codificação em oftalmologia congresso...- restritas as possibilidades para o 4º caractere (body...
TRANSCRIPT
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.
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 OperationsOverview
Destruction
Excision | Resection | Extraction
Drainage | Extirpation
Fragmentation
Bypass | Dilation | Occlusion | Restriction
Insertion | Change | Supplement | Removal | Replacement | Revision
Alteration
Inspection
Release | Reposition | Transfer | Reattachment | Repair
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 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®
Supplement | Replacement | Insertion | Change | Removal | Revision
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
Supplement | Replacement | Insertion | Change | Removal | Revision
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
Supplement | Replacement | Insertion | Change | Removal | Revision
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.
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 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
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
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
ICD-10-PCS
Section
Body System
Root Operation - MÉTODO e/ou OBJECTIVO?
Body Part
Approach
Device
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
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
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
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
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
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