AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2020 Issue 3; Ask the Editor
Plication of Diaphragm
A patient with respiratory embarrassment, elevation and partial paresis of the diaphragm presented for diaphragm plication. While in left lateral decubitus position, the chest was entered through the 6th interspace and multiple camera ports were placed. With gas insufflated, the diaphragm came down relatively nicely. It was completely flaccid. The diaphragm was plicated with three double mattress sutures with a pledget at both ends. This resulted in a substantial flattening of the diaphragm. Once all instrument and sponge counts were correct, the wounds were irrigated with antibiotic solution, and the ports were removed. How is this procedure coded in ICD-10-PCS? ...
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Article Overview
This article explains how a diaphragm plication case is coded in ICD-10-PCS. It is intended for coding professionals who need to classify an operative report involving the diaphragm and an endoscopic approach, with attention to the procedure setting and documentation elements that support code selection.
Why This Topic Matters
Accurate ICD-10-PCS reporting depends on correctly identifying the body part, root operation, and approach documented in the operative note. Articles like this help coders align procedural documentation with ICD-10-PCS structure for inpatient hospital coding.
What You Will Learn
- How a diaphragm plication operative note is interpreted for ICD-10-PCS coding
- Which ICD-10-PCS procedure category applies to this type of diaphragm repair
- What documentation elements in the operative report are relevant to procedure coding
- How an endoscopic approach affects ICD-10-PCS code selection
Who Should Read This
- Inpatient hospital coders
- ICD-10-PCS coding specialists
- Clinical documentation specialists
- Medical coding auditors
Codes Discussed
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