ICD-10 PCS Coding procedures common to all facilities

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ICD-10 PCSCoding procedures common to all
facilities

• Presented by
• AHIMA-Approved ICD-10-CM/PCS Trainers
• Deb Selland, RHIT, CCS
• Sue Roehl, RHIT, CCS

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Instructors

•  
• Sue Roehl, RHIT, CCS
• Sue is a Manager and Health Care Consultant with
  Eide Bailly LLP in Fargo, ND. She has more than
  thirty years of health care experience, with an
  emphasis in coding, health information and
  quality management. She provides ICD-9-CM and CPT
  coding, documentation, and compliance reviews for
  hospitals throughout the country. She also
  provides coding support for inpatient and
  outpatient accounts.
• Sue specializes in assisting hospital medical
  records coding staff, physicians, business
  services and ancillary departments with
  appropriate reimbursement. In addition, Sue
  offers onsite educational sessions and coding
  validation studies to determine if providers are
  assigning correct diagnosis and procedure codes
  for reimbursement and compliance.
• Sue completed the AHIMA ICD-10-CM/PCS training
  in 2009. She has twice served as President for
  the North Dakota Health Information Management
  Association, along with various other Board
  offices.
•  
• Deb Selland, RHIT, CCS
• Deb is employed by Blue Cross Blue Shield of
  North Dakota as the Reimbursement Coding
  Coordinator and is responsible for performing DRG
  Validation coding audits on all North Dakota
  participating facilities. She has been employed
  in the Health Information industry for over
  thirty years.
• Deb completed the AHIMA ICD-10 CM/PCS Academy
  certification in 2010. She has formerly served as
  President and Education Director for NDHIMA.

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Disclaimer

• The presenters have made every reasonable effort
  to ensure accuracy of the information provided in
  this material.
• The presenters make no guarantee the information
  compiled or presented is error-free.

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Objectives

• Review structure of PCS codes
• Code common procedures from various sections of
  ICD-10-PCS

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ICD-10-PCS
Procedure Classification System
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ICD-10-PCS (Procedures)
Used in inpatient hospital setting
Replaces Volume 3
Maintained by CMS
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Structures and Features Comparison
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ICD-9-CM Volume 3 Procedures ICD-10-PCS Procedures
-3 or 4 characters (numeric) -Always 7 characters per procedure (alphanumeric) -Digits 0-9 used -Letters A-H, J-N, P-Z (no I or O because of confusion with numbers 1 and 0)
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Documentation Alert

• ICD-10-PCS Coding Guideline
• A8 All seven characters must be specified to be
  a valid code. If the documentation is incomplete
  for coding purposes, the physician should be
  queried for the necessary information.

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Documentation Alert

• ICD-10-PCS Coding Guideline
• A11 Many of the terms used to construct PCS
  codes are defined within the system. It is the
  coders responsibility to determine what the
  documentation in the medical record equates to in
  the PCS definition. The physician is not expected
  to use the terms used in PCS code descriptions,
  nor is the coder required to query the physician
  when the correlation between the documentation
  and the defined PCS terms is clear. Example When
  the physician documents partial resection the
  coder can independently correlate partial
  resection to the root operation Excision without
  querying the physician for clarification.

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Structures and Features Comparison
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ICD-9-CM Volume 3 (Procedures) ICD-10-PCS (Procedures)
Consists of -Index -Tabular Consists of Index Provides first 3 or 4 values of the code - Tables Must be used to build complete code
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Structure and Features of ICD-10-PCS   Character
Meanings  
    Sections (16) 0 Medical Surgical        
For procedures in the Medical Surgical section
the first character will always be zero
(0). Sections 1-9 comprise the Medical
Surgical-related sections such as obstetrical
procedures and extracorporeal therapies, while
sections B-D and F-H contain the Ancillary
sections including procedures such as imaging and
nuclear medicine.
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  2nd Character Body
Systems (31)
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 3rd Character Root Operation
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ICD-10 PCS Coding Guidelines

• B3.1a In order to determine the appropriate root
  operation, the full definition of the root
  operation as contained in the PCS Tables must be
  applied.

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ICD-10 Procedure Coding SystemGlobal Root
Operations (Section 0-9)
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Alteration Definition-Modifying the anatomic structure of a body part without affecting the function of the body part Explanation-Principal purpose is to improve appearance Examples-Face lift, breast augmentation
Bypass Definition-Altering the route of passage of the contents of a tubular body part Explanation-Rerouting contents around an area of a body part to another distal (downstream) area in the normal route rerouting the contents to another different but similar route and body part or to an abnormal route and another dissimilar body part. It includes one or more concurrent anastomoses with or without the use of a device such as autografts, tissue substitutes and synthetic substitutes. Examples-Coronary artery bypass, colostomy formation
Change Definition-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. Explanation- All Change procedures are coded using the approach External Examples-Urinary catheter change, gastrostomy tube change
Control Definition-Stopping, or attempting to stop, postprocedure bleeding Explanation-The site of the bleeding is coded as an anatomical region and not to a specific body part. Examples-Control of post-prostatectomy hemorrhage, control of post-tonsillectomy hemorrhage
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Global Root Operations (Section 0-9)
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Creation Definition-Making a new genital structure that does not take over the function of a body part Explanation-Used only for sex change operations Examples-Creation of vagina in a male, creation of penis in a female
Destruction Definition-Physical eradicating all or a portion of a body part by the direct use of energy, force or a destructive agent Explanation- None of the body part is physically taken out. Examples-Fulguration of rectal polyp, cautery of skin lesion
Detachment Definition-Cutting off all or a portion of an upper or lower extremity Explanation-The body part value is the site of the detachment, with a qualifier if applicable to further specify the level where the extremity was detached Examples-Below knee amputation, disarticulation of shoulder
Dilation Definition-Expanding an orifice or the lumen of a tubular body part Explanation-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. Examples-Percutaneous transluminal angioplasty, pyloromyotomy
Division Definition-Cutting into a body part without draining fluids and/or gases from the body part in order to separate or transect a body part Explanation-All or a portion of the body part is separated into two or more portions Examples-Spinal cordotomy, osteotomy
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ICD-10 Procedure Coding SystemGlobal Root
Operations (Section 0-9)
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Drainage Definition-Taking or letting out fluids and/or gases from a body part Explanation-The qualifier DIAGNOSTIC is used to identify drainage procedures that are biopsies. Examples-Thoracentesis, incision and drainage
Excision Definition-Cutting out or off, without replacement, a portion of a body part Explanation-The qualifier DIAGNOSTIC is used to identify excision procedures that are biopsies Examples-partial nephrectomy, liver biopsy
Extirpation Definition-Taking or cutting out solid matter from a body part Explanation-The solid matter may be an abnormal byproduct of a biological function or a foreign body. The solid matter is imbedded in a body part, or is in the lumen of a tubular body part. The solid matter may or may not have been previously broken into pieces. No appreciable amount of the body part is taken out. Examples-Thrombectomy, choledocholithotomy
Extraction Definition-Pulling or stripping out or off all or a portion of a body part Explanation-The body part is pulled or stripped from its location by the use of force (e.g., manual, suction). The qualifier DIAGNOSTIC is used to identify extraction procedures that are biopsies. Examples-Dilation and curettage, vein stripping
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Global Root Operations (Section 0-9)
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Fragmentation Definition-Breaking solid matter in a body part into pieces. Explanation-The solid matter may be an abnormal byproduct of a biological function or a foreign body. Physical force (e.g., manual, ultrasonic) applied directly or indirectly through intervening body parts is used to break the solid matter into pieces. The pieces of solid matter are not taken out, but are eliminated or absorbed through normal biological functions. Examples-Extracorporeal shockwave lithotripsy, transurethral lithotripsy
Fusion Definition-Joining together portions of an articular body part rendering the articular body part immobile. Explanation-The body part is joined together by fixation device, bone graft, or other means. Examples-Spinal fusion, ankle arthrodesis
Insertion Definition-Putting in a non-biological appliance that monitors, assists, performs or prevents a physiological function but does not physically take the place of a body part. Explanation- None Examples-Insertion of radioactive implant, insertion of central venous catheter
Inspection Definition-Visually and/or manually exploring a body part. Explanation-Visual exploration may be performed with or without optical instrumentation. Manual exploration may be performed directly or through intervening body layers. Examples-Diagnostic arthroscopy, exploratory laparotomy
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ICD-10 Procedure Coding SystemGlobal Root
Operations (Section 0-9)
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Map Definition-Locating the route of passage of electrical impulses and/or locating functional areas in a body part Explanation-Applicable only to the cardiac conduction mechanism and the central nervous system Examples-Cardiac mapping, cortical mapping
Occlusion Definition-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 Examples-Fallopian tube ligation, ligation of inferior vena cava
Reattachment Definition-Putting back in or on all or a portion of a separated body part to its normal location or other suitable location Explanation-Vascular circulation and nervous pathways may or may not be reestablished Examples-Reattachment of hand, reattachment of avulsed kidney
Release Definition-Freeing a body part from an abnormal physical constraint by cutting or by use of force Explanation- Some of the restraining tissue may be taken out but none of the body part is taken out Examples-Adhesiolysis, carpal tunnel release
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ICD-10 Procedure Coding SystemGlobal Root
Operations (Section 0-9)
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Removal Definition-Taking out or off a device from a body part Explanation-If the device is taken out and a similar device is 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 the device is coded to the root operation REMOVAL and the procedure for putting in the new device is coded to the root operation performed. Examples-Drainage tube removal, cardiac pacemaker removal
Repair Definition-Restoring, to the extent possible, a body part to its normal anatomic structure and function Explanation-Used only when the method to accomplish the repair is not one of the other root operations Examples-Herniorrhaphy, suture of laceration
Replacement Definition-Putting in or on biological or synthetic material that physically takes the place of all or a portion of a body part Explanation-The biological material is non-living, or the biological material is living and from the same individual. The body part may have been previously taken out, previously replaced, or may be taken out concomitantly with the Replacement procedure. If the body part has been previously replaced, a separate Removal procedure is coded for taking out the device used in the previous replacement. Examples-Total hip replacement, free skin graft
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ICD-10 Procedure Coding SystemGlobal Root
Operations (Section 0-9)
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Reposition Definition-Moving to its normal location or other suitable location all or a portion of a body part Explanation-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. Examples-Reposition of undescended testicle, fracture reduction
Resection Definition-Cutting out or off, without replacement, all of a body part. Explanation-None Examples-Total nephrectomy, total lobectomy of lung
Restriction Definition-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. Examples-Esophagogastric fundoplication, cervical cerclage
Revision Definition-Correcting to the extent possible a malfunctioning or displaced device Explanation-Revision can include correcting a malfunctioning or displaced device by taking out or putting in components of the device such as a screw. Examples-Adjustment of pacemaker lead, adjustment of hip prosthesis
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ICD-10 Procedure Coding SystemGlobal Root
Operations (Section 0-9)
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Supplement Definition-Putting in or on biological or synthetic material that physically reinforces or augments the function of a body part Explanation-The biological material is non-living, or living and from the same individual. The body part may have been previously replaced. If the body part has been previously replaced, the Supplement procedure is performed to physically reinforce and/or augment the function of the replaced body part Examples-Herniorrhaphy using mesh, free nerve mitral valve ring annuloplasty, put a new acetabular liner in a previous hip replacement
Transfer Definition-Moving, without taking out, all or a portion of a body part to another location take over the function of all or a portion of a body part Explanation-The body part transferred remains connected to its vascular and nervous supply. Examples-Tendon transfer, skin pedicle flap transfer
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ICD-10 Procedure Coding SystemGlobal Root
Operations (Section 0-9)
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Transplantation Definition-Putting in or on all or a portion of a living body part taken from another individual or animal to physically take the place and/or function of all or a portion of a similar body part Explanation-The native body part may or may not be taken out, and the transplanted body part may take over all or a portion of its function Examples-Kidney transplant, heart transplant
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4th CharacterBody Part
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Comparing ICD-9-CM and ICD-10-PCS Release Carpal
Tunnel Release, Percutaneous In the ICD-9-CM
Alphabetic Index locate the main term release,
followed by subterm carpal tunnel (for nerve
decompression) which identifies code 04.43,
Release of carpal tunnel. In ICD-10-PCS, the
main term entry of release requires the coder
to select the body part being released. It is
necessary to know that the median nerve is
released during a carpal tunnel release. The body
part value assigned is the structure released
(median nerve) and not the structure cut (carpal
ligament) to obtain the release. The subterm
nerve, median below the main term release
leads to 01N5. The 01N table is then accessed to
construct the remainder of the code. The code
assigned for a percutaneous release of the median
nerve is 01N53ZZ.
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Approach
5th Character Approach (7 Options)

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ICD-10 Procedure Coding SystemMedical and
Surgical Approaches
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1 Open Cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure Example Abdominal hysterectomy
2 Percutaneous Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach the site of the procedure Example Needle biopsy of liver
3 Percutaneous Endoscopic Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach and visualize the site of the procedure Example Arthroscopy
4 Via natural or artificial opening Entry of instrumentation through a natural or artificial external opening to reach the site of the procedure Example Endotracheal intubation
5 Via natural or artificial opening endoscopic Entry of instrumentation through a natural or artificial external opening to reach and visualize the site of the procedure Example Sigmoidoscopy
6 Via natural or artificial opening endoscopic with percutaneous endoscopic assistance Entry of instrumentation through a natural or artificial external opening 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 Example Laparoscopic-assisted vaginal hysterectomy
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 Example Closed fracture reduction
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Device
 6th Character Device
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Types of Devices Devices that remain after the
procedure is completed

• 4 general types of devices
• Biological or synthetic material that takes the
  place of all or a portion of a body part (i.e.,
  skin graft, joint prosthesis)
• Biological or synthetic material that assists or
  prevents a physiological function (i.e., IUD)
• Therapeutic material that is not absorbed by,
  eliminated by, or incorporated into a body part
  (i.e., radioactive implant)
• Mechanical or electronic appliances used to
  assist, monitor, take the place of, or prevent a
  physiological function (i.e., cardiac
  defibrillator, orthopedic pin)
• Materials such as sutures, ligatures,
  radiological markers, and temporary
  post-operative wound drains are considered
  integral to the procedure and are not coded as
  devices.

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Qualifier

• 7th Character - Qualifier
• -Defines an additional attribute of the procedure
  performed, if applicable.

   


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Medical and Surgical Section (0)
ICD-9 Volume 3 ICD-10-PCS
81.91 Arthrocentesis Arthrocentesis, right knee, diagnostic, no device ___________________________
51.23 Laparoscopic cholecystectomy ____________________________
51.22 Open cholecystectomy _____________________________
54.91 Percutaneous abdominal drainage Not diagnostic, no device _____________________________
03.31 Spinal tap Diagnostic ______________________________
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Medical and Surgical Section (0)
ICD-9 Volume 3 ICD-10-PCS
86.04 Incision and drainage skin Left upper arm, diagnostic _______________________
54.51 Laparoscopic lysis of peritoneal adhesions _______________________
54.59 Open lysis of adhesions Greater omentum _______________________
34.04 Insertion chest tube Left, percutaneous with device _____________________________
64.0 Circumcision _____________________________
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Obstetric Section

• The obstetric section includes procedures
  performed on the products of conception only.
  Procedures on the pregnant female are coded in
  the Medical Surgical section (e.g.,
  episiotomy).
• The term products of conception refers to all
  physical components of a pregnancy, including the
  fetus, amnion, umbilical cord, and placenta.
  There is no differentiation based on gestational
  age.
• The specification of the products of conception
  as a zygote, embryo or fetus, or the trimester of
  the pregnancy is not part of the procedure code
  but can be found in the diagnosis code.

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Obstetric Section

• Character 1 - Section - always 1
• Character 2 - Body System - Pregnancy
• Character 3 - Root Operation
• Vaginal Delivery and Cesarean are both Extraction
  
• Character 4 - Body Part
• Products of Conception
• Products of Conception, retained
• Products of Conception, ectopic
• Character 5 - Approach
• Character 6 - Device (Fetal Monitor electrodes)
• Character 7 - Qualifier (type of extraction, type
  of Cesarean Section, or type of fluid taken out)

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Medical and Surgical Section (0)Obstetrics
Section (1)
ICD-9 Volume 3 ICD-10-PCS
73.6 Episiotomy _______________________
74.1 Low cervical cesarean section _______________________
73.09 AROM _______________________
75.4 Manual removal placenta _____________________________
72.79 Vacuum extraction _____________________________
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Obstetric Section

• Vaginal delivery, vacuum
• Extraction Extraction of Products of Conception,
  Vacuum, Via Natural or Artificial Opening
• Vaginal delivery with episiotomy
• Extraction Delivery of Products of Conception,
  External Approach
• Division of Female Perineum, External Approach
• Cesarean Section
• Extraction Extraction of products of conception,
  low cervical, open approach (Low cervical
  Cesarean section)

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Placement (2)

• Character 1 Section Always 2
• Character 2 Anatomical Region
• Anatomical Region or
• Anatomical Orifices
• Character 3 Root Operation
• No incision or puncture
• Compression Dressing Immobilization Packing
  and Traction are root operations in the Placement
  Section
• Character 4 Body Region/Orifice
• Character 5 Approach - Always External
• Character 6 Device almost always a device
• Character 7 Qualifier - always No Qualifier

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Placement

• Packing of external ear canal _________________
• Splinting of right ankle _______________________

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Administration (3)

• Administration section codes represent procedures
  for putting in or on a therapeutic, prophylactic,
  protective, diagnostic, nutritional, or
  physiological substance. The section includes
  transfusions, infusions, and injections, along
  with other similar services such as irrigation
  and tattooing.

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Administration Section (3)

• Character 1 - Section - always 3
• Character 2 - Body System
• Indwelling Device
• Physiological System and Anatomical Regions
• Circulatory System (transfusion procedures)
• Character 3 - Root Operation
• Introduction
• Irrigation
• Transfusion
• Character 4 - Body System/Region
• Character 5 - Approach
• Percutaneous injection, insertion of catheter to
  introduce contrast
• Character 6 - Substance
• Character 7 - Qualifier

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ICD-9 Volume 3 ICD-10-PCS
96.04 Endotracheal intubation Not endoscopic _______________________
96.71 Mechanical ventilation lt96 consecutive hours Less than 24 hours _______________________
99.15 TPN 2 codes (upper vein) __________________________________
73.4 Medical induction labor (IV Oxytocin) _____________________________
99.04 Packed cell transfusion _____________________________
75.34 External fetal monitoring _____________________________
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Extracorporeal Assistance and Performance Section
(5)

• In Extracorporeal Assistance and Performance
  procedures, equipment outside the body is used to
  assist or perform a physiological function. The
  section includes procedures performed in a
  critical care setting, such as mechanical
  ventilation and cardioversion it also includes
  other services such as hyperbaric oxygen
  treatment and hemodialysis.

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ResourceGrays Anatomy Bookcan be found
athttp//www.bartleby.com