Presentation on theme: "ICD-10 PCS Coding procedures common to all facilities"— Presentation transcript:
1 ICD-10 PCS Coding procedures common to all facilities Presented byAHIMA-Approved ICD-10-CM/PCS Trainers :Deb Selland, RHIT, CCSSue Roehl, RHIT, CCS
2 Instructors Sue Roehl, RHIT, CCS Sue Roehl, RHIT, CCSSue 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 She has twice served as President for the North Dakota Health Information Management Association, along with various other Board offices.Deb Selland, RHIT, CCSDeb 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 She has formerly served as President and Education Director for NDHIMA.
3 DisclaimerThe 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.
4 Objectives Review structure of PCS codes Code common procedures from various sections of ICD-10-PCS
6 ICD-10-PCS (Procedures) 6ICD-10-PCS(Procedures)Used in inpatient hospital settingReplaces Volume 3Maintained by CMSCPT will still be used in all outpatient settings
7 Structures and Features Comparison 7Structures and Features ComparisonICD-9-CM Volume 3ProceduresICD-10-PCS-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)I & O are not used in PCS but are used when coding diagnoses.
8 *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.This is another difference between ICD-10-CM and PCS.When coding diagnoses, the character length MAY be 3 to 7 characters long while in PCS the code will ALWAYS be 7 characters.
9 *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 coder’s 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.
10 Structures and Features Comparison 10Structures and Features ComparisonICD-9-CM Volume 3(Procedures)ICD-10-PCSConsists of:-Index-TabularIndexProvides first 3 or 4 values of the code- TablesMust be used to build complete codeIn ICD-10-PCS we define the coding process as “building” a code.
11 Structure and Features of ICD-10-PCS Character Meanings1234567SectionSections (#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.The first character in a 7 character PCS code will always indicate the Section.The Medical & Surgical Section will be the most common area that inpatient procedure codes will be assigned from and procedures from this sectionwill always begin with a first character of 0 (zero).
12 This screen lists the 16 sections of PCS This screen lists the 16 sections of PCS. The first character in a 7 character PCS code will always indicate the Section.This is another difference between ICD-10 diagnosis and procedure coding. A diagnosis code will always begin with a letter (alpha character)while procedure codes will begin with either an alpha OR numeric character depending on which section it is coded from.
13 Body Systems (#31) 1 2 3 4 5 6 7 Section Body System 2nd Character 1234567SectionBody System2nd CharacterBody Systems (#31)Body systems are specified in the second character.There are 31 Body Systems within the Medical & Surgical Section.Guideline B2.2 Body systems designated as upper or lower contain body parts located above or below the diaphragm respectively.
14 Root Operation 1 2 3 4 5 6 7 Section Body System Root Operation 1234567SectionBody SystemRoot Operation 3rd CharacterRoot OperationThe third character specifies the root operation, or the objective/intent of the procedure.There are 31 root operations within the Medical & Surgical Section.Each root operation has a precise definition.
15 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.ICD-9-PCS Coding Guidelines:B3.1a is just one of many coding guidelines regarding root operations.
16 ICD-10 Procedure Coding System Global Root Operations (Section 0-9) 16AlterationDefinition-Modifying the anatomic structure of a body part without affecting the function of the body partExplanation-Principal purpose is to improve appearanceExamples-Face lift, breast augmentationBypassDefinition-Altering the route of passage of the contents of a tubular body partExplanation-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 formationChangeDefinition-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 ExternalExamples-Urinary catheter change, gastrostomy tube changeControlDefinition-Stopping, or attempting to stop, postprocedure bleedingExplanation-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 hemorrhageThe following screens list the 31 root operations, their definitions and examples of procedures that are within each root operation.
17 Global Root Operations (Section 0-9) 17CreationDefinition-Making a new genital structure that does not take over the function of a body partExplanation-Used only for sex change operationsExamples-Creation of vagina in a male, creation of penis in a femaleDestructionDefinition-Physical eradicating all or a portion of a body part by the direct use of energy, force or a destructive agentExplanation- None of the body part is physically taken out.Examples-Fulguration of rectal polyp, cautery of skin lesionDetachmentDefinition-Cutting off all or a portion of an upper or lower extremityExplanation-The body part value is the site of the detachment, with a qualifier if applicable to further specify the level where the extremity was detachedExamples-Below knee amputation, disarticulation of shoulderDilationDefinition-Expanding an orifice or the lumen of a tubular body partExplanation-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, pyloromyotomyDivisionDefinition-Cutting into a body part without draining fluids and/or gases from the body part in order to separate or transect a body partExplanation-All or a portion of the body part is separated into two or more portionsExamples-Spinal cordotomy, osteotomy
18 ICD-10 Procedure Coding System Global Root Operations (Section 0-9) 18DrainageDefinition-Taking or letting out fluids and/or gases from a body partExplanation-The qualifier DIAGNOSTIC is used to identify drainage procedures that are biopsies.Examples-Thoracentesis, incision and drainageExcisionDefinition-Cutting out or off, without replacement, a portion of a body partExplanation-The qualifier DIAGNOSTIC is used to identify excision procedures that are biopsiesExamples-partial nephrectomy, liver biopsyExtirpationDefinition-Taking or cutting out solid matter from a body partExplanation-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, choledocholithotomyExtractionDefinition-Pulling or stripping out or off all or a portion of a body partExplanation-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
19 Global Root Operations (Section 0-9) 19FragmentationDefinition-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 lithotripsyFusionDefinition-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 arthrodesisInsertionDefinition-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- NoneExamples-Insertion of radioactive implant, insertion of central venous catheterInspectionDefinition-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
20 ICD-10 Procedure Coding System Global Root Operations (Section 0-9) 20MapDefinition-Locating the route of passage of electrical impulses and/or locating functional areas in a body partExplanation-Applicable only to the cardiac conduction mechanism and the central nervous systemExamples-Cardiac mapping, cortical mappingOcclusionDefinition-Completely closing an orifice or the lumen of a tubular body partExplanation-The orifice can be a natural orifice or an artificially created orificeExamples-Fallopian tube ligation, ligation of inferior vena cavaReattachmentDefinition-Putting back in or on all or a portion of a separated body part to its normal location or other suitable locationExplanation-Vascular circulation and nervous pathways may or may not be reestablishedExamples-Reattachment of hand, reattachment of avulsed kidneyReleaseDefinition-Freeing a body part from an abnormal physical constraint by cutting or by use of forceExplanation- Some of the restraining tissue may be taken out but none of the body part is taken outExamples-Adhesiolysis, carpal tunnel release
21 ICD-10 Procedure Coding System Global Root Operations (Section 0-9) 21RemovalDefinition-Taking out or off a device from a body partExplanation-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 removalRepairDefinition-Restoring, to the extent possible, a body part to its normal anatomic structure and functionExplanation-Used only when the method to accomplish the repair is not one of the other root operationsExamples-Herniorrhaphy, suture of lacerationReplacementDefinition-Putting in or on biological or synthetic material that physically takes the place of all or a portion of a body partExplanation-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
22 ICD-10 Procedure Coding System Global Root Operations (Section 0-9) 22RepositionDefinition-Moving to its normal location or other suitable location all or a portion of a body partExplanation-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 reductionResectionDefinition-Cutting out or off, without replacement, all of a body part.Explanation-NoneExamples-Total nephrectomy, total lobectomy of lungRestrictionDefinition-Partially closing an orifice or the lumen of a tubular body partExplanation-The orifice can be a natural orifice or an artificially created orifice.Examples-Esophagogastric fundoplication, cervical cerclageRevisionDefinition-Correcting to the extent possible a malfunctioning or displaced deviceExplanation-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 prosthesisResection—all of a body part.Excision—portion of a body part.
23 ICD-10 Procedure Coding System Global Root Operations (Section 0-9) 23SupplementDefinition-Putting in or on biological or synthetic material that physically reinforces or augments the function of a body partExplanation-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 partExamples-Herniorrhaphy using mesh, free nerve mitral valve ring annuloplasty, put a new acetabular liner in a previous hip replacementTransferDefinition-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 partExplanation-The body part transferred remains connected to its vascular and nervous supply.Examples-Tendon transfer, skin pedicle flap transfer
24 ICD-10 Procedure Coding System Global Root Operations (Section 0-9) 24TransplantationDefinition-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 partExplanation-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 functionExamples-Kidney transplant, heart transplant
25 4th Character Body Part 1 2 3 4 5 6 7 Section Body System Root OperationBody Part4th Character Body PartThe fourth character of a PCS code identifies the body part.ICE-10-PCS does not provide a specific value for every body part. The body part value selected would either be the whole body part value (e.g. alveolar process is part of the mandible), or with nerves and vessels, the body part value is coded to the closest proximal branch.
26 Comparing ICD-9-CM and ICD-10-PCS: Release Carpal Tunnel Release, PercutaneousIn 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.
27 5th Character Approach (7 Options) 1 2 3 4 5 6 7 Section Body System Root OperationBody PartApproach5th CharacterApproach (7 Options)The approach is the technique used to reach the site of the procedure and is the 5th character.
28 ICD-10 Procedure Coding System Medical and Surgical Approaches 281OpenCutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedureExample: Abdominal hysterectomy2PercutaneousEntry, 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 procedureExample: Needle biopsy of liver3Percutaneous EndoscopicEntry, 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: Arthroscopy4Via natural or artificial openingEntry of instrumentation through a natural or artificial external opening to reach the site of the procedure Example: Endotracheal intubation5Via natural or artificial opening endoscopicEntry of instrumentation through a natural or artificial external opening to reach and visualize the site of the procedureExample: Sigmoidoscopy6Via natural or artificial opening endoscopic with percutaneous endoscopic assistanceEntry 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 hysterectomy7ExternalProcedures 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 reductionThere are 7 different approaches in the Medical & Surgical section.This screen lists the definitions and examples of the various approaches.
29 Device 29 1 2 3 4 5 6 7 Section Body System Root Operation Body Part 1234567SectionBody SystemRoot OperationBody PartApproachDevice 6th CharacterDeviceThe device (if used) is specified in the sixth character.
30 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.The first bullet is taken from the Introduction section of the PCS codebook.The second bullet is PCS coding guideline B6.1b
31 7th Character - Qualifier 1234567SectionBody SystemRoot OperationBody PartApproachDeviceQualifier7th Character - Qualifier-Defines an additional attribute of the procedure performed, if applicable.The qualifier is specified in the seventh character. The qualifier contains unique values for individual procedures.Examples of qualifiers are the type of transplant (Allogeneic: same species, Syngeneic: genetically identical or Zooplastic: animal to human),or destination site of a bypass.
32 Medical and Surgical Section (0) ICD-9 Volume 3ICD-10-PCS81.91 ArthrocentesisArthrocentesis, right knee, diagnostic, no device0S9C3ZX51.23 Laparoscopic cholecystectomy0FT44ZZ51.22 Open cholecystectomy0FT40ZZ54.91 Percutaneous abdominal drainageNot diagnostic, no device0W9F3ZZ03.31 Spinal tapDiagnostic009U3ZX (spinal canal)009Y3ZX (lumbar spinal cord)_Spinal canal appears more appropriateIn ICD-9 we only know this is a joint aspiration (any joint, either side).0S9C3ZX--With ICD-10 we now identify with character 4 that this is the right knee joint.Lap chole 0FT44ZZChole 0FT40ZZPercutaneous abdominal drainage 0W9F3ZZ Drainage abdominal wall, perc,Spinal tap, drainage spinal canal, percutaneous, diagnostic 009U32X
33 Medical and Surgical Section (0) ICD-9 Volume 3ICD-10-PCS86.04 Incision and drainage skinLeft upper arm, diagnostic0H9CXZX54.51 Laparoscopic lysis of peritoneal adhesions0DNW4ZZ54.59 Open lysis of adhesionsGreater omentumADN50ZZ34.04 Insertion chest tubeLeft, percutaneous with device0W9B30Z64.0 Circumcision0VTTXZZI&D skin, drainage left upper arm, external approach, diagnostic. Need site and laterality 0H9CXZXLaparoscopic, peritoneal 0DNW4ZZOpen, greater omentum, multiple sites available 0DNS0ZZInsertion chest tube, drainage, left, percutaneous with device 0W9B30ZCircumcision (adult or newborn) 0VTTXZZ
34 Obstetric SectionThe 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.
35 Obstetric Section Character 1 - Section - always 1 Character 2 - Body System - PregnancyCharacter 3 - Root OperationVaginal Delivery and Cesarean are both ExtractionCharacter 4 - Body PartProducts of ConceptionProducts of Conception, retainedProducts of Conception, ectopicCharacter 5 - ApproachCharacter 6 - Device (Fetal Monitor electrodes)Character 7 - Qualifier (type of extraction, type of Cesarean Section, or type of fluid taken out)
36 Medical and Surgical Section (0) Obstetrics Section (1) ICD-9 Volume 3ICD-10-PCS73.6 Episiotomy0W8NXZZ Episiotomy10E0XZZ Delivery74.1 Low cervical cesarean section10D00Z173.09 AROM10907ZC (Amniotic fluid is considered a product of conception)75.4 Manual removal placenta10D17ZZ72.79 Vacuum extraction10D07Z6 (Extraction – vacuum is the qualifier)Episiotomy 0W8NXZZ (division female perineum, external approach) + 10E0XZZ for deliveryLow cervical cesarean section 10D00Z1:Vacuum delivery 10D07Z6 (qualifier is Vacuum)Manual removal placenta 10D17ZZAROM 10907ZC
37 Obstetric Section Vaginal delivery, vacuum: Extraction: Extraction of Products of Conception, Vacuum, Via Natural or Artificial OpeningVaginal delivery with episiotomy:Extraction: Delivery of Products of Conception, External ApproachDivision of Female Perineum, External ApproachCesarean SectionExtraction: Extraction of products of conception, low cervical, open approach (Low cervical Cesarean section)
38 Placement (2) Character 1 – Section Always 2 Character 2 – Anatomical RegionAnatomical Region or:Anatomical OrificesCharacter 3 – Root OperationNo incision or punctureCompression ;Dressing: Immobilization; Packing; and Traction are root operations in the Placement SectionCharacter 4 – Body Region/OrificeCharacter 5 – Approach - Always ExternalCharacter 6 – Device – almost always a deviceCharacter 7 – Qualifier - always No QualifierCharacter 6 -
39 Placement Packing of external ear canal: 2Y42X5Z Splinting of right ankle: 2W3LX1ZIf a device is taken out and similar device is put in to the same region (without cutting or puncture of skin or mucous membrane) it is “change”Packing ear – 2Y42X5Z (packing of ear using packing material)Splinting right ankle – 2W3LX1Z (immobilization of right lower extremity using splint).
40 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.
41 Administration Section (3) Character 1 - Section - always 3Character 2 - Body SystemIndwelling DevicePhysiological System and Anatomical RegionsCirculatory System (transfusion procedures)Character 3 - Root OperationIntroductionIrrigationTransfusionCharacter 4 - Body System/RegionCharacter 5 - ApproachPercutaneous injection, insertion of catheter to introduce contrastCharacter 6 - SubstanceCharacter 7 - Qualifier#6 – i.e. anesthetic, contrast, dialysate, blood products#7 – Autologous ( ) or nonautologous ( ) or to further specify substance
43 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.
44 Resources: Comprehensive Anatomy and Physiology for ICD-10-CM and -PCS Coding (Softbound) - ($149.95)This website provides free access to Gray’s Anatomy book with illustrations which may be beneficial for participants.