ICD-10 Hospital Procedures

🤔 Question: When patients are readmitted for follow up grafting or other procedures, providers often use CPT codes for the procedures. Are registrars required to try and find an equivalent ICD-10 procedure code to enter on the readmission form or can “CPT code #” be entered as the procedure code?
🌱 Answer: An ICD 10 code must be used. An ICD 10 code that is equivalent to the CPT code for the procedure should be found. Coders at your institution may be able to help you with this.

🤔 Question: Are procedures performed by other services included in procedures recorded?
🌱 Answer: Yes, all procedures performed in the operating room by any service are included in Hospital Procedures.

🤔 Question: Resources like vents, feeding tubes, intubation are recorded in the Resource Utilization Form. Should they also be recorded in Hospital Procedures?
🌱 Answer: If the activity (i.e. intubation, insertion of feeding tube) occurs in the operating room then, yes, you should document this in Hospital Procedures. If they occur at the bedside, you do not document them in Hospital Procedures, except for escharotomies/fasciotomies or procedures done at the bedside that have an operative note written.

🤔 Question: Should procedures done in the operating room (e.g. endotracheal tube change), that are also sometimes done in the emergency department or at the bedside, be recorded as ICD 10 Hospital Procedures?
🌱 Answer: Yes, enter any procedure done in the operating room (O.R.) in the Hospital Procedure fields. It doesn’t matter if the procedure could have been done at the bedside. Many procedures could meet that definition but are done in the O.R. along with other operative procedures.