3 Things will never be the same once we switch to ICD-10-PCS! Complete overhaul of the procedure classification system as we know it today.Tip! Refer to Appendix F: Character Meanings – this will save you!But don’t panic, it can be easily mastered!
4 More Tips…ICD-10-PCS codes include one digit for the root operation that the physician performs.Root operation is always the 3rd character in the seven character code.Start by reviewing the definitions of the various root operations. If you learn the root operations early, you’ll have a head start on learning how to code in ICD-10- PCS.
5 And The Best Tip!Always look first in the Alphabetic Index (will give you the first 3 or 4 characters) and then finish building the procedure code in the Tables.Key! You can’t jump around in the tables. Need to go across to get your procedure code!
6 Who Developed The ICD-10-PCS System? CMS awarded the contract to 3M Health Information Systems to develop a new procedure coding system for ICD-10.New system is intended to replace ICD- 9-CM Volume 3 for reporting hospital inpatient procedures.But what about the outpatient side?
7 General PrinciplesDiagnostic information is not included in the code description.A ‘not elsewhere classified’ option is allowed for new devices and substances.All substantially different procedures are defined.
8 General Principles “Limited NOS” Option A general body part, approach, or root operation can be used when the level of specificity is not available in the record or cannot otherwise be obtained.Should you query?
9 Limited NOS Option Body Part: Approach: Root Operation: Example: “Liver” is used when the specific liver lobe is not identified.Approach:“Open”, “Percutaneous” and “Via Natural or Artificial Opening” are used when a more specific type of approach is not documented and cannot otherwise be determined.Root Operation:“Repair” is used when the procedure documentation does NOT support a specific root operation and the information cannot otherwise be obtained.
10 ICD-9-CM vs. ICD-10-PCS ICD-9-CM (Volume 3) (Procedures) ICD-10-PCS Min. characters: 3Max. characters: 4Numeric format(+ V code)Decimal point3,000 procedure codesICD-10-PCS(Procedures)Min. characters: 7Max. characters: 7Alphanumeric formatNo decimal point71,918 procedure codes
11 Number of Codes in ICD-10-PCS SectionCodesMedical and Surgical**61,896Obstetrics300Placement861Administration1,384Measurement and Monitoring339Extracorporeal Assistance and Performance41Extracorporeal Therapies42Osteopathic100Other Procedures60Chiropractic90Imaging2,934Nuclear Medicine463Radiation Oncology1,939Rehabilitation and Diagnostic Audiology1,380Mental Health30Substance Abuse Treatment59Total71,918
12 ICD-10-PCS: Code Structure Seven Character Alphanumeric CodeAll procedure codes will be seven characters long“I” and “O” (letters) are never usedWhy not?34 possible values for each characterDigits 0 – 9Letters A-H, J-N, P-Z
13 System Structure 16 Sections Medical and SurgicalOther ProceduresObstetricsChiropracticPlacementImagingAdministrationNuclear MedicineMeasurement and MonitoringRadiation OncologyExtracorporeal Assistance and PerformancePhysical Rehabilitation and Diagnostic AudiologyExtracorporeal TherapiesMental HealthOsteopathicSubstance Abuse Treatment
14 ICD-10-PCS TablesEach table contains four columns and varying numbers of rows.Column: Specifies the allowable values for characters 4-7Row: Specifies the valid combinations of valuesBuilding block concept!
16 ICD-10-PCS CharactersSection: Identifies general type of procedure Body System: Identifies general body system Root Operation: Specifies objective of procedure Body Part: Identifies specific part of body system on which procedure is being performed Approach: Technique used to reach the site of the procedure Device: Identifies devices that remain after procedure is completed Qualifier: Provides additional information about a procedure, if necessary
17 ICD-10-PCS IndexProvides the first three or four characters of the procedure code.The tables must always be used to obtain the remaining digits for the complete code.No eponyms are included.Tables are used to construct a complete and valid code.Only characters appearing on the table may be used.
19 ICD-10-PCS Characters (Medical and Surgical Section) RootSection Operation Approach QualifierBody Body DeviceSystem Part
20 Susie Buys Root Beer At Dairy Queen 1st character = Section2nd character = Body System3rd character = Root Operation4th character = Body Part5th character = Approach6th character = Device7th character = Qualifier
21 Medical and Surgical Section Principles The root operation is based on the “objective or intent” of the procedure not by the procedure name.If multiple procedures as defined by distinct objectives are performed, then multiple ICD-10-PCS procedure codes are assigned.
22 Section Character (Character 1) 16 sections within ICD-10-PCS, the largest being the Medical & Surgical section.Defines the general ‘type’ of procedure, i.e., Med/Surg, OB, etc.Medical and Surgical Section the first character is always the number “0”.
23 Body System Character (Character 2) Identifies the body system, which is the general physiological system or anatomical region where the procedure is performed.Total of 31 body systems in ICD-10-PCS.Some traditional categories are subdivided into several body systems, for example:Cardiovascular is subdivided into 5 body systems:Heart and Great VesselsUpper ArteriesLower ArteriesUpper VeinsLower Veins
24 Body SystemsRefer to the ICD-10-PCS code book for a complete listing of the body systems (pg. 5).
25 Root Operation Character (Character 3) Defines the “objective” or “intent” of doing the procedure.33 different root operation valuesEach root operation identifies a precise and distinct objective.This is the most difficult part of procedural coding as the root operations may sound familiar, but may mean different things.Most time will be spent here!
26 Where Will The Confusion Be? The root operations ‘excision’ and ‘resection’ will be the most difficult to distinguish.Excision: Cutting out or off, without replacement a portion of a body partResection: Cutting out or off, without replacement, all of a body partThese definitions look very similar, but are very different as they involve a portion versus all of a body part.
28 Look at Procedures in a Whole New Way In ICD-10-PCS, every procedure falls into one of 33 root operations, which define the ‘objective’ of the procedure.Some root operations seem self-explanatory, i.e., transplantation or reattachment, others are not so easy.Procedure documentation may often include the term “removal”, but according to PCS definitions the physician actually performed an extraction or even an extirpation, Do not code directly what the physician lists as the procedure; rather, you should always read the OP report to determine what the physician actually did and which definition the procedure meets.
29 Potential Documentation Problem Procedure: Nonexcisional debridement of skin and back. There is no term in ICD-10-PCS for “debridement”, so based on definitions, the coder must review the body of the OP report to see what the physician actually performed. In this case, code the debridement as an extraction because it fits the definition (i.e., being pulled off a portion of the body part by use of force). In this case, skin is the body part.
30 Root Operation Principles The root operation is coded according to the objective of the procedure actually performed.Discontinued or modified procedures coded to procedure actually performed.Composite terms (i.e., colonoscopy, sigmoidectomy) are not root operations.Combination procedures are coded separatelyEach procedure with a distinct objective during an operative episode is coded separately.
31 More PrinciplesThe complete or partial redo of a procedure is coded to the root operation performed rather than “revision”.Revision is confined to correcting a malfunctioning or displaced deviceNew for ICD-10
32 Root Operation GroupsProcedures that take out or eliminate all or a portion of a body partProcedures that involve putting in or on, putting back, or moving body partsProcedures that take out or eliminate solid matter, fluids, or gases from a body partProcedures that only involve examination of body parts and regionsProcedures that can be performed only on tubular body partsProcedures that always involve devicesProcedures involving cutting or separation onlyProcedures involving other repairsProcedures with other objectives
33 Root Operations (1st Group) Procedures that take out or eliminate all or a portion of a body partExcisionResectionExtractionDestructionDetachment
34 ExcisionDefinition: 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 nephrectomyLiver Biopsy
35 ResectionDefinition: Cutting out or off, without replacement, all of a body partExamples:Total nephrectomyTotal lobectomy of lung
36 ExtractionDefinition: Pulling or stripping out or off all or a portion of a body part by the use of forceExplanation: The qualifier Diagnostic is used to identify extraction procedures that are biopsiesExamples:Dilatation and curettageVein stripping
37 DestructionDefinition: Physical eradication of 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 outExamples:Fulguration of rectal polypCautery of skin lesion
38 DetachmentDefinition: Cutting off all or part of the upper or lower extremitiesExplanation: 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 amputationDisarticulation of shoulder
39 Root Operations (2nd Group) Procedures that involve putting in or on, putting back, or moving living body partsTransplantationReattachmentRepositionTransfer
40 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 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 transplantHeart transplant
41 ReattachmentDefinition: 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 handReattachment of avulsed kidney
42 RepositionDefinition: 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 locationExamples:Reposition of undescended testiclesFracture reduction
43 TransferDefinition: Moving, without taking out, all or a portion of a body part to another location to take over the function of all or a portion of a body partExplanation: The body part transferred remains connected to its vascular and nervous supplyExamples:Tendon transferSkin pedicle flap transfer
44 Root Operations (3rd Group) Procedures that take out or eliminate solid matter, fluids or gases from a body partDrainageExtirpation (new term in ICD-10)Fragmentation
45 DrainageDefinition: Taking or letting out fluids and/or gases from a body partExplanation: The qualifier Diagnostic is used to identify drainage procedures that are biopsiesExamples:ThoracentesisIncision and drainage (I&D)
46 ExtirpationDefinition: 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 outExamples:ThrombectomyCholedocholithotomy
47 FragmentationDefinition: Breaking solid matter in a body part into piecesExplanation: The solid matter may be an abnormal byproduct of a biological function or a foreign body. Physical force, i.e. 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 functionsExample: Extracorporeal shockwave lithotripsy
48 Root Operations (4th Group) Procedures that only involve examination of body parts and regionsInspectionMap
49 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 layersExamples:Diagnostic arthroscopyExploratory laparotomy
50 MapDefinition: 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 mappingCortical mapping
51 Root Operations (5th Group) Procedures that can be performed only on tubular body partsBypassDilationOcclusionRestriction
52 BypassDefinition: 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 substitutesExamples:Coronary artery bypassColostomy formation
53 DilationDefinition: 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 partExamples:Percutaneous transluminal angioplastyPyloromyotomy
54 OcclusionDefinition: Completely closing the orifice or lumen of a tubular body partExplanation: The orifice can be a natural orifice or an artificially created orificeExamples:Fallopian tube ligationLigation of inferior vena cava
55 RestrictionDefinition: Partially closing the orifice or lumen of a tubular body partExplanation: The orifice can be a natural orifice or an artificially created orificeExample:Esophagogastric fundoplication
57 InsertionDefinition: Putting in a nonbiological appliance that monitors, assists, performs or prevents a physiological function but does not physically take the place of a body partExamples:Insertion of radioactive implantInsertion of central venous catheter
58 ReplacementDefinition: Putting in or on biological or synthetic material that physically takes the place and/or function 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 replaces, 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 replacementExample: Total knee/hip replacement
59 Total Knee Replacement in ICD-10-PCS Right Knee Joint Replacement ICD-9-CM: (Total Knee Replacement)SRDJZSection(Medical/Surgical)Body System(Lower Joints)Root Operation(Replacement)Body Part(Knee Joint, Right)Approach(Open)Device(Synthetic Substitute)Qualifier(No Qualifier)
60 SupplementDefinition: Putting in or on biological or synthetic material that physically reinforces or augments the function of a body partExplanation: The biological material in non-living, or the material is 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 meshNew acetabular liner in a previous hip replacement
61 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 as performedExamples: Drainage tube removalCardiac pacemaker removal
62 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 membraneExplanation: All Change procedures are coded using the approach ExternalExamples:Urinary catheter changeGastrostomy tube change
63 RevisionDefinition: 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 screwExamples:Adjustment of pacemaker leadAdjustment of hip prosthesis
65 DivisionDefinition: 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 cordotomyOsteotomy
66 ReleaseDefinition: 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:AdhesiolysisCarpal tunnel release
67 Root Operations (8th Group) Procedures involving other repairsControlRepair
68 ControlDefinition: Stopping, or attempting to stop, post-procedure bleedingExplanation: The site of the bleeding is coded as an anatomical region and not to a specific body partExamples:Control of post-prostatectomy hemorrhageControl of post-tonsillectomy hemorrhage
69 RepairDefinition: 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 operation (used as ‘default’)Examples:HerniorrhaphySuture of laceration
70 Root Operations (9th Group) Procedures with other objectivesAlterationCreationFusion
71 AlterationDefinition: Modifying the anatomical structure of a body part without affecting the function of the body partExplanation: Principal purpose is to improve appearanceExamples:Face liftBreast augmentation
72 CreationDefinition: 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 maleCreation of penis in a female
73 FusionDefinition: Joining together portions of an articular body part rendering the articular body part immobileExplanation: The body part is joined together by fixation device, bone graft, or other meansExamples:Spinal fusionAnkle arthrodesis
74 Body Part Character (Character 4) Identifies the body part or specific anatomical site where the physician performed a procedure34 possible body part values in each body systemHepatobiliaryLiverLiver, Right LobeLiver, Left LobeGallbladderHepatic Duct, RightHepatic Duct, Left
75 Approach Character (Character 5) Indicates the technique the physician used to reach the site of the procedure.Approaches may be through the skin or mucous membranes, through an orifice, or external.ICD-10-PCS will have 7 different approach values.
76 Different Approaches… Approaches through the skin or mucous membraneOpen (Abdominal hysterectomy)Percutaneous (Needle biopsy of liver)Percutaneous Endoscopic (Arthroscopy)
77 Approaches through an orifice Via Natural or Artificial Opening (Endotracheal intubation)Via Natural or Artificial Opening Endoscopic (Sigmoidoscopy)Via Natural or Artificial Opening Endoscopic with Percutaneous Endoscopic Assistance (Lap-assisted vaginal hysterectomy)
78 Final Approach…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 membraneExample: Closed fracture reduction
79 Device Character (Character 6) The term “device” includes only those devices that remain after the procedure is completed.Instruments that describe how a procedure is performed are not specified in the device character.Instruments for visualization are specified in the approach character, i.e., scope, etc.Materials that are incidental to a procedure (i.e., clips, sutures) are not considered devices and would use device character “Z” to indicate “no device” in the ICD-10-PCS code.
80 Device Values Four (4) Categories Of Devices: Grafts and ProsthesesImplantsSimple or Mechanical AppliancesElectronic ApplianceSome of the devices used in musculoskeletal system procedures are internal and external fixation devices, bone growth stimulators, and drainage devices.
81 Device CategoriesBiological 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. urinary catheter, IUD).Therapeutic material that is not absorbed by, eliminated by, or incorporated into a body part (i.e. radioactive implant, orthopedic pins). Therapeutic materials that are considered devices can be removed.
82 Mechanical or electronic appliances used to assist, monitor, take the place of, or prevent a physiological function (i.e., diaphragmatic pacemaker, hearing device).
84 Last But Not Least… Qualifier! Defines an additional attribute of the procedure performed, if applicable.May have a narrow application, to a specific root operation, body system, or body part.Examples of QualifiersType of transplantSecond site for a bypassDiagnostic excision (biopsy)
85 Coding ExampleCHIEF COMPLAINT: Foreign body in nose. HISTORY OF PRESENT ILLNESS: The patient is a 3-year-old child who comes in today after having put a raisin in her left nostril while playing at home. Grandmother was unable to remove it. EMERGENCY DEPARTMENT COURSE: The raisin was grasped by bayonet forceps and removed atraumatically. Examination of the nostril fails to reveal any further foreign body or problems. DIAGNOSIS: Foreign body in nostril with removal.
86 Coding Example ICD-10-CM (Diagnosis) ICD-9-CM: 932 (Foreign body in nose)ICD-10-CM: 2 options which contain more specific information about anatomic site and encounter.T170xxA = Foreign body in nasal sinus, initial encounterT171xxA = Foreign body in nostril, initial encounter
87 Coding Example ICD-10-PCS (Procedure) ICD-9-CM: (Removal of intraluminal foreign body from nose without incision)ICD-10-PCS: Only 1 translation and/or coding option09CKXZZ = Extirpation of matter from nose, external approach