© 2014
Long Island Health Information
Management Association
2014 Annual Meeting-ICD-10-PCS Boot Camp
April 2, 2014
John W. Ruth, MBA, RHIA
Director, Health Industries Advisory PricewaterhouseCoopers, LLP
PREPARATION IS THE KEY TO SUCCESS
• 2014 ICD-10-PCS available at
www.cms.hhs.gov/ICD10
•
2014 Code Tables and Index
o ICD-10-PCS 2014 Tables
o Definitions
o Index
•
2014 ICD-10-PCS Reference Manual
© 2014 3
PREPARATION IS THE KEY TO SUCCESS
Guidelines
• ICD-10-PCS Draft Coding Guidelines (2014)
appear in the
ICD-10-PCS 2014 Code Book
Four Sections of Guidelines
A. Conventions B. Medical and Surgical Section C. Obstetrics Section D. Selection of Principal Procedure© 2014
Guidelines
• There are multiple guidelines documented within the AHIMA ICD-10-PCS workbook and Official Coding Guidelines
• We will focus on those guidelines which may be more prone to coding difficulties
• Today’s discussion will include the first 3 Character Groups-Section, Body System, Root Operation, with most focus on Root Operation
• We will briefly discuss Body PartApproach, Device, Qualifier
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PREPARATION IS THE KEY TO SUCCESS
Conventions
A.1–A.2 Code composition
A.6–A.7 Alphabetic Index
A.9 PCS Tables
A.10 “And”
A.8 and A.11 Documentation
© 2014
Guideline A. 11.
• 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 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.
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Index
• Main index term is
a
root operation,
root procedure
type, or common
procedure name.
Examples are:
– Resection
– Fluoroscopy
– Prostatectomy
Tables
• When reviewing
tables, sometimes
there are
multiple
tables
for the first
three characters
and they may
cover multiple
pages in the code
book.
© 2014
ICD-10-PCS Section
• The first character of a code determines the broad
procedure category, or section, where the code is
located. For example, “0” represents the Medical
and Surgical section in the first character.
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PREPARATION IS THE KEY TO SUCCESS
ICD-10-PCS Section
• All codes in PCS are seven characters • Letters O and I not used in PCS
oNumbers 0 and 1 used • Each character has a meaning • Meanings change by sections
• Section provides first character value
Character 1 Character 2 Character 3 Character 4 Character 5 Character 6 Character 7 Section Body System Root Operation
© 2014
ICD-10-PCS
Section
11
Sections:
0 Medical and Surgical 1 Obstetrics
2 Placement 3 Administration
4 Measurement and Monitoring 5 Extracorporeal Assistance and Performance 6 Extracorporeal Therapies 7 Osteopathic 8 Other Procedures 9 Chiropractic
ICD-10-PCS
Section
Sections: B Imaging C Nuclear Medicine D Radiation TherapyF Physical Rehabilitation and Diagnostic Audiology
G Mental Health
© 2014
ICD-10-PCS Sections
Knowledge Challenge:
• Match the following procedures with the section of ICD-10-PCS where it is found:
• (Hint: The first character identifies the section.) • 1. 0B110F4, Tracheostomy
• 2. 8E0H30Z, Acupuncture
• 3. F07L0ZZ, Manual physical therapy for range of motion and mobility, patient right hip, no special equipment
• 4. 3E1M39Z, Peritoneal dialysis via indwelling catheter • 5. 4A02XM4, Cardiac stress test, single measurement • 6. BW03ZZZ, Chest x-ray, AP/PA and lateral views
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PREPARATION IS THE KEY TO SUCCESS
ICD-10-PCS Sections
Knowledge Challenge-Answers
• 1. Answer: Medical and Surgical • 2. Answer: Other Procedures
• 3. Answer: Physical Rehabilitation and Diagnostic Audiology • 4. Answer: Administration
• 5. Answer: Measurement and Monitoring • 6. Answer: Imaging
© 2014
ICD-10-PCS Body Systems
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PREPARATION IS THE KEY TO SUCCESS
ICD-10-PCS Body System
• The second character defines the body system which is the general physiological system or anatomical region involved.
• Examples of body systems include Central Nervous System, Upper Arteries, Respiratory System, Tendons, Muscles, and Upper Joints.
Character 1 Character 2 Character 3 Character 4 Character 5 Character 6 Character 7 Section Body System Root Operation
© 2014
Body System
Body Part
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PREPARATION IS THE KEY TO SUCCESS
Body System Guidelines
B2.1a
Anatomical
Regions
B2.1b
Upper or
Lower
© 2014
Body System Guidelines
• The procedure codes in the general anatomical regions body systems should only be used when the procedure is performed on an anatomical region rather than a specific body part (e.g., root operations Control and Detachment, drainage of a body cavity) or on the rare occasion when no information is available to support assignment of a code to a specific body part
• Example: Control of postoperative hemorrhage is coded to the root operation Control found in the General Anatomical Regions body systems.
• Where the general body part values Upper and Lower are provided as an option in the Upper Arteries, Lower Arteries, Upper Veins, Lower Veins, Muscles and Tendons body systems, Upper or Lower specifies body parts located above or below the diaphragm, respectively.
• Example: Vein body parts above the diaphragm are found in the Upper Veins body system; vein body parts below the diaphragm are found in the Lower Veins body system.
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PREPARATION IS THE KEY TO SUCCESS
Body System-Medical/Surgical
• The Medical and Surgical section is the largest of the 16 sections of ICD-10-PCS.
• Some of the procedures found in this section are: •• Thrombectomy
•• Lithotripsy
•• Inguinal hernia repair •• Gastrostomy tube change •• Cardiac mapping
© 2014
Body System-Medical/Surgical
Knowledge Check
1. Which of the following body systems is assigned multiple body system values in ICD-10-PCS?
• a. Urinary system • b. Respiratory system • c. Musculoskeletal system • d. Gastrointestinal system
2. Which of the following root operations does not share similar attributes with the other three root operations and therefore is not within the same group?
• a. Removal • b. Excision • c. Resection • d. Destruction
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PREPARATION IS THE KEY TO SUCCESS
Body System-Medical/Surgical
Knowledge Check
3. True or false? The meaning of the second character in the Medical and Surgical section is body part.
• a. True • b. False
© 2014
Body System-Obstetrics
The Obstetrics section follows the same conventions established in the Medical and Surgical section, with all seven characters retaining the same meaning. Obstetrics procedure codes have a first character value of 1 and the second character value for body system is Pregnancy. There are a total of 12 root operations in the Obstetrics section, 10 are in Medical/Surgical section.
The Obstetrics section also includes two additional root operations unique to this section:
Value Root Operation Description Definition
A Abortion: Artificially terminating a pregnancy
E Delivery: Assisting the passage of the products of conception from the genital canal
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PREPARATION IS THE KEY TO SUCCESS
© 2014
ICD-10-PCS Root Operations
• Objective of procedure
• 31 root operations • Arranged by similar
attributes • Multiple codes
Examples of Root Operations: • Bypass • Drainage • Reattachment • Resection • Inspection 25 Character 1 Character 2 Character 3 Character 4 Character 5 Character 6 Character 7 Section Body System Root Operation
Body Part Approach Device Qualifier
PREPARATION IS THE KEY TO SUCCESS
Root Operation Guidelines
B3.1a
B3.1a
• Full definition
B3.1b B3.1b• Integral to procedure
B3.2 B3.2• Multiple procedures
B3.3 B3.3• Discontinued procedures
B3.4aB3.4a
• Biopsy Procedures
B3.4b
B3.4b
• Biopsy followed by treatment
B3.5© 2014
ICD-10-PCS Body Part
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PREPARATION IS THE KEY TO SUCCESS
ICD-10-PCS Body Part
• Fourth character • Anatomical site
for procedure • 34 possible values
per body system
Examples of Body Parts: • Liver • Kidney • Thalamus • Ascending Colon • Optic Nerve • Tonsil Character 1 Character 2 Character 3 Character 4 Character 5 Character 6 Character 7 Section Body System Root Operation
© 2014
Body Part Guidelines
B4.1a
• Portion of body part
B4.1b• “Peri”
B4.2
• Branches of body parts
B4.3• Bilateral body part values
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PREPARATION IS THE KEY TO SUCCESS
Body Part Guidelines
B4.4 • Coronary ArteriesB4.5 • Tendons, Ligaments, Bursae, Fascia Near a Joint
B4.6 • Skin, Subcutaneous Tissue, Fascia Overlying Joint
B4.7 • Fingers and Toes
© 2014
Coding Note: Central Nervous System (0) vs. Peripheral Nervous System (1)
It is important to review anatomy regarding nerves.
•Examples of Central Nervous System: brain, optic nerve, trigeminal nerve, vagus nerve, spinal meninges
•Examples of Peripheral Nervous System: cervical nerve, ulnar nerve, radial nerve, thoracic nerve, tibial nerve, sciatic nerve, sacral plexus
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PREPARATION IS THE KEY TO SUCCESS
© 2014
ICD-10-PCS Approaches
• Fifth character – approach or technique used
to reach procedure
• Seven different approach values
• Approach may be
oThrough skin or mucous membrane
oThrough orifice oExternal 33 Character 1 Character 2 Character 3 Character 4 Character 5 Character 6 Character 7 Section Body System Root Operation
Body Part Approach Device Qualifier
PREPARATION IS THE KEY TO SUCCESS
Approaches
Skin or Mucous Membranes • Open • Percutaneous • Percutaneous Endoscopic Through an Orifice• Via Natural or Artificial Opening
• Via Natural or Artificial Opening Endoscopic • Via Natural or Artificial
Opening with Percutaneous Endoscopic Assistance
© 2014
Note:
When assigning the
approach value, remember that
the approach defines the technique
used to reach the procedure site,
not necessarily the instruments
used.
35
PREPARATION IS THE KEY TO SUCCESS
Approaches
0 • Open
3 • Percutaneous
4 • Percutaneous Endoscopic
7 • Via Natural/Artificial Opening
8 • Natural/Artificial Opening Endoscopic
F
• Natural/Artificial Opening with Percutaneous Endoscopic Assistance
© 2014
Approach Guidelines
• B5.2
• B5.2
Endoscopic
Assistance
• B5.3a
• B5.3b
• B5.3a
• B5.3b
External
Approach
• B5.4
• B5.4
Percutaneous
Procedure via
Device
37PREPARATION IS THE KEY TO SUCCESS
© 2014
ICD-10-PCS Device
Sixth character Device must be left
in place Review definitions of categories 39 Character 1 Character 2 Character 3 Character 4 Character 5 Character 6 Character 7 Section Body System Root Operation
Body Part Approach Device Qualifier
PREPARATION IS THE KEY TO SUCCESS
ICD-10-PCS Device
Four basic groups
• Grafts and Prostheses
• Implants
• Simple or Mechanical Appliances
• Electronic Appliances
© 2014 • Examples of Device Values: o Drainage device o Radioactive element o Autologous tissue substitute o Extraluminal device o Intraluminal device o Synthetic substitute o Nonautologous tissue substitute
Coding Note: Devices
Only procedures that have a device that remains after the procedure is completed will have a specific device value
assigned. Remember that all codes require seven characters. The default value to indicate that NOdevice was involved is Z.
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PREPARATION IS THE KEY TO SUCCESS
NEC in Medical/Surgical Section
Root
Operation
Value Q -RepairDevice
Value Y – Other DeviceCoding Note:
Materials
incidental to a
procedure, such as clips
and sutures, are not
considered devices.
© 2014
Coding Note: Appendix B
Appendix B in the ICD-10-PCS Reference Manualdiscusses the distinguishing features of device, substance, and equipment as classified in ICD-10-PCS, to provide further guidance for correct identification and coding. 43
PREPARATION IS THE KEY TO SUCCESS
Device Guidelines
General
Drainage
Device
• B6.1a Device must remain • B6.1b Integral to procedure • B6.1c Procedures performed on device • B6.2 Separate procedure to put in drainage device
© 2014
ICD-10-PCS Qualifier
• Seventh character
• Provides additional information
• May have narrow application
• There are no specific guidelines for qualifiers.
45 Character 1 Character 2 Character 3 Character 4 Character 5 Character 6 Character 7 Section Body System Root Operation
Body Part Approach Device Qualifier
PREPARATION IS THE KEY TO SUCCESS
ICD-10-PCS Qualifier
Type of
transplant
Type of
transplant
Second
site for a
bypass
Second
site for a
bypass
Diagnostic
excision
(biopsy)
Diagnostic
excision
(biopsy)
© 2014
Coding Note:
Most
procedures will not have
an applicable qualifier. The
default value to indicate that
NO
qualifier is needed is
Z
.
Z
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PREPARATION IS THE KEY TO SUCCESS
Check Your Understanding
Guideline Review
© 2014 1. 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.
Answer: a. True
Rationale:A device is specified in the sixth character and is used to identify devices that remain after the procedure is completed (Coding Guideline B6.1a).
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PREPARATION IS THE KEY TO SUCCESS
2. True or false? According to ICD-10-PCS Coding Guidelines, if a diagnostic biopsy is followed by a therapeutic definitive procedure at the same site, code only the therapeutic excision or resection.
Answer: b. False
Rationale:Coding Guideline B3.4b states if a diagnostic excision (biopsy) is followed by a more definitive procedure at the same procedure site, both the biopsy and more definitive treatment are coded.
© 2014
3.
True or false? In the root operation, Release, the body part character is defined as the body part being freed and not the tissue that is being cut to free the body part.Answer: a. True
Rationale:
In the root operation Release, the body
part value coded is the body part being freed and not
the tissue being manipulated or cut to free the body
part (Coding Guideline B3.13).
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PREPARATION IS THE KEY TO SUCCESS
4. True or false? Two codes would be assigned for this procedure: Resection of a joint with joint replacement.
Answer: b. False
Rationale:Components of a procedure specified in the root operation definition and explanation are not coded separately (Coding guideline B3.1b).
Example: 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.
© 2014 5.True or false? If the prefix periis used with a body part to identify the site of the procedure, the procedure is coded to the body part named.
Answer: a. True
Rationale:If the prefix periis combined with a body part to identify the site of the procedure, the procedure is coded to the body part named (Coding Guideline B4.1b). Example: A procedure site identified as perirenal is coded to the kidney body part.
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PREPARATION IS THE KEY TO SUCCESS
6.True or false? Irrigation of a percutaneous nephrostomy tube is coded to the root operation Irrigation of indwelling device in the Administration section.
Answer: a. True
Rationale: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 (Coding Guideline B6.1c).
Example: Irrigation of percutaneous nephrostomy tube is coded to the root operation Irrigation of indwelling device in the Administration section.
© 2014 7. True or false? Body systems designated as upper or
lower contain the body parts that are above or below the diaphragm respectively.
Answer: a. True
Rationale:Where the general body part values Upper and Lower are provided as an option in the Upper Arteries, Lower Arteries, Upper Veins, Lower Veins, Muscles and Tendons body systems, Upper or Lower specifies body parts located above or below the diaphragm respectively. (Coding Guideline B2.1b). Example: Vein body parts above the diaphragm are found in the Upper Veins body system; vein body parts below the diaphragm are found in the Lower Veins body system.
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PREPARATION IS THE KEY TO SUCCESS
Check Your Understanding
Root Operation Review
© 2014 8. True or false? In ICD-10-PCS, when an entire lymph
node chain is cut out, the appropriate root operation is Resection.
Answer: a. True
Rationale:When an entire lymph node chain is cut out, Resection is used. When a lymph node(s) is cut out, the root operation is Excision. Resection is defined as cutting out or off, without replacement, all of a body part (ICD-10-PCS Reference Manualp. 39).
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PREPARATION IS THE KEY TO SUCCESS
9. True or false? The root operation Detachment is used exclusively for amputation procedures.
Answer: a. True
Rationale: Detachment represents a narrow range of procedures, and it is used exclusively for amputations (ICD-10-PCS Reference Manualp. 40—41).
© 2014 10. True or false? Forceps removal of a foreign body is
an example of an extirpation procedure.
Answer: a. True
Rationale: Extirpation represents a range of
procedures where the body part itself is notthe focus of the procedure. Instead, the objective is to remove solid material such as a foreign body, thrombus, or calculus from the body part (ICD-10-PCS Reference Manual p. 47).
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PREPARATION IS THE KEY TO SUCCESS
11. True or false? The root operation Restriction is coded when the objective of the procedure is to close off a tubular body part or orifice.
Answer: b. False
Rationale:Restriction is defined as partially closing an orifice or the lumen of a tubular body part. Occlusion is defined as completely closing an orifice or the lumen of a tubular body part (ICD-10-PCS Reference Manual p. 58-59).
© 2014
12. True or false? Typical Change procedures
include exchange of drainage devices and
feeding devices.
Answer: a. True
Rationale:
Typical Change procedures include
exchange of drainage devices and feeding
devices (
ICD-10-PCS Reference Manual
p. 69).
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PREPARATION IS THE KEY TO SUCCESS
13. True or false? All codes in the ICD-10-PCS Administration section define procedures where a diagnostic or therapeutic substance is given to the patient, such as a platelet
transfusion.
Answer: a. True
Rationale: The Administration section includes infusions, injections, and transfusions, as well as other related
procedures, such as irrigation and tattooing. All codes in the section define procedures where a diagnostic or therapeutic substance is given to the patient (ICD-10-PCS Reference Manualp. 89).
© 2014 14. True or false? In ICD-10-PCS, the term
measurementrefers to a series of levels obtained at intervals, while monitoring describes a single
level taken.
Answer: b. False
Rationale:Measurement describes a single level taken, while Monitoring describes a series of levels obtained at intervals (ICD-10-PCS Reference Manual p. 90).
PREPARATION IS THE KEY TO SUCCESS
Root Operation Groupings
Root Operations That Take Out Some or All of a Body Part
Root Operations That Take Out Solids/ Fluids/Gases From a Body Part
Root Operations Involving Cutting or Separation Only
Root Operations That Put in/Put Back or Move Some/All of a Body Part
Nine
Groups
Arranged
by Similar
Attributes
© 2014
Root Operation Groupings
Root Operations That Alter the
Diameter/Route of a Tubular Body Part Root Operations That Always Involve a Device
Root Operations Involving Examination Only
Root Operations That Define Other Repairs
Root Operations That Define Other Objectives
Nine
Groups
Arranged
by Similar
Attributes
67Root Operations That Take Out
Some or All of a Body Part
© 2014
Excision (B)
Excision B
Definition 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, breast lumpectomy, breast reduction for medical reasons (for cosmetic reasons is
Alteration), Excisional debridement (non-excisional debridement is Extraction)
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Excision
•
Excisionis coded when a portion of a body part is cut out or off using a sharp instrument. All root operations that employ cutting to accomplish the objective allow the use of any sharp instrument, including but not limited to: – Scalpel – Wire – Scissors – Bone saw – Electrocautery tip© 2014
Coding Note: Bone Marrow and Endometrial Biopsies– Bone
marrow and endometrial biopsies are not coded to Excision. They are coded to Extraction, with the qualifier Diagnostic.
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Resection (T)
ResectionT
Definition Cutting out or off, without replacement, all of a body part
Explanation N/A
Examples Total nephrectomy, total lobectomy of lung, total mastectomy
Resectionis similar to Excision exceptResection includes all of a body part, or any subdivision of a body part that has its own body part value in ICD-10-PCS, whileExcision includes only a portion of a body part.
© 2014 When an entire lymph node
chainis cut out, the appropriate root operation is Resection. When a lymph node(s) is cut out, the root operation is Excision
.
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Coding
Note
PREPARATION IS THE KEY TO SUCCESS
© 2014
Coding Note: Documentation
There is an opportunity to provide physician education on the need for more complete documentation in the medical record on the following:
• Lymph node(s) versus the complete chain
• The complete body part removal versus a portion
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PREPARATION IS THE KEY TO SUCCESS
Detachment (6)
Detachment 6
Definition Cutting off all or part of the upper or lower extremities 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, amputation above elbow
© 2014
Detachment = Amputation
Detachment
procedure codes are found only in
body systems
X, Anatomical Regions, Upper
Extremities
and
Y, Anatomic Regions, Lower
Extremities
because amputations are performed on
extremities across overlapping body layers and so
could not be coded to a specific musculoskeletal
body system such as the bones or joints.
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PREPARATION IS THE KEY TO SUCCESS
The specific qualifiers used for Detachmentare dependent on the body part value in the upper and lower extremities body systems.
Definitions
established for:
• Upper arm and leg
• Hand and foot
• Thumb, finger, toe
• Complete/partial
• High, Mid, Low
Detachment
Qualifiers
© 2014
Coding Note: Documentation
There is an opportunity to provide physician education on the need for more complete documentation in the medical record on the actual location of the amputation. According to the definition, the coding professional needs to know if the amputation is at the proximal middle, or distal portion of the shaft of the humerus, femur, radius/ulna, or tibia/fibula. According to the definition, the coding professional needs to know if the amputation is at the proximal middle, or distal portion of the shaft of the humerus, femur, radius/ulna, or tibia/fibula.
PREPARATION IS THE KEY TO SUCCESS
Coding Note: Qualifier Value– When a surgeon uses the word “toe” to describe the amputation, but the operative report says he extends the amputation to the midshaft of the fifth metatarsal, which is the foot, the qualifier is Partial 5thRay.
© 2014
Destruction (5)
Destruction 5
Definition Physical eradication of 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, fulguration of endometrium
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PREPARATION IS THE KEY TO SUCCESS
Destruction
• Destruction“takes out”a body part in the sense that it obliterates the body part so it is no longer there.
• Defines a broad range of common procedures, since it can be used anywhere in the body to treat a variety of conditions, including:
o Skin and genital warts
o Nasal and colon polyps
o Esophageal varices
o Endometrial implants
© 2014
Extraction (D)
Extraction D
Definition Pulling or stripping out or off all or a portion of a body part by the use of force
Explanation The qualifier Diagnosticis used to identify extraction procedures that are biopsies
Examples Dilation and curettage, vein stripping, phacoemulsification without IOL implant (phacoemulsification with IOL implant is
Replacement), non-excisional debridement (excisional debridement is excision), liposuction for medical reasons (liposuction for cosmetic reasons is Alteration)
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Extraction
Extraction
is coded when the method employed to
take out the body part is
pulling or stripping
.
Minor cutting, such as that used in vein stripping
procedures, is included in
Extraction
if the
objective of the procedure is nevertheless met by
pulling or stripping. Cutting used to reach the
procedure site is specified in the approach value.
© 2014
PREPARATION IS THE KEY TO SUCCESS
85
When coding a D&C in ICD-10-PCS, the Dilation is not separately coded because procedural steps necessary to reach
the operative site and close the operative site are not coded separately (Coding Guideline B3.1b).
The cervical canal is widened with a metal rod, and then the curette is passed. A curette is described as an instrument with a metal loop on the end of a long, thin handle, or spoon shaped with sharp edges.
This curette gently scrapes the endometrium.
endometrial tissue from inside the uterus. The dilation--widening the and curettage--scraping walls of uterus. Two components:
Dilation (D) is a widening of the cervix to allow instruments into the uterus.
Curettage (C) is the scraping of the walls of the uterus.
PREPARATION IS THE KEY TO SUCCESS
During liposuction, a small incision is made in the skin and a suction tube with a sharp end is inserted into the fat pockets. The instrument has been described as a long, thin, hallow shaft ending in a small, sharp-edged spoon. This is swept through the area between the skin layers and the deeper subcutaneous tissue, and then the vacuum pump suctions it out.
In a vein stripping, two small incisions are made—one above and one below the specified vein. These incisions are included in the Extraction root operation (see definitions above). A thin, flexible plastic wire is then threaded into the vein (at the top part) and guided toward the other cut. The vein is pulled out when the wire is pulled out through the lower cut. Hooks may also be used in the procedure.
Visit MedlinePlus at the US National Library of Medicine National Institutes of Health to get information on these and other surgical procedures. Many excellent videos and tutorials are available.
© 2014
Coding Note: Documentation
Be careful of documentation. It is important to convert common terminology to the appropriate root operation according to the intent of the procedure. For example, the procedure documentation may say“removal,” but in actuality, using PCS definitions, an extraction was performed. Removal of a thumbnail would be coded to Extraction. The root operation of Removal is not correct because by definition a Removal in ICD-10-PCS is defined as taking out or off a device from a body part.
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PREPARATION IS THE KEY TO SUCCESS