Long Island Health Information Management Association

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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

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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

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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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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

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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.

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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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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

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ICD-10-PCS

Section

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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 Therapy

F Physical Rehabilitation and Diagnostic Audiology

G Mental Health

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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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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

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ICD-10-PCS Body Systems

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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

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Body System

Body Part

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Body System Guidelines

B2.1a

Anatomical

_Regions

B2.1b

Upper or

_Lower

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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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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

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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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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

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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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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

Root Operation Guidelines

B3.1a

• Full definition

B3.1b B3.1b

• Integral to procedure

B3.2 B3.2

• Multiple procedures

B3.3 B3.3

• Discontinued procedures

B3.4a

• Biopsy Procedures

B3.4b

• Biopsy followed by treatment

B3.5

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ICD-10-PCS Body Part

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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

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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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Body Part Guidelines

B4.4 • Coronary Arteries

B4.5 • Tendons, Ligaments, Bursae, Fascia Near a Joint

B4.6 • Skin, Subcutaneous Tissue, Fascia Overlying Joint

B4.7 • Fingers and Toes

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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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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

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

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Note:

When assigning the

approach value, remember that

the approach defines the technique

used to reach the procedure site,

not necessarily the instruments

used.

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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

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Approach Guidelines

• B5.2

Endoscopic

Assistance

• B5.3a

• B5.3b

• B5.3a

• B5.3b

External

Approach

• B5.4

Percutaneous

Procedure via

Device

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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

ICD-10-PCS Device

Four basic groups

• Grafts and Prostheses

• Implants

• Simple or Mechanical Appliances

• Electronic Appliances

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© 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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NEC in Medical/Surgical Section

Root

Operation

Value Q -Repair

Device

Value Y – Other Device

Coding Note:

Materials

incidental to a

procedure, such as clips

and sutures, are not

considered devices.

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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

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

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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

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)

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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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Check Your Understanding

Guideline Review

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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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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.

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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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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.

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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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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.

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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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Check Your Understanding

Root Operation Review

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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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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).

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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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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.

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).

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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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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).

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measurementrefers to a series of levels obtained at intervals, while monitoring describes a single

level taken.

Rationale:Measurement describes a single level taken, while Monitoring describes a series of levels obtained at intervals (ICD-10-PCS Reference Manual p. 90).

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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

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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

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Root Operations That Take Out

Some or All of a Body Part

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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

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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)

Resection

T

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.

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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

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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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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

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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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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

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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.

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 5th_Ray.

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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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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

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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

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.

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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.

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.

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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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