by Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA
Coding the root operation of Detachment when the surgeon doesn’t document the ICD-10-PCS terminology of high, mid, or low amputations can be a challenge. Physicians don’t need to document these words, but they do need to give the coder enough documentation to know where the amputation took place. Documenting that a “below-the-knee amputation” took place really isn’t sufficient. How far below the knee is that?
Words like proximal, middle, and distal really help but not all surgeons document in that way. These words apply when the long structures of the extremities are being detached. This includes even the very small long structures of the fingers and toes. Think of these structures as being divided into thirds. Anywhere in the proximal third is high, the middle third is mid, and the distal third is low.
ICD-10-PCS Guideline A11 does say that it is the coder’s responsibility to interpret the documentation, but when in doubt, the coder should query. Interpreting the documentation means looking for clues that the surgeon leaves for the coder, such as “3 finger breaths above the medial malleolus.” To me, this means a low amputation and no query is required. Similarly, “3 centimeters below the tibial tuberosity” to me means a high amputation was performed and no query is required. A mid-level amputation can be more challenging to spot. I typically look for documentation that says something about calf area or mid-shaft for the leg or the middle phalanx for fingers and toes. Read carefully looking for the clues about the surgical landmarks.
If there are no clues, and the level can’t be determined, then you need to query. But, education in a query never hurts. Mention the PCS terminology of high (proximal third), mid (middle third), and low (distal third) to help the surgeon document the correct ICD-10-PCS qualifier in the answer.
For additional information on detachment that involves fish-mouth incisions and flaps, review one of my previous blogs here.
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