1. ICD-10-CM ICD-10-PCS Presented by: Virginia Wernet, RHIT, CCS
Coding Concepts Too, LLC
P.O. Box
Erie, MI 48133

2. History of ICD-10-CM
ICD-10-CM classification system was developed by the national Center for Health Statistics (NCHS) as a clinical modification to the ICD 10 system developed by the World Health Organization (WHO), primarily as a unique system for use in the United States for morbidity and mortality reporting.

3. Organization
ICD-9-CM has 17 chapters with supplementary classifications V and E codes.
ICD-10-CM presents 21 chapters, including preventative and external cause codes within the body of the chapter.

4. Organization Continued
ICD-10-CM also contains a Table of Drugs and Chemicals, an External Cause Index, and a Table of Neoplasms.
Chapters are subdivided into subchapters or blocks that contain 3 character categories that form the foundation of the code. Decimal points follow the 3 characters and additional characters may be necessary to code to the highest level of specificity.

5. Organization Continued
ICD10-CM is structured to include many more combination codes (identifying etiology and/or manifestations) than ICD-9-CM, resulting in fewer cases requiring more than one code.
Examples:
H Cataract with neovascularization, bilateral
M00.0 Staphylococcal arthritis and polyarthritis
Use additional code (B95.6-B95.7) to identify bacterial agent

6. CHAPTER 9 Diseases of Circulatory System (100-199)
Hypertension
Atherosclerotic coronary artery disease and angina
Intraoperative and Postprocedural cerebrovascular accident
Sequelae of Cerebrovascular Disease
Acute myocardial infarction (AMI)

7. Hypertension Hypertension with Heart Disease
Hypertensive Chronic Kidney Disease
Hypertensive Heart and Chronic Kidney Disease
Hypertensive Cerebrovascular Disease
Hypertensive Retinopathy
Hypertension, Secondary

8. Hypertension Continued
Hypertension, Transient
Hypertension, Controlled
Hypertension, Uncontrolled

9. Coding Guideline I.C.19.e.5.c Underdosing
Underdosing refers to taking less of a medication than is prescribed by a physician or a manufacturer’s instruction. For underdosing, assign the code from categories T36-T50. Noncompliance (Z91.12-Z91.13) or complication of care (Y63.61, Y63.8-Y63.9) codes are to be used with an underdosing code to indicate intent, if known.

10. Scenario #1
This 85 year old patient is seen in the hospital with a diagnosis of congestive heart failure due to hypertensive heart disease. Patient also has Stage V chronic kidney failure. The patient had been prescribed Lasix previously but admits that he forgets to take his medication every day. This is due to his advanced age. Code(s):_______________________________________
I13.2, I50.9, N18.5, T50.1X6A, Z91.130

11. Scenario #1 Rationale
The combination code for heart and renal disease is used in the situation because both heart and renal disease exist along with the hypertension. According to the Official Coding Guidelines for hypertensive heart disease, the causal relationship is implied with the word “hypertensive.” An additional code from category I50 is used to identify the type of heart failure. The use “additional code” statement under code I13.2 indicates the use of the N18.5 code to indentify the stage of the chronic kidney disease. In ICD-10-CM, underdosing of medication can now be identified.

12. Atherosclerotic Coronary Artery Disease and Angina
ICD-10-CM has combination codes for atherosclerotic heart disease with angina pectoris.
The subcategories are
I25.11 Atherosclerotic heart disease of a native coronary artery with angina pectoris
I25.7 Atherosclerosis of coronary artery bypass graft and coronary artery of transplanted heart with angina pectoris.

13. Scenario #2 Code(s):_______________________________
This 63 year old male is being seen for treatment of his unstable angina. This gentleman has a history of 2-vessel coronary artery bypass approximately 18 months ago. A recent cardiac catheterization shows continued evidence of coronary arteriosclerosis but both of the bypass grafts are patent. Also, of note, is that this patient suffered a cerebrovascular infarction three years ago which resulted in right-side (dominant) hemiparesis.
Code(s):_______________________________
I25.110, I69.351, Z95.1

14. Scenarion#2 Rationale
The coronary artery disease of the native vessel is coded because the previous cardiac catheterization showed that the bypass grafts are patent. Also, per the Official Coding Guidelines, ICD-10-CM has combination codes for atherosclerotic heart disease with angina pectoris. When using one of these combination codes it is not necessary to use an additional code for angina pectoris. A causal relationship can be assumed in a patient with both atherosclerosis and angina pectoris, unless the documentation indicates the angina is due to something other than atherosclerosis.

15. Intraoperative and Postprocedural Cerebrovascular Accident
Proper code assignment depends on whether it was an infarction or hemorrhage and whether it occurred intraoperatively or postoperatively. If it was a cerebral hemorrhage, code assignment depends on the type of procedure performed. Medical record documentation should clearly specify the cause and effect relationship between the medical intervention and the CVA in order to assign this code.

16. Sequelae of Cerebrovascular Disease
Category I69, Sequelae of Cerebrovascular disease - used to indicate conditions classifiable by to category I60-I67
Codes from Category I69 with codes from I60-I67 , may be coded if patient has a current CVA and deficits from an old CVA.
Code Z86.73 – Personal history of TIA

17. Scenario #3
This pleasant gentleman is seen in the clinic to follow up from a previous stroke. He suffered a CVA 6 months ago which left him with left-sided hemiparesis and aphasia. The patient will be referred to outpatient rehabilitation for speech, physical, and occupational therapy.
Code(s):______________________________
I69.320, I69.354

18. Acute Myocardial Infarction
ST elevation myocardial infarction (STEMI) and Non ST elevation myocardial infarction (NSTEMI)
Acute myocardial infarction, unspecified
AMI documented as nontransmural or subendocardial but site provided
Subsequent acute myocardial infarction

19. Scenario #4
This 54 year old female with a previous acute non-ST anterior wall MI and on chronic medication for her atrial fibrillation presents to the ER two weeks later and was diagnosed with an acute inferior wall MI. She is still being monitored following her initial heart attack three weeks earlier and continues on medication for her AFIB. She will be transferred to a larger facility for cardiac catheterization and possible further intervention. Which of the following codes sets is correct?
I21.19, I21.4, I48.0
I22.1, I25.2, I48.0
I21.19, I25.2, I48.0
I22.1, I21.4, I48.0
Answer D

20. CHAPTER 13: Diseases of the Musculoskeletal System and Connective Tissue (M00-M99)
Site and laterality
Acute traumatic versus chronic or recurrent musculoskeletal conditions
Coding of Pathologic Fractures
Osteoporosis

21. Site and Laterality
Most codes in Chapter 13 have site and laterality designations. The site represents either the bone, joint or the muscle involved. There is a “multiple sites” code available, as well as multiple codes for the different sites involved.
Bone versus Joint- If the portion of the bone affected is at the joint, the site designation will be the bone, not the joint.

22. Coding Guideline I.C.13a Site and Laterality
Most of the codes within Chapter 13 have site and laterality designations. The site represents either the bone, joint, or muscle involved.
Coding Note: ICD-10-CM has three different categories for pathologic fractures- due to neoplastic disease, due to osteoporosis, and due to other specified disease.

23. Scenario # 5
This 76 year old man, originally diagnosed with left upper lobe carcinoma five years ago, is seen for a fracture of the shaft of the right femur. Eight months ago, he was diagnosed with metastatic bone cancer and this fracture is a result of the metastatic disease. This patient’s lung cancer was treated with radiation and is no longer under treatment. What are the correct code assignments for this case?
M84.553A, C79.51, Z85.11
M84.551A, C79.51, Z85.11
M84.553A, C79.51, C34.12
M84.551A, C79.51, C34.12

24. Acute Traumatic Versus Chronic or Recurrent Musculoskeletal Conditions
Chronic and recurrent conditions should generally be coded from chapter 13.
Any current , acute injury should be coded from chapter 19.
If it is difficult to determine from the documentation in the record, query the physician.

25. Coding of Pathologic Fractues
7th character A is for use as long as the patient is receiving active treatment for the fracture.
Examples: Surgical Treatment, ED Encounter, Evaluation/Treatment by physician.
7th character D is for encounters after the patient has completed active treatment.
The other 7th characters, are to be used for subsequent encounters associated with treatment of problems and healing.

26. Osteoporosis Osteoporosis without pathological fracture
-Category M81, patients with osteoporosis without a pathological fracture due to the osteoporosis.
Osteoporosis with current pathological fracture
-Category M80, patients with current pathological fracture at the time of encounter.

27. Coding Guideline I.C.13.d.2 Osteoporosis with Current Pathological Fracture
Category M80, Osteoporosis with current patholgical fracture, is for patients who have a current pathologic fracture at the time of an encounter. The codes under M80 identify the site of the fracture. A code from categoryM80, not a traumatic fracture code, should be used for any patient with know osteoporosis who suffers a fracture, even if that patient had a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone.

28. Scenario #6
Julia is an 80 year old female with senile osteoporosis. She presents to the ED complaining of severe back pain with no history of trauma. X-rays revealed pathological compression fractures of several lumbar vertebrae. Julia’s medications are reviewed and this includes Benicar for hypertension and long term use of Coumadin for atrial fibrillation. Code(s):___________________________________

29. ICD-10-PCS: Root Operations in Medical/Surgical Section
Essential Characteristics
Completeness
Expandability
Multiaxial
Standard Terminology

30. General Principles No diagnosis information included
Not Otherwise Specified (NOS) restricted
Not Elsewhere Classifier limited use
Level of specificity

31. Code Structure

32. Character 3: Root Operation
The third character is the root operation or the objective of the procedure
There are 31 root operations in the Medical/Surgical section

33. 31 Root Operations Alteration Insertion Transplantation
Bypass Inspection
Change Map
Control Occlusion
Creation Reattachment
Destruction Release
Detachment Removal
Dilation Repair
Division Replacement
Drainage Reposition
Excision Resection
Extirpation Restriction
Extraction Revision
Fragmentation Supplement
Fusion Transfer

34. Groupings Take out some/all of a body part
Take out solids/fluids/gases from a body part
Involve cutting or separation only
Put in/put back or move some/all of a body part
Alter the diameter/route of a tubular body part
Include other repairs
Examination only
Always involve a device
Include other objectives

35. Root Operations that take out solids/fluids/gases from a body part
Drainage
Extirpation
Fragmentation

36. Definition: Taking or letting out fluids and/or gases from a body part
Drainage
Definition: Taking or letting out fluids and/or gases from a body part

37. Drainage Thoracentesis I & D
Diagnostic percutaneous paracentensis for ascites
I & D of external perianal abscess
Routine foley catheter placement
Hip arthrotomy with drain placement
Laparoscopy with ovarian cystotomy and drainage
Percutaneous chest tube placement
Urinary nephrostomy catheter placement
Endoscopic drainage of ethmoid sinus

38. Definition: taking or cutting out solid matter from a body part
Extirpation
Definition: taking or cutting out solid matter from a body part

39. Extirpation Percutaneous mechanical thrombectomy
Forceps removal of foreign body in the left nostril
Foreign body removal, skin of right index finger
Removal of foreign body, left cornea
EGD with removal of a bezoar from stomach
Transurethral cystoscopy with removal of bladder calculus
Laparoscopy with excision of old suture from mesentery
I & D of right lacrimal duct calculus
Declotting of AV dialysis graft

40. Definition: Breaking solid matter in a body part into pieces
Fragmentation
Definition: Breaking solid matter in a body part into pieces

41. Fragmentation
ESWL
Transurethral cystoscopy with fragmentation of bladder neck calculus
ERCP with lithotripsy of common bile duct stone
Hysteroscopy with intraluminal lithotripsy of the left fallopian tube calcification
Transurethral lithotripsy
Thoracotomy with crushing of pericardial calcifications

42. Root operations involving cutting or separation only
Division
Release

43. Division
Definition: Cutting into a body part without draining fluids and/or gases from the body part in order to separate or transect a body part

44. Division Spinal cordotomy Osteotomy
Division of Achilles tendon, percutaneous
LHC with division of bundle of HIS
Sacral rhizotomy for pain control, percutaneous
EGD with esophagotomy of GE junction

45. Release
Definition: Freeing a body part from an abnormal physical constraint by cutting or by use of force

46. Release Lysis of adhesions
Shoulder arthroscopy with coracoacromial ligament release
Laparoscopy with freeing of bilateral ovaries and fallopian tubes
Open carpal tunnel release
Open tarsal tunnel release
Incision of scar contracture
Manual rupture of should joint adhesions under general anesthesia

47. Root operations that put in/put back or move some/all of a body part
Transplantation
Transfer
Reattachment
Reposition

48. Transplantation
Definition: 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

49. Transplantation Kidney transplant
Orthotopic heart transplant using porcine heart, open
Liver transplant with donor matched liver
Lung transplant, open, using organ donor match
Open transplant of large intestine, organ donor match

50. Reattachment
Definition: Putting back in or on all or a portion of a separated body part to its normal location or other suitable location

51. Reattachment Reattachment of a finger Replanation of avulse scalp
Reattachment of a severed ear
Reattachment of a severed hand
Closed replanation of three avulsed teeth, upper jaw

52. Transfer
Definition: Moving, without taking out, all or portion of a body part to another location to take over the function of all or portion of a body part

53. Transfer Tendon transfer Nerve transfer Advancement flap
Transfer of right index finger to right thumb position, open
Skin pedicle flap transfer

54. Reposition
Definition: Moving to its normal location or other suitable location or a portion of a body part

55. Reposition Open fracture reduction with internal fixation
Relocation of bilateral undescended testicles
Open reduction fracture
Closed reduction with percutaneous internal fixation
Right knee arthroscopy with reposition of patellar ligament
Laparoscopy with gastropexy for malrotation

56. Root operations that alter the diameter/route of a tubular body part
Restriction
Dilation
Occlusion
Bypass

57. Restriction
Definition: Partially closing an orifice or the lumen of a tubular body part

58. Restriction Esophagogastric fundoplication Cervical cerclage
Thoracotomy with banding of left pulmonary artery with extraluminal device
Restriction of thoracic duct with intraluminal stent
Craniotomy with clipping of cerebral aneursym
Non-incisional, transnasal placement of a restrictive stent in the nasolacrimal duct

59. Occlusion
Definition: Completely closing an orifice or the lumen of a tubular body part

60. Occlusion Fallopian tube ligation Ligation of inferior vena cava
Uterine artery embolization
Ligation of esophageal vein
Suture ligation of failed AV graft of brachial artery
Complete embolization of vascular supply of intracranial meningioma

61. Occlusion vs. Restriction
For embolization procedures, if the objective is to completely close off a vessel then Occlusion is coded. If the objective is to partially close a vessel or narrow the lumen of a vessel, then Restriction is coded. Need to know if the embolization is complete or partial.

62. Definition: Expanding an orifice or the lumen of a tubular body part
Dilation
Definition: Expanding an orifice or the lumen of a tubular body part

63. Dilation Coronary angioplasty
ERCP with balloon dilation of common bile duct
Cystoscopy with intraluminal dilation of bladder neck
Dilation of anastomosis of femoral artery
Peripheral angioplasty
Hysteroscopy with balloon dilation of fallopian tubes
Cystoscopy with dilation of ureteral stricture

64. Bypass
Definition: Altering the route of passage of the contents of a tubular body part

65. Bypass Coronary artery bypass Colostomy formation Gastric bypass
Tracheostomy formation with T-tube insertion
Peripheral artery bypass
Urinary diversion, ureter, using ileal conduit to skin
Pleuroperitoneal shunt

66. Root operations that include other repairs
Control
Repair

67. Definition: Stopping, or attempting to stop, postprocedural bleeding
Control
Definition: Stopping, or attempting to stop, postprocedural bleeding

68. Control
Any type of procedure performed to control postoperative bleeding
Ligation of post op arterial bleeders
Reopening laparotomy site with ligation of arterial bleeder
Hysteroscopy with cautery of post-hysterectomy bleeding

69. Repair
Definition: Restoring, to the extent possible, a body part to its normal anatomic structure and function

70. Repair Inguinal herniorrhaphy Suture of radial nerve laceration
Laparotomy with suture traumatic duodenal laceration
Suture of right biceps tendon laceration
Closure of abdominal wall stab wound

71. Root operations that involve examination only
Inspection
Map

72. Definition: Visually and/or manually exploring a body part
Inspection
Definition: Visually and/or manually exploring a body part

73. Inspection Diagnostic colposcopy with examination of cervix
Thoracotomy with exploration of right pleural cavity
Diagnostic laryngoscopy
Exploration arthrotomy of the knee
Endoscopy of sinuses
Laparotomy with palpation of the liver
Colonoscopy
Transurethral diagnostic cystoscopy

74. Map
Definition: Locating the route of passage of electrical impulses and/or locating functional areas in a body part

75. Map Percutaneous mapping of basal ganglia
Heart cath with cardiac mapping
Intraoperative whole brain mapping via craniotomy
Mapping left cerebral hemisphere
Intraoperative cardiac mapping during open heart surgery

76. Root operations that always involve a device
Insertion
Change
Replacement
Removal
Supplement
Revision

77. Insertion
Definition: Putting in a non-biological device that monitors, assists, performs or prevents a physiological function but does not physically take the place of a body part

78. Insertion Port-a-cath placement
Open placement of a pacemaker in the chest wall
Percutaneous placement of pacemaker lead into left atrium
Percutaneous placement of intrathecal infusion pump for pain management
Cystoscopy with placement of brachytherapy seeds in the prostate

79. Replacement
Definition: Putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part

80. Replacement
Phacoemulsification of cataract of right eye with intraocular lens implantation
Right hip hemiarthroplasty, open
Open aortic valve replacement using porcine valve
Percutaneous penetrating keratoplasty of the left cornea with donor matching cornea
Total knee replacement with insertion of a total knee prosthesis
Bilateral mastectomy with free TRAM flap reconstruction
Partial-thickness skin graft to right lower leg, autograft

81. Supplement
Definition: Putting in or on biologic or synthetic material that physically reinforces and/or augments the function of a portion of a body part

82. Supplement Open anterior colporrhaphy with polypropylene mesh
Laparoscopic inguinal hernia repair with Marlex mesh
Open mitral valve annuloplasty using ring
Implantation of CorCap cardiac support device, open
Open abdominal wall hernia with synthetic mesh
Open resurfacing procedure on acetabular surface
Open tendon graft using autograft

83. Definition: Taking out or off a device from a body part
Removal
Definition: Taking out or off a device from a body part

84. Removal Removal of an ET tube Removal of a tracheostomy tube
Removal of external fixator
Removal of PEG tube
Non-incisional removal of Swan Ganz from superior vena cava
Transurethral removal of brachytherapy seeds
Cystoscopy with removal of ureteral stent

85. Revision
Definition: Correcting, to the extent possible, a malfunctioning or displaced device

86. Revision Adjustment of a pacemaker lead
Open revision of hip replacement
Percutaneous adjustment of position of left pacemaker lead in the left atrium
Reposition of Swan Ganz catheter in superior vena cava
Revision of VAD reservoir placement in chest wall

87. Root operations that include other objectives
Fusion
Creation
Alteration

88. Fusion
Definition: Joining together portions of an articular body part rendering the articular body part immobile

89. Fusion Arthrodesis of the right ankle Spinal fusion procedures
Intercarpal fusion of left hand with bone bank graft
Radiocarpal fusion of right hand with internal fixation

90. Alteration
Definition: Modifying the natural anatomic structure of a body part without affecting the function of the body part

91. Alteration Abdominoplasty Breast augmentation Liposuction Face lift
Cosmetic rhinoplasty
Cosmetic blepharoplasty

92. Creation
Definition: Making a new genital structure that does not physically take the place of a body part
Sex change operations

93. Important 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 definitions. The physician is not expected to use the terms in PCS code descriptions, nor is the coder to query the physician when the correlation between the documentation and the defined PCS terms is clear.

94. Questions?