Why Words Matter. Revenue Cycle Solutions Consulting & Management Services. Through a Critical Care/Pulmonary Lens

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1 Revenue Cycle Solutions Consulting & Management Services Why Words Matter Through a Critical Care/Pulmonary Lens 2014 The Advisory Board Company advisory.com

2 Key Objectives for Today s Session 1. Develop understanding of the role documentation plays in determining patient severity of illness (SOI), risk of mortality (ROM) and physician quality scores 2. Understand definition and key terminology changes in ICD-10-CM and ICD- 10-PCS 3. Understand the concepts of linking conditions and manifestations for more accurate depiction of patient s clinical status 2014 The Advisory Board Company 2 advisory.com

3 Road Map for Discussion 1 Importance of Documentation and Basics of ICD-10-CM/PCS 2 Concepts Drive Documentation Requirements 3 Examples of Critical Care/Pulmonary Diagnoses in ICD-10-CM 3

4 The Evolution of Clinical Documentation What was once a tool for communication between providers and clinicians is now the primary data source to determine quality of patient care. Market forces are leading to Increase in documentation scrutiny. Who is the audience for your notes? Self Care Team State Government Insurance Companies Other Doctors Patients Federal Government 2014 The Advisory Board Company 4 advisory.com

5 Increased Transparency For Patients MyCigna.com HealthGrades- all material and images are sourced from (accessed on 6/18/2012) Leapfrog- all material and images are sourced from (accessed on 6/18/2012) 2014 The Advisory Board Company 5 advisory.com

6 Transition from ICD-9-CM to ICD-10-CM/PCS Per Bill H.R. 4302, The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD 10-CM/PCS code sets. Benefits and Goals of ICD-10-CM/PCS Provides better detail, a more accurate depiction, and improved communication of patients clinical status Allows for more accurate payment for new procedures Improves capture of morbidity and mortality data Reduces the number of miscoded, rejected and improper claims for reimbursement 2011, The Clinical documentation Improvement Specialist's Guide to ICD-10 p.9 Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPR, C-CDI, CCDS and Sylvia Hoffman, RN, C-CDI, CCDS The Advisory Board Company 6 advisory.com

7 ICD-9-CM vs. ICD-10-CM/PCS: A Comparison 69,000 72,000 14,000 4,000 Why so many new codes? The main difference between ICD-9-CM and ICD-10-CM/PCS codes, outside of structural changes, is the SPECIFICITY of the code. ICD-10-CM/PCS codes specify several components not found ICD-9-CM, such as causal agent, type, laterality, approach, episode of care, root operation, etc. ICD-9 Diagnosis Codes ICD-10 Procedure Codes 1) Code Volume Expansion in ICD-10-CM/PCS Source: Nichols, J.C. (2011). ICD-10 Physician impacts. Advisory Board Applications and Technologies Collaborative; CMS (2013). ICD-10 Implementation guide for small hospitals 2014 The Advisory Board Company 7 advisory.com

8 Introduction to ICD-10-CM Diagnosis Coding Structure ICD-10-CM Codes will Contain 3-7 Alphanumeric Characters with the Following Structure α # α/# α/# α/# α/# α/# Category Sub-categories (Etiology, Anatomic Site, Severity, Laterality, Complication) Extension (3-16 options depending on category) Key ICD-10-CM Documentation Concepts Specific anatomical location Type (primary, secondary, unspecified) Acuity (acute, subacute, chronic, acute on chronic, or unspecified ) Trimester (1,2,3,unspecified) Degree (mild, moderate, severe, or unspecified; total/complete vs. partial/incomplete) Episode of Care (Initial, Subsequent, Sequelae) Laterality (Right, Left, bilateral, or unspecified) Number of fetus (1-5, other) 2014 The Advisory Board Company 8 advisory.com

9 Introduction to ICD-10-PCS Coding Structure In this exercise, we will dissect the structure of an ICD-10-PCS code α/# α/# α/# α/# α/# α/# α/# Section Body System Root Operation Body Part Approach Device Qualifier 1. Section 16 options identifying the general type of procedure. Example: Medical/Surgical Section represents the vast majority of procedures reported in an inpatient setting 2. Body System - e.g. circulatory system, respiratory system 3. Root Operation - 31 options, based on the objective of the procedure 4. Body Part - e.g. pericardium, coronary artery, heart, atrium, mitral valve 5. Approach - 7 options, e.g. open, percutaneous, percutaneous endoscopic 6. Device - 4 basic groups: Grafts/prostheses, implants, simple or mechanical appliances, and electronic appliance 7. Qualifier - e.g. identify destination site in a Bypass, Diagnostic, Full thickness burn Physician documentation required: Type and intent of procedure (root operation) Specific anatomic sites treated Approach Specific type of device used Validate surgical complications Diagnoses that support inpatient medical necessity Source: AHIMA; The Advisory Board Company research 2014 The Advisory Board Company 9 advisory.com

10 Road Map for Discussion 1 Importance of Documentation and Basics of ICD-10-CM/PCS 2 Key Concepts To Capture in Your Documentation 3 Examples of Critical Care/Pulmonary Diagnoses in ICD-10 10

11 Remember: Signs, Symptoms & Test Results Must Be Linked to Related Diagnoses While important pieces of the medical record, signs, symptoms and test results are not sufficient for coders to assign a diagnosis. Linking signs and symptoms to diagnoses may increase SOI and ROM in the inpatient setting. (The terms probable, likely, or suspected are all acceptable on the inpatient record) In the ambulatory setting, documentation regarding patient condition should be to the highest level known, treated or evaluated Abnormal findings (laboratory, x-ray, pathology and other diagnostic test results) cannot be coded and reported unless the clinical significance is identified by the treating provider ICD-10-CM Official Coding Guidelines III.B Reminder: The attending physician is responsible for: Documenting all conditions in the progress notes and discharge summary Resolving conflicts in the documentation 2014 The Advisory Board Company 11 advisory.com

12 Linking Conditions Critical to Capturing Patient Severity There is a significant increase in the number of combination codes available in the ICD-10-CM/PCS code set. These codes can help capture the highest level of complexity and acuity in the public eye. Linking clinically relevant conditions, where appropriate, is the key takeaway for physicians. Coders cannot assume clinical relationships. Examples: Linking Diseases Hypertension with heart disease Endocarditis due to staph aureus Right heart failure due to primary pulmonary hypertension Use terms like due to or with Note: Lists, commas, and the word and do not link conditions 2014 The Advisory Board Company 12 advisory.com

13 Severity of Illness (SOI) and Risk of Mortality (ROM) Documentation drives SOI and ROM level assignment. These levels are used to measure patient acuity, and therefore drive expected patient LOS and mortality rate. Breakdown of SOI/ROM and their Implication on Quality Measures Four mutually exclusive SOI/ROM categories exist (1-4), and are determined based on a number of factors including primary and secondary diagnoses, comorbidities, demographics, patient history, treatment/procedure delivered, etc. Level Assigned SOI/ROM Category Minor 1 Moderate 2 Major 3 Extreme The Advisory Board Company 13 advisory.com

14 Road Map for Discussion 1 Importance of Documentation and Basics of ICD-10-CM/PCS 2 Key Concepts To Capture in Your Documentation 3 Examples of Critical Care/Pulmonary Diagnoses in ICD-10 14

15 ICD-10-CM/PCS Critical Care/Pulmonary Topics Covered Today Let s start with these diagnoses to help explain what documentation will be like in ICD-10-CM/PCS 1 Cerebral Vascular Accidents/ Glasgow Coma Scale 2 Respiratory 3 Acute Myocardial Infarctions 4 Heart Failure 5 Sepsis 6 Kidney Disease 7 Tobacco Exposure 8 Asthma 9 COPD & Emphysema 2014 The Advisory Board Company 15 advisory.com

16 Glasgow Coma Scale GCS Score can now be captured in ICD-10-CM GCS Score Criteria Type & Points Eyes Open Never¹ To pain¹ To sound Spontaneous N/A N/A Best Verbal Response Best Motor Response None¹ None¹ Incomprehensible words¹ Extension to painful stimuli¹ Inappropriate words Abnormal flexion to painful stimuli Confused conversation Flexion withdrawal from painful stimuli¹ Oriented; converses normally Localizes painful stimuli N/A Obeys commands Note Used in conjunction with: Traumatic brain injury Acute Cerebrovascular disease Other sequelae of cerebrovascular disease Scale: Minor, GCS > 13 Moderate, GCS 9-12 Severe, GCS <9 Documentation Tip Report each of the subcategory scores rather than just the total score Some coma diagnoses codes are categorized as MCCs 1) ¹Indicates MCC designation 16

17 CVA Documentation Key Points Acuity Laterality Identify if hemorrhage or infacrtion Site of non-traumatic intracerebral hemorrhage Hemisphere Brain stem Cerebellum Intraventricular Multiple localized Cerebral infarctions documentation must include: Embolism Thrombosis Stenosis/occlusion Artery if known Associated symptoms Presence of hemiparesis and/or hemiplegia Hand dominance of patient (right, left, or ambidextrous) tpa administration in a different facility in the last 24 hours 17

18 Sequelae (Late Effects) 4 Critical Components to Capture for all Sequelae/Late Effects Identified: Can include: Cognitive deficits Speech & Language deficits Aphasia 1. Document Deficits Present Dysphasia (include type) Dysarthria Fluency disorder Stuttering following non-traumatic SAH Monoplegia Hemiplegia & hemiparesis 2. Document Time Onset for Each Is this deficit new or old? Sequelae Clearly link all deficits to the appropriate event 3. Document Laterality of Deficit Example: hemiplegia on left side, non-dominant side Left-handed 4. Document Patient s Dominance Right-handed Ambidextrous Documentation Tip There is no time limit on when a sequelae (late effect) codes can be used The term sequelae replaces the term late effect in ICD-10-CM. This diagnosis will require the provider documentation to link the sequelae to the initial event 18

19 Pneumonia & Influenza ICD-10-CM Pneumonia & Influenza Documentation Concepts Identify the organism Pneumonia Viral or Bacterial Known or suspected organism Example: Probable pneumonia due to MRSA Link any associated conditions to the pneumonia Aspiration Pneumonia Remember: Probable, likely and suspected are acceptable terms in the inpatient setting Sepsis due to pneumonia Acute respiratory failure due to pneumonia Due to solids or liquids anesthesia during labor and delivery anesthesia during puerperium Documentation Tips: Remember to document tobacco use Do not need a + CXR or culture Documentation of CAP, HCAP, FAP, or HAP doesn t capture severity of illness Influenza Type Influenza virus Associated conditions Pneumonia Respiratory illness (laryngitis, pharyngitis) Encephalopathy Myocarditis 19

20 Respiratory Failure Acuity Specificity Tobacco Use ICD-10-CM Documentation Concepts Acute Chronic Acute on Chronic With Hypoxia Hypercapnia Unspecified Document if patient has exposure to environmental tobacco smoke history of tobacco use occupational exposure to tobacco smoke Documentation Teaching Point: Mild, moderate or severe respiratory distress and respiratory insufficiency do not equal respiratory failure Clarify the need for continuous home oxygen dependence on home oxygen does not capture severity of illness Blood gases and mechanical ventilation are not required 20

21 Understanding Implications for AMI Changes Limited time frame for acute designation will require increased specificity PMH: Patient suffered a STEMI involving the left circumflex coronary artery two weeks ago and was discharged home. Same patient is admitted today for a STEMI of the anterior wall. Patient history of STEMI two weeks ago Patient enters ER with symptoms MD identifies AMI of the anterior wall Specify in days for accurate code selection Understand implications for MIs a month ago > 28 Days? 28 Days Notes Acute MI within the last 28 days Subsequent MI additional MI within 28 days New Acute MI additional MI after 28 days Old MI MI more than 28 days old 21

22 Acute Myocardial Infarction Initial ST elevation (STEMI) myocardial infarction of anterior wall involving left main coronary artery I Consistent across all AMIs Order Type and Site Specific artery Initial STEMI Inferior Wall STEMI Anterior Wall Left main coronary artery Left anterior descending coronary artery Myocardial Infarction STEMI Unspecified site Other coronary artery Subsequent STEMI Other site NSTEMI 22

23 Specify: STEMI or NSTEMI Specific Wall i.e. Anterior, Inferior Documentation Requirements: Specific Artery i.e. Left main, Left anterior descending Was tpa administered? At transferring facility or current facility? Tobacco exposure Current complication of STEMI Hemopericardium will need further clarification if related to and a complication of the MI; or unrelated and not a complication of the MI. Documentation Teaching Point: Unless otherwise specified, AMI defaults to STEMI in ICD-10-CM Carry all clinically significant information from the cath report / echo report or other testing results into the progress notes to ensure it will be captured in the coded record 23

24 Look Out For These Conditions Atherosclerosis, Angina, and Acute Coronary Syndrome (ACS) Key Points: ICD-10-CM assumes Angina pectoris is to due atherosclerosis unless otherwise documented Acute coronary syndrome (ACS) sequences to a nonspecific diagnosis of unspecified acute ischemic heart disease Clarifying ACS and Angina (unstable, with spasm, other, unspecified) can impact SOI/ROM and DRG assignment 24

25 A Valid Question Some doctors might have noticed unspecified options for both the vessel type and angina. Why should I document them both if a coder can code without it? 25

26 Specificity Drives Severity Which means that vessel type and angina type matter. In some cases, presence of angina serve as a severity driver Unspecified Coronary Bypass Graft Angina (Unspecified) No comorbid condition (CC) present Native Coronary Artery Of Transplanted Heart Unstable Angina Pectoris Comorbid condition (CC) present Autologous Vein Coronary Artery Bypass Graft Angina with Documented Spasm Comorbid condition (CC) present 26

27 Heart Failure Specificity for Severity of Illness Link all pieces of an illness to get the highest severity of illness to support tests, procedures or therapies Components to Best Practice Documentation Specify Acuity: Acute, Chronic or Acute on Chronic Heart Failure Specify Type: Systolic, Diastolic, or Combined systolic and diastolic Clarify the relationship of the hypertension to the heart disease or heart failure Linking together may impact the severity of illness and risk of mortality of the patient Identify, if known, the underlying etiology of the failure Is it an exacerbation of stable heart failure, due to fluid overload, or due to missed dialysis Echocardiogram Findings If available, document findings of systolic, diastolic or combined heart failure from the echo in your progress notes and discharge summary Heart Failure Combination Codes Examples: Hypertensive heart disease with heart failure Heart failure following surgery 27

28 What Are They CCs and MCCs? Comorbid Conditions (CCs) and Major Comorbid Conditions (MCCs). To capture severity of illness (SOI), please specify in your documentation Comorbid Conditions (CCs) Systolic heart failure Chronic systolic heart failure Diastolic heart failure Chronic diastolic heart failure Combined systolic and diastolic heart failure Heart failure due to hypertension with CKD Stage 5 or ESRD Rheumatic heart failure Left ventricular heart failure Major Comorbid Conditions (MCCs) Acute systolic heart failure Acute on chronic systolic heart failure Acute diastolic heart failure Acute on chronic diastolic heart failure Acute combined systolic and diastolic heart failure Acute on chronic combined systolic and diastolic heart failure Acute pulmonary edema of lung without heart disease or heart failure Specificity Matters CHF Systolic Heart Failure (CC) Acute Systolic Heart Failure (MCC) Chest Pain Unstable Angina (CC) Probable NSTEMI (MCC) 28

29 Heart Failure Acute systolic heart failure I Heart Failure Type of Heart Failure Severity Diastolic Acute Heart Failure Systolic Chronic Combined Systolic + Diastolic Acute on Chronic Documentation Teaching Point: If a patient has HTN and CHF, the physician documentation needs to identify a cause and effect relationship. Example: Hypertensive heart disease with acute systolic heart failure due to medication noncompliance Unspecific Unspecified 29

30 Documenting Practice: Echocardiogram Evidence Be sure to document any of the following complications identified on Echocardiogram A Comprehensive Chart is Always Best Practice! Aneurysm Intracavitary thrombus Papillary muscle rupture Thrombosis in the atrium, appendage, or ventricle Pericardial effusion Right ventricular infarction Pseudoaneurysm Septal defect: atrial or ventricular 30

31 Sepsis, Severe Sepsis and Septic Shock Properly documenting sepsis in ICD-10-CM has a significant impact on severity captured. Documentation Concepts Bacteremia vs Sepsis in the coding world It is imperative the physician clarifies if the patient has a systemic infection (sepsis) or only has the finding of bacteria in the bloodstream Bacteremia is an abnormal lab finding and is considered a sign and symptom, it does not represent a systemic process Sepsis replaces the term Septicemia used in ICD-9-CM Sepsis Documentation Should: Link the underlying local infection (e.g. PNA) to the systemic infection Identify the suspected/known organism and any drug resistance Clarify if there is associated shock or organ failure Severe Sepsis is sepsis with documented organ failure. Documentation required: Identification of the suspected/known organism Identification of associated organ failure Example: Acute renal failure due to E Coli sepsis Septic Shock generally refers to circulatory failure associated with severe sepsis. Documentation required: Identification of the suspected/known organism Identification of associated organ failure Temp Pulse RR WBC SIRS Criteria < 96.8 F(36 C) or > F (38 C) > 90 bpm > 20 breaths/min or PaCO2 < 32 mmhg 12,000 or < 4,000 cells/mm 3 or > 10% bands Septic Shock Severe Sepsis Sepsis 31

32 Kidney Disease ICD-10-CM provides further specificity of type of kidney damage in order to reflect accurate severity Document the Type of Damage Identify the Stage Acute Renal Failure/Injury Acute Renal Failure or Acute Kidney Injury with : Tubular necrosis (N17.0) Acute cortical necrosis (N17.1) Medullary necrosis (N17.2) Associated underlying condition Chronic Kidney Disease Stage I-V (stages IV-V are CCs) Is the CKD related to Hypertension or Diabetes? If so, document the linkage ( due to / with ) Transplant Status Document if the patient has had a transplant or If the patient is a candidate for a transplant CKD as a Manifestation, link diseases Examples: Type 2 DM with diabetic CKD stage 5 Hypertensive heart disease with CKD stage 3 and with chronic diastolic heart failure Hypertensive with CKD Stage 4 Use terms like due to or with Note: Lists, commas, and the word and do not link conditions 32

33 Tobacco Exposure ICD-10-CM requires documentation of tobacco exposure, specifically for: Pulmonary disease Diseases of the head, neck, mouth and esophagus During pregnancy, birth and puerperium Document Level of Usage No Use Type of Usage/Exposure Exposure During pregnancy, birth and puerperium Environmental tobacco smoke (2 nd hand smoke) Use Tobacco use (current) Tobacco use (past) Dependence Nicotine dependence and source ( e.g. cigarettes, chewing tobacco, other) Nicotine dependence in remission With or without other nicotineinduced disorders 2014 The Advisory Board Company 33 advisory.com

34 Asthma ICD-10-CM Documentation Concepts (now aligned with National Heart, Lung, and Blood Institute (NHLBI) guidelines) Documentation Tip: Types: Intermittent Persistent Acuity: Mild Moderate Severe With Uncomplicated Acute exacerbation Status asthmaticus Document (if present): Exercise-induced bronchospasm Cough variant asthma Detergent asthma Eosinophilic asthma Miners asthma Wood asthma Wheezing Always document tobacco exposure Severe persistent asthma with acute exacerbation J Chronic lower respiratory diseases (Asthma) Type and acuity With 34

35 Severity of Asthma Classification Presentation of Asthma Before Treatment* Acuity Symptoms Mild Intermittent Symptoms 2x/week Asymptomatic/normal PEF between exacerbations Exacerbations of varying intensity are brief Nighttime Awakenings Lung Function 2x/month FEV or PEF 80% predicted PEF variability < 20% Mild Persistent Symptoms > 2x/week but < 1x per day Exacerbation may affect activity Moderate Persistent Daily Symptoms Daily use of inhaled shortacting beta-agonist Exacerbations affect activity Exacerbation 2x/week or 1 per day > 2x/month FEV or PEF 80% predicated PEF variability 20-30% > 1x/week FEV or PEV 60-80% predicted PEF variability >30% Severe Persistent Symptoms throughout the day Limited physical activity Frequent exacerbations Frequent FEV or PEV 60% predicted PEF variability > 30% 2014 The Advisory Board Company Source: based on the National Heart, Lung, advisory.com and Blood 35 Institute (NHLBI) asthma severity classification scale

36 COPD & Emphysema ICD-10-CM Documentation Concepts Key Concepts to Remember: COPD Emphysema Other considerations Associated with acute lower respiratory infection Acute exacerbation? Specify type Unilateral Panlobar Centrilobular Compensatory Secondary to inhalation of chemical gases, fumes, or vapors Chronic obstructive bronchitis Interstitial Mediastinal Surgical subcutaneous Traumatic subcutaneous Reminder: Always document tobacco exposure 36

37 Documentation of Complications of Care ICD-10-CM coding terminology will change to more accurately identify when complications occur Two Key Components to Remember: ICD-10-CM has replaced the term post-operative with post-procedural or post-surgical Conditions occurring in the post-operative period should be clarified as: An expected post-procedural or post-surgical condition An unexpected post-procedural or post-surgical condition related to surgical care (a complication of care) An unexpected post-procedural or post-surgical condition, unrelated to surgical procedure An unexpected post-procedural or post-surgical condition, related to the patient s underlying medical comorbidities 37

38 For Reference: Root Definitions for ICD-10-PCS Terms Term Alteration Bypass Definition Modifying the natural anatomic structure of a body part without affecting the function of the body part Altering the route of passage of the contents of a tubular 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 Control Stopping, or attempting to stop, post procedural bleeding Creation Detachment Dilation Division Drainage Making a new genital structure that does not take over the function of a body part Cutting off all or a portion of the upper or lower extremities Expanding an orifice or the lumen of a tubular body part Cutting into a body part without draining fluids and/or gases from the body part in order to separate or transect a body part Taking or letting out fluids/or gases from a body part Excision Cutting out or off, without replacement, a portion of a body part Extirpation Extraction Taking or cutting out solid matter from a body part (the solid matter may be an abnormal byproduct, imbedded or may be or may not have been broken into pieces) Pulling or stripping out or off all or a portion of a body part by the use of force (A qualifier of diagnostic is used for biopsies) 2014 The Advisory Board Company 38 advisory.com

39 Root Definitions Continued Term Fragmentation Breaking solid matter in a body part into pieces Definition Fusion Joining together portions of an articular body part rendering the articular body part immobile 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 Inspection Visually and/or manually exploring a body part Map Locating the route of passage of electrical impulses and/or locating functional areas in a body part Occlusion Reattachment Completely closing an orifice or lumen of a tubular body part Putting back in or on all or a portion of a separated body part to its normal location or other suitable location Release Removal Freeing a body part from an abnormal physical constraint by cutting or by use of force Taking out or off a device from a body part 2014 The Advisory Board Company 39 advisory.com

40 Root Definitions Continued Repair Term Definition Restoring, to the extent possible, a body part to its normal anatomic structure and function Replacement 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 Reposition Moving to its normal location or other suitable location all or a portion of a body part Resection Cutting out or off, without replacement, all of a body part Restriction Partially closing the orifice or lumen of a tubular body part Revision Correcting, to the extent possible, a malfunctioning or displaced device Supplement Putting in or on biological or synthetic material that physically reinforces and/or augments the function of a portion of a body part Transfer Moving, without talking 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 Transplantation Putting in or on all or a portion of a living body part taken from another individual or animal to physician take the place and/or function of all or a portion of a similar body part 2014 The Advisory Board Company 40 advisory.com

41 ICD-10-PCS: Approach Approach Definition 1. Open Cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure 2. Percutaneous Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and/or any other body layers necessary to reach the site of the procedure 3. Percutaneous Endoscopic Entry, by puncture or minor inclusion, of instrumentation through the skin or mucous membrane and/or any other body layers necessary to reach and visualize the site of the procedure 4. Via Natural or Artificial Opening 5. Via Natural or Artificial Opening Endoscopic 6. Via Natural or Artificial Opening Endoscopic with Percutaneous Endoscopic Assistance Entry of instrumentation through a natural or artificial external opening to reach the site of the procedure Entry of instrumentation through a natural or artificial external opening to reach the site of the procedure Entry of instrumentation through a natural or artificial external opening to reach and visualize the site of the procedure, and entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to aid in the performance of the procedure 7. External Procedures performed directly on the skin or mucous membrane and procedures performed indirectly by the application of external force through the skin or mucous membrane The Advisory Board Company 41 advisory.com