Incision vs excision vs resection

Knowing the difference in incision, excision or resection will assist the coder in more accurate coding ICD-10 PCS.

1. INCISION VS EXCISION VS RESECTION Cynthia Brown, MBA, RHIT, CCS CyntCoding Health Information Services Coding Yesterday’s Nomenclature Today®

2. STANDARDIZED TERMINOLOGY One of the supposed drawbacks of the ICD-9 CM/PCS nomenclature is its lack of standardized terminology. Standardized terminology is a universal language designed to be shared and recognized by users. In the health care setting, standardized terminologies are crucial for the accurate documentation of patient care and outcomes. Likewise, for accurate coding and reimbursement the coding nomenclature must also be standardized. Coding is essential for the capturing of standards of care, influencing policy, and funding services; therefore standardized terminology in coding is a must. Some of the benefits of standardized coding terminology are:   Increased reimbursement for services Decreased Third Party claim rejections Decreased compliance issues Decreased inefficient coding practices Increased ability to track services and diseases for research Increased ability to share data Increased consistency in educational guidelines for coding

3. Knowing the Difference

4. DEFINITIONS & EXAMPLES FOR ICD-9 PCS

5. DEFINITIONS & EXAMPLES FOR ICD-9 PCS

6. COMPARISON/CONTRAST PROCEDURE ICD-9 PCS ICD-10 PCS INCISION Incisions are performed for several reasons (i.e., drainage of a site, exploration, insertion/removal of device, removal of solid matter, and reopening of operative site). The coder can usually find these procedures by going to the alphabetical index under incision and then the site of the incision. The same procedures can be found in the Medical and Surgical Section; then by locating the Body System and referring to the particular Root Operation (i.e., Drainage, Inspection, Insertion/Removal of device, Extirpation). Incisional procedures must be found using their root operation rather than the term “incision.” For example, “drainage” for the “incision and drainage” of a site. EXCISION Excision can mean both the partial and complete surgical removal of a body part. The removal of a lesion from a body part is considered a partial excision of a body part. On the other hand, the excision of the pituitary gland is the complete or total removal of the pituitary gland. Excision means that only a portion of the body part is removed. The entire body part is NEVER removed when the root operation “excision” is used. RESECTION Resection can mean both the partial and complete surgical removal of a body part. The alphabetical index tells the coder to “ see also Excision, by site.” Resection means that the entire body part is removed. The partial or excisional removal of a body part is NEVER appropriate when a resection is performed.

7. Coding Yesterday’s Nomenclature Today® Cynthia Brown, MBA, RHIT, CCS AHIMA Approved ICD-10 CM/PCS Trainer CyntCoding Health Information Services Phone: [phone]/E-Fax: [phone] P.O. Box 3019 Decatur, GA 30031 [email protected] www.cyntcodinghealthinformationservices.com Coding Yesterday’s Nomenclature Today®