medial canthusInferior tarsal plate

Body PartExtraocular muscleLacrimal gland

Lacrimal duct

Body PartExtraocular muscleLacrimal gland

Lacrimal ductLacrimal punctumLacrimal canaliculusLacrimal sacNasolacrimal duct

Body Part

Pupil

ÍrisRetinal Vessel

Cornea

Retina

Lens

Vitreous

ChoroidAnterior chamber

Sclera

Eye

Conjunctiva

Body Part

Conjunctiva

Pupil

ÍrisRetinal Vessel

Cornea

Retina

Lens

Vitreous

ChoroidAnterior chamber

Sclera

MaculaOptic disc

Plica semilunaris

EyePosterior chamberCiliary body

Body PartFluxo do Humor Aquoso

Approach

0 Open

3 Percutaneous

7 Via Natural or Artificial Opening

8 Via Natural or Artificial Opening Endoscopic

X External

Device

“A device is coded only if a device remains after the procedure is completed.”

7 Autologous Tissue Substitute

K Nonautologous Tissue Substitute

J Synthetic Substitute

0 Synthetic Substitute, Intraocular Telescope - Implantable Miniature Telescope™ (IMT)

0 Drainage device

C Extraluminal device

D Intraluminal device

5 Epiretinal Visual Prosthesis

1 Radioactive Element - Brachytherapy seeds

3 Infusion device

Qualifier

X Diagnostic

Z No Qualifier

3 Nasal cavity

4 Sclera

Os problemas do dia-a-dia

ICD-10-PCS

Section

Body System

Root Operation - MÉTODO e/ou OBJECTIVO?

Body Part

Approach

Device

Qualifier


Destruction? Bypass? Drainage?

destruction > iris > percutaneous?...


bypass > anterior chamber?...



drainage > eye > external > no device > no qualifier


!

drainage > eye > external > no device > no qualifier

Vias lacrimais

Dacriocistorrinostomia 081 (XY) 0J3bypass > lacrimal duct > open > synthetic substitute > nasal cavity

Sondagem das vias lacrimais 087 (XY) 7ZZdilation > lacrimal duct > via natural or artificial opening > no device > no qualifier

Reconstrução de canalículos 08U (XY) 0JZsupplement > lacrimal duct > via natural or artificial opening > synthetic substitute > no qualifier

Entubação bicanalicular

Vias lacrimais

Colocação de plug perfurado 087 (XY) 7DZdilation > lacrimal duct > via natural or artificial opening > intraluminal device > no qualifier

Colocação plug não perfurado 08L (XY) 7DZocclusion > lacrimal duct > via natural or artificial opening > intraluminal device > no qualifier

Oculoplástica

Excisão de lesão pálpebra 08B (NPQR) XZZexcision > eyelid > external > no device > no qualifier

Reparação de laceração palpebral 08Q (NPQR) XZZ repair > eyelid > external > no device > no qualifier

Blefaroplastia 080 (NPQR) XZZ / 08B (NPQR) XZZalteration > eyelid > external > no device > no qualifierexcision > eyelid > external > no device > no qualifier

Implante de peso de ouro na pálpebra 08U (NP) 0JZsupplement > eyelid > open > synthetic substitute > no qualifier

Tarsorrafia 08Q (NPQR) XZZ ?repair > eyelid > external > no device > no qualifier

Oculoplástica

Encurtamento da aponevrose/do elevador da pálpebra 08B (NP) 3JZexcision > eyelid > open > no device > no qualifier

Ptose

Oculoplástica

Suspensão frontal 08U (NP) 3JZsupplement > eyelid > percutaneous > synthetic substitute > no qualifier

Ptose

Oculoplástica

Suspensão frontal 08U (NP) 3JZsupplement > eyelid > percutaneous > synthetic substitute > no qualifier

Oculoplástica

Reinserção dos retractores da pálpebra inferior 08S (NPQR) 0ZZreposition > eyelid > open > no device > no qualifier

Tira tarsal 08S (NPQR) 0ZZreposition > eyelid > open > no device > no qualifier

Tarsotomia transversa 08S (NPQR) 0ZZreposition > eyelid > open > no device > no qualifier

Ectropion Entropion

Órbita

Enucleação com implante orbitário e conformador 08R (01) 0JZreplacement > eye > open > synthetic substitute > no qualifier

Evisceração com implante orbitário e conformador 08R (01) 0JZreplacement > eye > open > synthetic substitute > no qualifier

Órbita

Head and Facial Bones

Descompressão orbitária 0NB (PQ) 0ZZexcision > orbit > open > no device > no qualifier

Glaucoma

Ciclofotocoagulação 085 (01) XZZdestruction > eye > external > no device > no qualifier

Glaucoma

Trabeculectomia 081 (23) 3Z4bypass > anterior chamber > percutaneous > no device > sclera

Glaucoma

Válvula de Ahmed 081 (23) 3J4bypass > anterior chamber > percutaneous > synthetic substitute > sclera

EX-Press® Mini Glaucoma Shunt 081 (23) 3J4bypass > anterior chamber > percutaneous > synthetic substitute > sclera

Ahmed®

EX-Press®

Válvula de Ahmed 081 (23) 3J4bypass > anterior chamber > percutaneous > synthetic substitute > sclera

EX-Press® Mini Glaucoma Shunt 081 (23) 3J4bypass > anterior chamber > percutaneous > synthetic substitute > sclera

iStent® Trabecular Micro-Bypass Stent 081 (23) 3J4bypass > anterior chamber > percutaneous > synthetic substitute > sclera

Glaucoma

Esclerectomia profunda não penetrante com Esnoper clip 081 (23) 3J4bypass > anterior chamber > percutaneous > no device > sclera

Glaucoma

Glaucoma

Viscocanalostomia ?dilation > ...

Canalostomia ?dilation > …

Estrabismo

Ressecção (resection) 08B (LM) 0ZZexcision > extraocular muscle > open > no device > no qualifier

Avanço / Plicatura / Tuck / Harada-Ito 08S (LM) 0ZZreposition > extraocular muscle > open > no device > no qualifier

Recuo (recession) 08S (LM) 0ZZreposition > extraocular muscle > open > no device > no qualifier

Miopexia retroequatorial (fio de Cuppers) 08Q (LM) 0ZZreposition > extraocular muscle > open > no device > no qualifier

Suturas ajustáveis 08S (LM) 0ZZreposition > extraocular muscle > open > no device > no qualifier

Estrabismo

Transposição 08X (LM) 0ZZtransfer > extraocular muscle > open > no device > no qualifier

Estrabismo

Colocação de espaçador 08U (LM) 0JZsupplement > extraocular muscle > open > synthetic substitute > no qualifier

Desbridamento 08N (LM) 0ZZrelease > extraocular muscle > open > no device > no qualifier

Aplicação de toxina botulínica 3E0C3GC Administration > Physiological Systems and Anatomical Regions

introduction > eye > percutaneous > other therapeutic substance > other substance

Córnea

Transplante de córnea/Queratoplastia penetrante 08R (89) 3KZreplacement > cornea > external > nonautologous tissue substitute > no qualifier

Colocação de queratoprótese 08R (89) 3JZreplacement > cornea > external > synthetic substitute > no qualifier

Autoenxerto de córnea 08R (89) 37Zreplacement > cornea > external > autologous tissue substitute > no qualifier

S.A.L.K. / D.A.L.K. 08R (89) XKZreplacement > cornea > external > nonautologous tissue substitute > no qualifier

D.S.E.K./D.M.E.K. 08R (89) 3KZreplacement > cornea > percutaneous > nonautologous tissue substitute > no qualifier

Córnea

Transplante de córnea/Queratoplastia penetrante 08R (89) 3KZreplacement > cornea > external > nonautologous tissue substitute > no qualifier

Colocação de queratoprótese 08R (89) 3JZreplacement > cornea > external > synthetic substitute > no qualifier

Autoenxerto de córnea 08R (89) 37Zreplacement > cornea > external > autologous tissue substitute > no qualifier

S.A.L.K. / D.A.L.K. 08R (89) XKZreplacement > cornea > external > nonautologous tissue substitute > no qualifier

D.S.E.K./D.M.E.K. 08R (89) 3KZreplacement > cornea > percutaneous > nonautologous tissue substitute > no qualifier

Remoção de suturas da córnea 8E09XY8 Other procedures > Physiological Systems and Anatomical Regions

other procedures > head and neck region > external > other method > suture removal

Córnea

Aplicação de membrana amniótica 08U (89) XKZsupplement > cornea > external > nonautologous tissue substitute > no qualifier

Aplicação de lente de contacto 08U (89) XJZsupplement > cornea > external > synthetic substitute > no qualifier

Excisão de pterigium com autoenxerto de células límbicas 08R (ST) X7Zreplacement > conjunctiva > external > autologous tissue substitute > no qualifier

Córnea

Segmentos corneanos 08U (89) XJZsupplement > cornea > external > synthetic substitute > no qualifier

Crosslinking do colagénio corneano 08Q (89) XZZrepair > cornea > external > no device > no qualifier

E.D.T.A. 08C (89) XZZextirpation > cornea > external > no device > no qualifier

Refractiva

L.A.S.I.K. 085 (89) XZZdestruction > cornea > external > no device > no qualifier

Implante de LIO ICL® 08U (01) 3JZsupplement > eye > percutaneous > synthetic substitute > no qualifier

Implante de LIO Artisan®/Artiflex® 08U (01) 3JZsupplement > eye > percutaneous > synthetic substitute > no qualifier

Iridectomia 08B (CD) 3ZZexcision > iris > percutaneous > no device > no qualifier

Administration > Physiological Systems and Anatomical Regions

Lavagem de hifema 3E1C38Zirrigation > eye > percutaneous > irrigating substance > no qualifier

Câmara Anterior

Paracentese diagnóstica da câmara anterior 089 (23) 3ZXdrainage > anterior chamber > percutaneous > no device > diagnostic

Câmara Anterior

Facoemulsificação + aspiração de catarata + L.I.O. 08R (JK) 3JZreplacement > lens > percutaneous > synthetic substitute > no qualifier

Facoemulsificação + aspiração de catarata 08D (JK) 3ZZextraction > lens > percutaneous > no device > no qualifier

Inserção secundária de L.I.O. 08R (JK) 3JZreplacement > lens > percutaneous > synthetic substitute > no qualifier

Cristalino

Revisão de L.I.O. de câmara posterior 08W (JK) 3JZrevision > lens > percutaneous > synthetic substitute > no qualifier

Explante de L.I.O. de câmara posterior 08P (JK) 3JZremoval > lens > percutaneous > synthetic substitute > no qualifier

Troca de LIO 082 (01) XYZchange > eye > external > other device > no qualifier

Cristalino

Lise de sinéquias posteriores 08N (CD) 3ZZrelease > iris > percutaneous > no device > no qualifier

Redução de hérnia de íris 08Q (89) XZZreposition > iris > percutaneous > no device > no qualifier

Vitrectomia anterior 08B (45) 3ZZexcision > vitreous > percutaneous > no device > no qualifier

Sutura de córnea 08Q (89) XZZrepair > cornea > external > no device > no qualifier

Cristalino

Sinéquias posteriores

Hérnia de íris

Extracção de fragmentos de catarata segmento posterior 08C (45) 3ZZextirpation > vitreous > percutaneous > no device > no qualifier

Cristalino

Indentação escleral 08U (01) 0JZsupplement > eye > open > synthetic substitute > no qualifier

Vitrectomia via pars plana 08T (45) 3ZZresection > vitreous > percutaneous > no device > no qualifier

Endolaser/Crioterapia 085 (EF) 3ZZdestruction > retina > percutaneous > no device > no qualifier

Retinotomia 08B (EF) 3ZZexcision > retina > percutaneous > no device > no qualifier

Pelagem de MER/VRP/ILM 08N (EF) 3ZZrelease > retina > percutaneous > no device > no qualifier

Retina e Vítreo

Vitrectomia via pars plana com substituição do vítreo 08R (45) 3JZreplacement > vitreous > percutaneous > synthetic substitute > no qualifier

Extracção de silicone 08P (01) 3JZremoval > eye > percutaneous > synthetic substitute > no qualifier

Retina e Vítreo

Implante intravítreo de Ozurdex® | Retisert® | Iluvien® 08H (01) 33Zinsertion > eye > percutaneous > infusion device > no qualifier

Iluvien®

Ozurdex®

Retisert®

Retina e Vítreo

Vitreólise enzimática com ocriplasmina - Jetrea® 08N (EF) 3ZZ e/ou? 3E0C3TZrelease > retina > percutaneous > no device > no qualifierintroduction > eye > percutaneous > destructive agent > no qualifier

Retina e Vítreo

Administration > Physiological Systems and Anatomical Regions

Injecção intravítrea de triancinolona 3E0C33Z introduction > eye > percutaneous > anti-inflammatory > no qualifier

Injecção intravítrea de ceftazidima | vancomicina 3E0C329introduction > eye > percutaneous > anti-infective > other anti-infective

Injecção intravítrea de bevacizumab - Avastin® 3E0C3GCintroduction > eye > percutaneous > other therapeutic substance > other substance

Injecção intravítrea de ranibizumab - Lucentis® 3E0C3GCintroduction > eye > percutaneous > other therapeutic substance > other substance

Injecção intravítrea de aflibercept - Eylea® 3E0C3GCintroduction > eye > percutaneous > other therapeutic substance > other substance

e/ou 08Q (EF) 3ZZ ?repair > retina > percutaneous > no device > no qualifier

Retina e Vítreo

Retina e Vítreo

Obrigada!

[email protected]

codificação em oftalmologia congresso...- restritas as possibilidades para o 4º caractere (body...

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