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ICD-10 PCS CODING 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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Presentation on theme: "ICD-10 PCS CODING PROCEDURES COMMON TO ALL FACILITIES Presented by AHIMA-Approved ICD-10-CM/PCS Trainers : Deb Selland, RHIT, CCS Sue Roehl, RHIT, CCS."— Presentation transcript:

1 ICD-10 PCS CODING PROCEDURES COMMON TO ALL FACILITIES Presented by AHIMA-Approved ICD-10-CM/PCS Trainers : Deb Selland, RHIT, CCS Sue Roehl, RHIT, CCS

2 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 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 She has formerly served as President and Education Director for NDHIMA. 2

3 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. 3

4 Objectives Review structure of PCS codes Code common procedures from various sections of ICD-10-PCS 4

5 ICD-10-PCS Procedure Classification System 5

6 ICD-10-PCS (Procedures) Used in inpatient hospital setting Replaces Volume 3 Maintained by CMS 6 6

7 Structures and Features Comparison 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) 7 7

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. 8

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. 9

10 Structures and Features Comparison 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 10

11 Structure and Features of ICD-10-PCS Character Meanings Section 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. 11

12 12

13 SectionBody System 2 nd Character Body Systems (#31) 13

14 SectionBody System Root Operation 3rd Character Root Operation 14

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. 15

16 ICD-10 Procedure Coding System Global Root Operations (Section 0-9) AlterationDefinition-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 BypassDefinition-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 ChangeDefinition-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 ControlDefinition-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 16

17 Global Root Operations (Section 0-9) 17 CreationDefinition-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 DestructionDefinition-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 DetachmentDefinition-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 DilationDefinition-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 DivisionDefinition-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 17

18 ICD-10 Procedure Coding System Global Root Operations (Section 0-9) DrainageDefinition-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 ExcisionDefinition-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 ExtirpationDefinition-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 ExtractionDefinition-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 18

19 Global Root Operations (Section 0-9) FragmentationDefinition-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 FusionDefinition-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 InsertionDefinition-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 InspectionDefinition-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 19

20 ICD-10 Procedure Coding System Global Root Operations (Section 0-9) MapDefinition-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 OcclusionDefinition-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 ReattachmentDefinition-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 ReleaseDefinition-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 20

21 ICD-10 Procedure Coding System Global Root Operations (Section 0-9) RemovalDefinition-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 RepairDefinition-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 ReplacementDefinition-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 21

22 ICD-10 Procedure Coding System Global Root Operations (Section 0-9) RepositionDefinition-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 ResectionDefinition-Cutting out or off, without replacement, all of a body part. Explanation-None Examples-Total nephrectomy, total lobectomy of lung RestrictionDefinition-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 RevisionDefinition-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 22

23 ICD-10 Procedure Coding System Global Root Operations (Section 0-9) SupplementDefinition-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 TransferDefinition-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 23

24 ICD-10 Procedure Coding System Global Root Operations (Section 0-9) TransplantationDefinition-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 24

25 4 th Character Body Part SectionBody SystemRoot Operation Body Part 25

26 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. 26

27 Approach SectionBody SystemRoot Operation Body Part 5 th Character Approach (7 Options) 27

28 ICD-10 Procedure Coding System Medical and Surgical Approaches 1OpenCutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure Example: Abdominal hysterectomy 2PercutaneousEntry, 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 3Percutaneous 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 4Via natural or artificial opening Entry of instrumentation through a natural or artificial external opening to reach the site of the procedure Example: Endotracheal intubation 5Via 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 6Via 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 7ExternalProcedures 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 28

29 Device SectionBody SystemRoot Operation Body PartApproach 6 th Character Device 29

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. 30

31 SectionBody SystemRoot Operation Body PartApproachDevice 7 th Character - Qualifier -Defines an additional attribute of the procedure performed, if applicable. Qualifier 31

32 Medical and Surgical Section (0) ICD-9 Volume 3ICD-10-PCS ArthrocentesisArthrocentesis, right knee, diagnostic, no device 0S9C3ZX Laparoscopic cholecystectomy0FT44ZZ Open cholecystectomy0FT40ZZ Percutaneous abdominal drainageNot diagnostic, no device 0W9F3ZZ Spinal tapDiagnostic 009U3ZX (spinal canal) 009Y3ZX (lumbar spinal cord)_Spinal canal appears more appropriate 32

33 Medical and Surgical Section (0) ICD-9 Volume 3ICD-10-PCS Incision and drainage skinLeft upper arm, diagnostic 0H9CXZX Laparoscopic lysis of peritoneal adhesions 0DNW4ZZ Open lysis of adhesionsGreater omentum ADN50ZZ Insertion chest tubeLeft, percutaneous with device 0W9B30Z 64.0 Circumcision0VTTXZZ 33

34 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. 34

35 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) 35

36 Medical and Surgical Section (0) Obstetrics Section (1) ICD-9 Volume 3ICD-10-PCS 73.6 Episiotomy0W8NXZZ Episiotomy 10E0XZZ Delivery 74.1 Low cervical cesarean section10D00Z AROM10907ZC (Amniotic fluid is considered a product of conception) 75.4 Manual removal placenta10D17ZZ Vacuum extraction10D07Z6 (Extraction – vacuum is the qualifier) 36

37 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) 37

38 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 38

39 Placement Packing of external ear canal: 2Y42X5Z Splinting of right ankle: 2W3LX1Z 39

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. 40

41 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 41

42 ICD-9 Volume 3ICD-10-PCS Endotracheal intubationNot endoscopic 0BH17EZ Mechanical ventilation <96 consecutive hours Less than 24 hours 5A1935Z TPN2 codes (upper vein) 05HY33Z 3E0336Z 73.4 Medical induction labor (IV Oxytocin) 3E033VJ (intro, peripheral vein, hormone) Packed cell transfusion30233N External fetal monitoring4A1HXCZ 42

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. 43

44 Resources: Comprehensive Anatomy and Physiology for ICD-10-CM and - PCS Coding (Softbound) - ($149.95) s-Anatomy.html t=/icd10 44


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