4 Why Now? ICD-10-PCS is completely different from ICD-9-CM, Vol. 3 Multi-axial structureCompletenessExpandabilityStandardized terminologyStandardized level of specificityNo explicit options of “NOS” and limited use of “NEC” code
5 ICD-9-CM Vol. 3 vs ICD-10-PCS ICD-9-CM Volume 3ICD-10-PCSFollows ICD structure (designed for DX coding)Designed and developed to meet healthcare needs for a procedure coding systemCodes available as fixed and finite set in list formCodes constructed from flexible code components using TableCodes are 3 to 4 digits long with a decimal point places after the second digitCodes are 7 characters longCodes are numericCodes are alphanumeric
6 Number of Codes in ICD-10-PCS at the time of printing the 2014 Official Draft Code Set manual: 71,924For 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:NumberLetter for each character, with a total of 7 charactersIMPORTANT: The Tables must be used to paint a complete and accurate picture!
8 ICD-10-PCS Format & Structure Character 1Character234567SectionBody SystemRootOperationBodyPartApproachDeviceQualifierEach code is seven characters and can be alphabetical or numericTen digits 0-9 and 24 letters A-H, J-N, and P-Z are usedEach of the characters has a well-defined meaning
9 Section ~ Character 1 All Codes in PCS are seven characters 234567SectionBody SystemRootOperationBodyPartApproachDeviceQualifierAll Codes in PCS are seven charactersLetters O and I are not used – 0 and 1 are usedEach number has a meaningMeanings change depending on sectionsSection provides first character value
10 SectionMedical 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.
12 Body System~ Character 2 34567SectionBody SystemRootOperationBodyPartApproachDeviceQualifierSecond characterBody System, general physiological system or anatomical region involvedReview Body Systems in training manualAppendix G
14 Root Operations ~ Character 3 234567SectionBody SystemRootOperationBodyPartApproachDeviceQualifierObjective of Procedure31 root operationsArranged by similar attributesMultiple codes
15 Examples of Root Operations BypassDrainageReattachmentResectionInspection
16 Root OperationsAlterationDivisionInspectionRepositionBypassDrainageMapResectionChangeExcisionOcclusionRestrictionControlExtirpationReattachmentRevisionCreationExtractionReleaseSupplementDestructionFragmentationRemovalTransferDetachmentFusionRepairTransplantationDilationInsertionReplacementThere 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 procedure 234567SectionBody SystemRootOperationBodyPartApproachDeviceQualifierFourth characterAnatomical site for procedure34 possible values per body system
18 Examples of Body Parts Liver Kidney Thalamus Ascending Colon Optic NerveTonsilAxillary vein, leftRadial nerveCerebellumUpper lung lobe (R)
19 Approach ~ Character 5Character 1Character234567SectionBody SystemRootOperationBodyPartApproachDeviceQualifierFifth character – approach or technique used to reach procedureSeven different approach valuesMay be through: skin, mucous membrane, orifice or external
20 Examples of Approaches Skin or Mucous Membranes~ Open, percutaneous or percutaneous endoscopicThrough an Orifice~ Via Natural or Artificial Opening~ Via Natural or Artificial Opening Endoscopically~ Via Natural or Artificial Opening with Percutaneous Endoscopic AssistanceExternal
21 Root Operations~ Character 5 Approach contains three components:Access locationMethodType of instrumentationTypes of approaches:OpenPercutaneous & percutaneous endoscopicVia natural/artificial OpeningNatural/Artificial Opening EndoscopicNatural/Artificial Opening with Percutaneous Endoscopic AssistanceExternal
22 Device ~ Character 6Character 1Character234567SectionBody SystemRootOperationBodyPartApproachDeviceQualifierOnly 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 AppliancesElectronic Appliances
24 Qualifier ~ Character 7 Provides additional information 234567SectionBody SystemRootOperationBodyPartApproachDeviceQualifierProvides additional informationMay have narrow applicationThere are NO specific guidelines for qualifiers
25 TIP!Most procedures will not have an applicable qualifier…the default value to indicate that NO qualifieris 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 KnowledgeAll ICD-10-PCS codes have _____________ characters.3 to 53 to 75 to 77Materials such as sutures, ligatures, radiological markers, and temporary postop wound drains should be coded separately using ICD-10-PCS device codesa. Trueb. FalseWhen 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 guidelinesB3.1a. In order to determine the appropriate root operation, the full definition of the root operation as contained in the PCS Tables must be appliedB3.1b 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 partd. 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 inspectedB3.4a. Biopsy Procedures:Are coded using the root operations, Extraction, or Drainage and the qualifier Diagnostic. The qualifier Diagnostic is ONLY used for biopsiesB3.4b. 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 partExplanation: The qualifier DIAGNOSTIC is used to identify excision procedures that are biopsiesExamples: Partial Nephrectomy, Liver biopsy
34 Example Case OneA 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: _________________________________
36 Answer Case One What is the ICD-10-PCS code for this procedure? Root operation: ExcisionSpecific Body Part: Duodenum identified with 4th characterSeventh Character: “X” for diagnosticICD-10-PCS Code: 0DB98ZX
37 Medical & Surgical Section: Root Operation - Resection Resection - T:Definition: Cutting out, or off, without replacement, all of a body partExplanation: N/AExamples: Total Nephrectomy, total lobectomy of lung
38 Example Case TwoA 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: _________________________________
40 Answer Case Two What is the ICD-10-PCS code for this procedure? Root operation: ResectionSpecific Body Part: No deviceSeventh Character: No qualifierICD-10-PCS Code: 07TP0ZZ
41 Medical & Surgical Section: Root Operations That Always Involve a Device B6. DeviceB6.1a. 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 ThreeThe 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: _________________________________
50 Resources UsedApplication of ICD-10-PCS Root Operations, Audio Seminar, October 23, 2012 AHIMAICD-10-CM Official Guidelines for Coding and Reporting 2014:ICD-10-PCS Code Set:ICD-10-PCS, The Complete Official Draft Code Set 2014, OptumRoot Operations: Key to Procedure Coding in ICD-10-PCS, Ann Barta & Ann Zeisset, AHIMA, 2011