1. Crossing the Bridge Preparing for ICD-10-PCS
Crystal Clack, MS, RHIA, CCS
AHIMA Approved ICD-10-CM/PCS Trainer
OrHIMA Fall Conference 2013

2. Objectives A Brief History ICD-9-CM, Vol. 3 to ICD-10-PCS
Format and Structure of ICD-10-PCS
Spotlight: Root Operations
Practice
Preparing for the Great Transition
Conclusion
Resources

3. A Brief History O

4. Why Now? ICD-10-PCS is completely different from ICD-9-CM, Vol. 3
Multi-axial structure
Completeness
Expandability
Standardized terminology
Standardized level of specificity
No explicit options of “NOS” and limited use of “NEC” code

5. ICD-9-CM Vol. 3 vs ICD-10-PCS
ICD-9-CM Volume 3
ICD-10-PCS
Follows ICD structure (designed for DX coding)
Designed and developed to meet healthcare needs for a procedure coding system
Codes available as fixed and finite set in list form
Codes constructed from flexible code components using Table
Codes are 3 to 4 digits long with a decimal point places after the second digit
Codes are 7 characters long
Codes are numeric
Codes are alphanumeric

6. Number of Codes in ICD-10-PCS at the time of printing the 2014 Official Draft Code Set manual:
71,924
For 2014, seven new technology codes were added to the system, and three were deleted.

7. Format & Structure Manual contains an Index and Table section
Codes may be found in the index based on the general type of procedure. Based on the first three values of the code provided in the Index, the table that corresponds to the procedure can be referenced to complete the entire code.
Tables and characters are arranged as follows:
Number
Letter for each character, with a total of 7 characters
IMPORTANT: The Tables must be used to paint a complete and accurate picture!

8. ICD-10-PCS Format & Structure
Character 1
Character 2 3 4 5 6 7
Section
Body System
Root
Operation
Body
Part
Approach
Device
Qualifier
Each code is seven characters and can be alphabetical or numeric
Ten digits 0-9 and 24 letters A-H, J-N, and P-Z are used
Each of the characters has a well-defined meaning

9. Section ~ Character 1 All Codes in PCS are seven characters2 3 4 5 6 7
Section
Body System
Root
Operation
Body
Part
Approach
Device
Qualifier
All Codes in PCS are seven characters
Letters O and I are not used – 0 and 1 are used
Each number has a meaning
Meanings change depending on sections
Section provides first character value

10. Section
Medical procedures are divided into sections that identify the general type of procedure. The first character of the procedure code always specifies the section – or where you can locate the code in the book.

11. Sections of ICD-10-PCS as follows:
Value
Section
Medical & Surgical 9
Chiropractic 1
Obstetrics B
Imaging 2
Placement C
Nuclear Med 3
Administration D
Radiation Tx 4
Measuring & Monitoring F
Physical Rehab & Diagnostic Audiology 5
Extracorporeal Assistance & Performance G
Mental Health 6
Extracorporeal Therapies H
Substance Abuse Treatment 7
Osteopathic
BOLD italics = Ancillary 8
Other Procedures

12. Body System~ Character 23 4 5 6 7
Section
Body System
Root
Operation
Body
Part
Approach
Device
Qualifier
Second character
Body System, general physiological system or anatomical region involved
Review Body Systems in training manual
Appendix G

13. Body System 0 - Central Nervous Sys. C – Mouth & Throat
Q – Lower Bones
1 – Peripheral Nervous Sys
D – Gastro System
R – Upper Joints
2 – Heart & Great Vessels
F – Hepatobiliary System & Pancreas
S – Lower Joints
3 – Upper Arteries
G – Endocrine System
T – Urinary System
4 – Lower Arteries
H – Skin & Breast
U – Female Reproductive System
5 – Upper Veins
J – SQ Tissue & Fascia
V – Male Reproductive System
6 – Lower Veins
K – Muscles
W – Anatomical Regions, General
7 – Lymphatic & Hemic
L - Tendons
X – Anatomical Regions, Upper Extremities
8 – Eye
M – Bursae & Ligaments
Y – Anatomical Regions, Lower Extremities
9 – Ear Nose & Sinus
N – Head & Facial Bones
B – Respiratory System
P – Upper Bones

14. Root Operations ~ Character 32 3 4 5 6 7
Section
Body System
Root
Operation
Body
Part
Approach
Device
Qualifier
Objective of Procedure
31 root operations
Arranged by similar attributes
Multiple codes

15. Examples of Root Operations
Bypass
Drainage
Reattachment
Resection
Inspection

16. Root Operations
Alteration
Division
Inspection
Reposition
Bypass
Drainage
Map
Resection
Change
Excision
Occlusion
Restriction
Control
Extirpation
Reattachment
Revision
Creation
Extraction
Release
Supplement
Destruction
Fragmentation
Removal
Transfer
Detachment
Fusion
Repair
Transplantation
Dilation
Insertion
Replacement
There are 31 different root operations! The root is the reason, or objective, for the procedure

17. Body Part ~ Character 4 Fourth character Anatomical site for procedure2 3 4 5 6 7
Section
Body System
Root
Operation
Body
Part
Approach
Device
Qualifier
Fourth character
Anatomical site for procedure
34 possible values per body system

18. Examples of Body Parts Liver Kidney Thalamus Ascending Colon
Optic Nerve
Tonsil
Axillary vein, left
Radial nerve
Cerebellum
Upper lung lobe (R)

19. Approach ~ Character 5
Character 1
Character 2 3 4 5 6 7
Section
Body System
Root
Operation
Body
Part
Approach
Device
Qualifier
Fifth character – approach or technique used to reach procedure
Seven different approach values
May be through: skin, mucous membrane, orifice or external

20. Examples of Approaches
Skin or Mucous Membranes
~ Open, percutaneous or percutaneous endoscopic
Through an Orifice
~ Via Natural or Artificial Opening
~ Via Natural or Artificial Opening Endoscopically
~ Via Natural or Artificial Opening with Percutaneous Endoscopic Assistance
External

21. Root Operations~ Character 5
Approach contains three components:
Access location
Method
Type of instrumentation
Types of approaches:
Open
Percutaneous & percutaneous endoscopic
Via natural/artificial Opening
Natural/Artificial Opening Endoscopic
Natural/Artificial Opening with Percutaneous Endoscopic Assistance
External

22. Device ~ Character 6
Character 1
Character 2 3 4 5 6 7
Section
Body System
Root
Operation
Body
Part
Approach
Device
Qualifier
Only procedures with a remaining device after the procedure will have a specific device value. All codes require seven characters. The default value to indicate that NO device was involved is Z. Materials incidental to the procedure (clips and sutures) are not considered devices.

23. Four Groups of Devices Grafts Prostheses Implants
Simple or Mechanical Appliances
Electronic Appliances

24. Qualifier ~ Character 7 Provides additional information2 3 4 5 6 7
Section
Body System
Root
Operation
Body
Part
Approach
Device
Qualifier
Provides additional information
May have narrow application
There are NO specific guidelines for qualifiers

25. TIP!
Most procedures will not have an applicable qualifier…the default value to indicate that NO qualifier
is necessary is…… Z

26. Simple Way to Remember the Seven Character Meanings!
Sally = Selection Bought = Body System Root = Root Operation Beer = Body Part At = Approach Dairy = Device Queen = Qualifier

27. True or False?
A biological or synthetic material that takes the place of all or a portion of a body part such as a joint prosthesis would qualify as a device in ICD-10-PCS. A: True Rationale: A device is specified in the sixth character and is used to identify devices that remain after the procedure is complete

28. Test Your Knowledge
All ICD-10-PCS codes have _____________ characters.
3 to 5
3 to 7
5 to 7 7
Materials such as sutures, ligatures, radiological markers, and temporary postop wound drains should be coded separately using ICD-10-PCS device codes
a. True
b. False
When coding in ICD-10-PCS, it is necessary to consult the Alphabetic Index and then proceed to the Tables.

29. Medical and Surgical Section (0): Root Operations
There are 31 root operations in ICD-10-PCS; each identifies the objective of a procedure and holds the key to the highly specific details and precision of the code values.

30. Root Operation Guidelines
B3. Root Operation - General 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
B3.1b Components of a procedure specified in the root operation definition are not coded separately. Procedural steps necessary to reach the operative site and close the operative site are also not coded separately.
EXAMPLES:
Resection of a joint as part of a joint replacement procedure is included in the root operation definition of Replacement and is not coded separately. Laparotomy performed to reach the site of an open liver biopsy is not coded separately. In a resection of sigmoid colon with anastomosis of descending colon to rectum, the anastomosis is not coded separately.

31. B3. Root Operation - General guidelines continued:
B3.2. Multiple Procedures:
During the same operative episode, multiple procedures are coded if:
a. The same root operation is performed on different body parts as defined by distinct values of the body part character.
b. The same root operation is repeated at different body sites that are included in the same body part value.
c. Multiple root operations with distinct objectives are performed on the same body part
d. The intended root operation is attempted using one approach, but it converted to a different approach

32. B3. Root Operation - General guidelines continued:
B3.3. Discontinued Procedures:
If the intended procedure is discontinued, code the procedure to the root operation performed. If a procedure is discontinued before any other root operation is performed, code the root operation inspection of the body part or anatomical region inspected
B3.4a. Biopsy Procedures:
Are coded using the root operations, Extraction, or Drainage and the qualifier Diagnostic. The qualifier Diagnostic is ONLY used for biopsies
B3.4b. Biopsy followed by a more definitive treatment:
If a diagnostic Excision, Extraction, or Drainage procedure is followed by a more definitive procedure, such as Destruction, Excision or Resection at the same procedure site, both the biopsy and more definitive treatment are coded

33. Medical & Surgical Section: Root Operations That Take Out Some/All of a Body Part
Excision B:
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

34. Example Case One
A 32-year-old female patient experienced melena gradually worsening over the last five days. Patient complains of weakness and dizziness to the point of passing out at work. She was admitted to the hospital for observation and an EGD. An EGD of the duodenum was performed the following morning.
What is the ICD-10-PCS code for this procedure?
Root operation: _________________________________
Specific Body Part: _________________________________
Seventh Character: _________________________________
ICD-10-PCS Code: _________________________________

35. Example Case One Snapshot of PCS Coding Book

36. Answer Case One What is the ICD-10-PCS code for this procedure?
Root operation: Excision
Specific Body Part: Duodenum identified with 4th character
Seventh Character: “X” for diagnostic
ICD-10-PCS Code: 0DB98ZX

37. Medical & Surgical Section: Root Operation - Resection
Resection - T:
Definition: Cutting out, or off, without replacement, all of a body part
Explanation: N/A
Examples: Total Nephrectomy, total lobectomy of lung

38. Example Case Two
A 45-year-old male patient was diagnoses with acquired hemolytic anemia, autoimmune type with warm-reactive antibodies, and has been treated with glucocoricoids. Given the aggressive nature of his anemia, he was advised to have a total splenectomy to eliminate the body’s further destruction of red blood cells. Open splenectomy was performed without complications.
What is the ICD-10-PCS code for this procedure?
Root operation: _________________________________
Specific Body Part: _________________________________
Seventh Character: _________________________________
ICD-10-PCS Code: _________________________________

39. Example Case Two Snapshot of PCS Coding Book

40. Answer Case Two What is the ICD-10-PCS code for this procedure?
Root operation: Resection
Specific Body Part: No device
Seventh Character: No qualifier
ICD-10-PCS Code: 07TP0ZZ

41. Medical & Surgical Section: Root Operations That Always Involve a Device
B6. Device
B6.1a. A device is coded only if a device remains after the procedure is completed, if no device remains, the device value No Device is coded.
B6.1b. Materials such a sutures, ligatures, radiological markers and temporary post-operative wound drains are considered integral to the performance of a procedure and not coded as devices.
B6.1.c. Procedures performed on a device only and not on a body part are specified in the root operations Change, Irrigation, Removal and Revision and are coded to the procedure performed.

42. Medical & Surgical Section: Root Operation - Replacement
Replacement - R:
Definition: Putting in or on a biological or synthetic material that physically takes the place and/or function of all or a portion of the body part.
Explanation: The body part may have been taken out or replaced, or may be taken out, physically eradicated or rendered nonfunctional. A Removal procedure is coded for taking out the device used in previous replacement procedure.

43. Example Case Three
The patient had a total right knee replacement 9 years ago. The patient was found to have an aseptic loosening and it was recommended to have total knee revision arthroplasty. The patient was taken to the OR where a ® TKR revision was carried out. During the procedure the previous prosthetic device was removed and a new cemented prosthetic device was inserted.
What is the ICD-10-PCS code for this procedure?
Root operation: _________________________________
Specific Body Part: _________________________________
Seventh Character: _________________________________
ICD-10-PCS Code: _________________________________

44. Example Case Three Snapshot of PCS Coding Book

45. Answer Case Three What is the ICD-10-PCS code for this procedure?
Root operation: Replacement
Specific Body Part: Knee component and laterality
Seventh Character: cemented
ICD-10-PCS Code: 0SRC0J9

46. ICD-10-PCS
DO WE HAVE TO CLIMB THAT?!

47. Preparing for the Inevitable:
10/01/2014

48. Don’t be a Fish out of Water!
Brush up on your anatomy
Review your pathophysiology
Don’t procrastinate!
START NOW

49. Many, Many Web Resources!

50. Resources Used
Application of ICD-10-PCS Root Operations, Audio Seminar, October 23, 2012 AHIMA
ICD-10-CM Official Guidelines for Coding and Reporting 2014:
ICD-10-PCS Code Set:
ICD-10-PCS, The Complete Official Draft Code Set 2014, Optum
Root Operations: Key to Procedure Coding in ICD-10-PCS, Ann Barta & Ann Zeisset, AHIMA, 2011

51. Summer, 2015…..Life is Good!