ICD-10-PCS Training Samantha Muncy This presentation is on the ICD-10-PCS coding system and how to build and create codes. Samantha Muncy

What is the ICD-10-PCS coding system. ICD-10-PCS stands for The International Classification System of Diseases, The 10th revision, Procedural Coding System. ICD-10-PCS was developed to replace ICD-10-CM Volume 3 procedure codes. Devised by the World Health Organization and The Centers for Medicaid and Medicare Services . Codes do not contain any diagnostic information . NOS commands are restricted, and NEC commands are limited but availability does exist. The ICD-10-Coding System is a classification system that contains codes for inpatient and hospital setting procedures. It’s the International Classification System of Diseases, the 10th Revision, Procedural Coding System. It was developed and devised by the Centers for Medicaid and Medicare services and by the World Health Organization. These codes do not contain any diagnostic information, the NOS codes are restricted and the NOS codes are limited but availability is limited. All procedure codes are to be specified according to this classification system.

The Seven Code Characters All codes have 7 characters and every character is specific to its place in the lineup each with its own specific meaning or value. Characters may be alphabetic or numeric. Every number 0-9 can be used, and any letter A-H, J-N, or P-Z may be used except for O and I, as they resemble the numbers 0 and 1. The first character of every code designates its section in the code book which is separated by common types of procedures into 16 sections. The 16 sections are divided into 3 main subsections : Medical and Surgical, Medical and Surgical Related, and Axillary. (Universal Class, 2018). O J H T 3 V Z Each code has seven characters that are alphanumerical and every character is specific to its place in the lineup and each has its own specific meaning or value. Numbers 0-9 and letters A-H, J-N, or P-Z may be used except for O and I. The first character of every code designates its place within the codebook which is separated by common types of procedures performed. The codes are divided into sixteen sections which has three subsections . The subsections are Medical and Surgical, Medical and Surgical Related, and Axillary.

Steps to Coding a Procedural Code Locate the main term used in the medical report with the main term being the main procedure that was used to treat the diagnosis. Could be root operations or other common procedures performed. Use the main term to look up what table to use in the alphabetic index. Continue to build the code with the appropriate table . (Bowie, 2018, pg. 465). To code a procedure first you must locate its main terms from the alphabetical index , with the main term being the procedure that was used to treat the principal diagnosis. Could be either a root operation or other common procedures. The main term is used to look up the tables that you will use to code the remaining 4 characters of the code as the first three are depicted in the first three character values which are located above the table. Continue to use the table to sdtermine the remaining values of the code. The three values above and the 4 values within the table correspond to a specific part of the procedure as follows: 3 values above 1st: Section 2nd. Body Systems 3rd. Root Operation 4th. Body Part 5th. Approach 6th. Devices 7th. Qualifier

Building Codes with Tables. First reference the alphabetical index as a guide to help you locate the table that will be used to formulate the correct code. Use the main terms as what you use to locate term in the procedure that will be used to locate the correct table. Main terms are either the root operation or other common procedures performed. Index lists the main terms in alphabetical order and usually supplies the first 3 characters of the code, to allow you to locate the correct table. Then reference the table to continue and finish the code, and there is a required set number of 7 characters in any code. Some tables will have various rows listed within in, only can select one row and the characters should be selected by going straight across all given sections of the table. (Universal Class, 2018). To successfully build an ICD-10-PCS code first reference the alphabetical index to locate the correct table to use to finish building your code. Use the main terms as the reference for the word or phrase you will uses to look up the correct tables in the index. Main terms are either root operations or other common procedures. Index lists the main terms in alphabetical order and supplies you with the first three character values of the code which is also the three character values above the table you will need to finish the code, which has to be 7 characters long and any placeholders require the use of the letter Z. Some tables will have various rows listed within the rows of the table. You may only use one row straight across to select your remaining characters from based on body part, approach, devices, and qualifiers.

Example of How to Build a ICD-10-PCS Code using the Tables Procedure: Insertion of Infusion Pump into the trunk subcutaneous tissue and fascia, percutaneous approach. Locate the main procedure and locate it within the index by main term to find the correct 3 letters that correspond with the table used to build or select the correct code. ( OJH) Locate the table, Build the remaining 4 characters of the code from the table by the specific meaning or value for each place. (Bowie, 2018, pg. 265). 1st character value- section 0 -Medical and Surgical 2nd character value-body systems J- Subcutaneous Tissue and Fascia 3rd character value-root operation H -Insertion 4th character value-body part. When using the table you locate the row that signifies the trunk as the body part, then you choose 0 or 3 for the approach from the next column T-Subcutaneous Tissue and Fascia, Trunk 5th character value-approach Choose from 0-percutaneous or 3 for open 3 -Percutaneous 6th character value-devices Choose either I for radioactive element, 3 for infusion device, V for infusion device, pump, or Y for other devices. V – Infusion Device , Pump 7th character value-the qualifier , if any Z –No Qualifier 0JHT3VZ Revisied final draft Step one locate section of the code book Then the body system Then the root opporation Then the body part The approach The device The qualifier Then verify the code in the index and tab list An example of building a code is to create a code for: Insertion of infusion pump into the trunk subcutaneous tissue and fascia using a percutaneous approach. So first the section of the code book this is listed under is medical and surgical which correlates to the character 0 which is the first character value. Then the second character value is supposed to be specific to body systems which is the subcutaneous tissue and fascia of the trunk, requiring the value J, the root operation performed was insertion which signifies a character of H as the third character value. These three values can be located at the top of the table that you need to finish the code. Then use the table to fill in the remaining four characters. The fourth character is specific with the body part which is subcutaneous tissue and fascia, trunk, which signifies the use of character T, the fifth character value is specific with the approach which was percutaneous, character value 3, the sixth character is specific with any devices used which a infusion pump devise was so you use the character V, and the seventh and last character is Z used as the placeholder because there is no qualifier.

References Universal Class. (2018). What is ICD-10_PCS?. Retrieved from: https://www.universalclass.com/articles/medicine/medical-coding/what-is-icd-10-pcs.htm Bowie, Mary J. (2018). Introduction to ICD-10-PCS. Understanding ICD-10-CM and ICD-10-PCS, A worktext. Boston, MA. : Cengage Learning