7. Instructions for Coding Procedures/Use of Tabular List
a. Refer to the Tabular List to verify that the code selected is in accordance with
the desired classification of the procedure.
b. Read and be guided by the inclusion or exclusion notes that may appear not
only under the particular code but also under the category code or section title for that
particular code.
c. Use as many codes as necessary to adequately classify a surgical procedure,
unless instructed otherwise by the term "omit code."
8. Sequencing Guidelines
a. Report all significant procedures. A significant procedure is one which carries
an operative or anesthetic risk, or requires highly trained personnel, and requires
special facilities or equipment. Verify procedures were performed and not just
scheduled. To increase accuracy and specificity of coding, examine the discharge
summary, operative reports, x-rays, pathology reports, notes, and orders for additional
procedures not listed on the Inpatient Treatment Record Coversheet (ITRCS) by the
physician.
b. The principal procedure is listed as the first procedure statement on the ITRCS.
The principal procedure is that procedure most related to the principal diagnosis. A
principal procedure is one which was performed for definitive treatment (therapeutic)
rather than one performed for diagnostic or exploratory purposes.
c. When a diagnostic procedure is relat ed to the principal diagnosis and a
therapeutic procedure is related to a secondary diagnosis, then the principal procedure
is the therapeutic procedure.
d. When two or more therapeutic procedures are performed and all or none are
related to the principal diagnosis, then the procedure during which tissue was removed
or the procedure which subjected the patient to the greatest risk is selected as the
principal procedure.
e. If diagnostic procedures are performed and all or none of them relate to the
principal diagnosis, select the procedure which impacts most dramatically on resource
usage.
f. An incidental appendectomy (47.1) should not be coded as a principal procedure.
g. If there is a disagreement between the ITRCS and the operation/tissue rep ort,
refer the record back to the supervisor and/or physician for clarification.
MD0753
A-15
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