“ICD-10-CM/PCS”
Sharpening the Focus for Accurate Data and DRG Assignment
Module 2
Workshop # 3
Pulmonary & Respiratory
PCS Procedures and DRGs
Objectives for ICD-10 PCS Workshop
Review Official CMS Coding Guidelines and current
Coding Clinic Issues for Pulmonary Procedures.
Examine example procedure cases for guideline
application, and DRG impact.
Access resources and tools for Data Evaluation, and
Identification of DRG Shift(s).
Top Procedures for Pulmonary & Respiratory
Common Terminology for Procedures:
Bronchoscope With and without washing
brushing
Bronchoscope with and without endo bronchial
and or transbronchial lung biopsy
Lung Decortication
Lobectomy, pneumonectomy
Wedge resection of lung
Thorocoscopy with biopsy, with wedge resection
Thorocoscopy with Pleurodesis –scarification
using talc antibiotics other
Open lung biopsy
Lung repair
Common Terminology for Procedures:
Pleurectomy
Plication of lung
Tracheotomy temp – permanent and revision
Medestinal procedures
Pulmonary vessel procedures
Shunt procedures
Open and closed repairs to lung and
surrounding structures
Reconstruction and replacement procedures
Pleural and Surrounding structure procedures
Chest tubes
Drainage of pleura and lung
Respiratory System Anatomy
MS DRGs Surgery/Procedure Hierarchy
Major Chest
• DRG 163 MAJOR CHEST PROCEDURES WITH MCC • DRG 164 MAJOR CHEST PROCEDURES WITH CC
• DRG 165 MAJOR CHEST PROCEDURES WITHOUT CC/MCC
Other Resp Procedure
• DRG 166 OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC • DRG 167 OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC • DRG 168 OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT
CC/MCC
Ventilator for Respiratory DX
• DRG 207 RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS
• DRG 208 RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <96 HOURS
MDC 4 APR-DRGs
DRG SOI Description
120 1 Major Respiratory & Chest Procedures 120 2 Major Respiratory & Chest Procedures 120 3 Major Respiratory & Chest Procedures 120 4 Major Respiratory & Chest Procedures
DRG SOI Description
121 1 Other Respiratory & Chest Procedures 121 2 Other Respiratory & Chest Procedures 121 3 Other Respiratory & Chest Procedures 121 4 Other Respiratory & Chest Procedures
Major Chest Procedures
Bold are the Approach that Links to Surgical DRGs
Via natural or artificial
opening
Via natural or artificial
opening Endoscopic
3= Percutaneous
4= Endoscopic
Percutaneous
0=Open
External
Major Pulmonary Structures Major Pulmonary Vessels Lungs
Bronchus More Invasive Root operations that link to Surgical DRGs
1- bypass 3-control 5-destruction 9-drainage B- excision C- extirpate D- extraction F-fragmentation H- insertion J- inspection L-occlusion M- reattachment N-release P- removal Q-repair R-replacement S-reposition T-resection U-supplement V-restriction W-revision Y-transplantation Section D:
10
Other Respiratory Procedures
Bold Approaches that Link to
Surgical DRGs
Via natural or artificial
opening
Via natural or artificial
opening Endoscopic
3= Percutaneous
4= Endoscopic
percutaneous
0= Open
External
Smaller pulmonary structures and
surrounding tissues
Less Invasive
Root operations that link to
Surgical DRGs
1- bypass 5-destruction 7- dilatation 8- division 9-drainage B- excision C- extirpate D- extraction F-fragmentation H- insertion J- inspection L-occlusion M- reattachment N-release P- removal Q-repair R-replacement S- reposition T-resection U-supplement V-restriction11
PCS Characters
Root Operation, Body Part and Approach are key
Assigning the Correct Root Operation for
Respiratory System
Remember to assign the root operation that matches the Objective. No
not code the operative steps.
Lung wedge resection is often documented by the surgeon, but it is
most often coded with the root operation excision. Review the operative
report carefully.
When an entire lymph node chain is cut out the root operation is
resection. When only some of the lymph nodes are cut out, the root
operation is excision. Physicians may refer to a lymph node as a lymph
node level.
Assigning the correct Body part for Respiratory
System
Procedures performed specifically on the pleural cavity, rather than the
pleura itself, are classified to the Anatomic Regions body system.
ICD-10 PCS differentiates between the palatine and lingual tonsils.
Lingual tonsils are coded to the pharynx body part, based on the body
part key.
Surgeon documentation can provide important details about the
amount of lung tissue being resected. A segmentectomy is excision of a
portion of the lung lobe. A lobectomy is resection of the entire lung
lobe. A pneumonectomy is resection of the entire left or right lung.
Pleural biopsies are performed directly on the pleura not the pleural
cavity.
The Surgery & Procedure Details
The Operative Report is the most likely source for the review and assignment of PCS
codes. All related documents should be examined for complete procedure identification
and comparison to the Code description.
Support Documents:
Brief Operative progress note-check for Bedside procedures also
Informed consent
Operative Report
Interventional Radiology Report
Pathology Report –Cytology Report
Anesthesia Record
Bronchoscope Approach
Via natural or artificial
opening endoscopic
Trans Bronchial FNA and Endo Bronchial Biopsy
Endoscopic Percutaneous
Via Natural Orifice and Percutaneous Respiratory Procedures
Videoscopic Assisted and Imaging Assisted Percutaneous Procedures
Transbronchial Biopsy PCS Codes for Case
PREP/SEDATION: Prep/Sedation:
· Patient Position- supine
· Site Prep- usual sterile procedure followed · Anesthesia- 1% lidocaine
· Sedation- fentanyl, midazolam
PROCEDURE DETAILS: Bronchoscopy:
· Route -nasal
· Bronchoscopy Findings Nodularity of mucosa b/l. No other endobronchial lesions. No bleeding.
4 TBBX done RtUL.
One biopsy of carina LtUL done · Estimated Blood Loss 0 mL · Tolerance good
· Specimen obtained and sent to lab
0BBC4ZX
Excision of right upper lobe lung
Percu Endo Approach Diagnostic
0BB24ZX
Excision Carina Percu Endo
Approach Diagnostic
Pathology Report for Biopsy
Transbronchial Biopsy
26
DRG 167 Other Respiratory System O.R. Procedures with CC
SWI 1.9144
Reimb $
27,268.58
0BBC4ZX Excision of Right Upper Lung Lobe, Perc Endo Approach,
Transbronchial Fine Needle Aspiration
27
DRG 197 Interstitial Lung Disease with MCC
SWI 1.0215
Reimb $
16,327.55
0B9C42X Drainage Right Upper Lung Lobe, Perc Endo Approach,
Bronchoscopies
28
The list of codes on a bronchoscopy can be numerous.
There are 8 locations that could require diagnosis or tx, including the
main right and left bronchus, the 3 lobes on the right, and the two lobes
plus the lingula on the left.
Keep track of the procedures performed on each bronchus and follow
the multiple procedure guideline for code assignment.
When drainage and extirpation are performed together in the same
bronchus, code only the extirpation because the fluid is typically used to
loosen the mucus plug to allow its removal in one piece.
AHA Coding Clinic Advice
Coding Clinic for Complex Transbronchial Biopsy
Question:
A patient with moderately differentiated
adenocarcinoma status post right upper
lobectomy presents due to enlarging
mediastinal nodes and planned
bronchoscopy with fine needle
aspiration of the lymph nodes.
An
endobronchial ultrasound (EBUS) scope
was introduced and the one abnormal
lymph node was visualized and was
suspicious for malignancy.
An
endobronchial ultrasound guided
transbronchial needle aspiration
was performed.
What is the
appropriate ICD-PCS code assignment?
Should the “percutaneous endoscopic”
approach value be assigned since a
bronchoscope was used but the lymph
node was not aspirated via a natural
opening
Answer:
For the trans-bronchial endoscopic lymph
node aspiration biopsy, assign the
following ICD-10-PCS code:
07974ZX drainage of thorax lymphatic,
percutaneous endoscopic approach, diagnostic
In ICD-10-PCS, percutaneous endoscopic approach is defined as entry, by puncture or minor incision, of instrumentation through the skin or mucous membranes and any other body layers necessary to reach and visualize the site of the procedure. Therefore in this case, use the “percutaneous endoscopic” approach value, since more closely describes what was actually done.
The ICD-10-PCS tables currently use approaches containing the phrase “via natural or artificial opening” for body parts within the confines of the orifice were tubular body part without traversing the lumen wall to get to a different body part. The use of this approach for other body parts could change over
30
Official Guidelines for Coding and Reporting
CMS Official PCS Guidelines 2016
Medical and Surgical Section Guidelines (section 0)
Conventions
A8
All seven characters must be specified to be a valid code. If the documentation is incomplete for coding purposes,
the
physician should be queried for the necessary information.
A9
Within a PCS table, valid codes include all combinations of choices in characters 4 through 7 contained in the same row
of the table. In the example below, 0JHT3VZ is a valid code, and 0JHW3VZ is not a valid code.
A10
“And,” when used in a code description, means “and/or.”
Example: Lower Arm and Wrist Muscle means lower arm and/or wrist muscle.
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 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.
CMS Official PCS Guidelines 2016
Medical and Surgical Section Guidelines (section 0)
B3. Root Operation
General guidelines
B3.1a
In order to determine the appropriate root operation, the full definition of
the root operation as contained in the PCS Tables must be applied.
B3.1b
Components of a procedure specified in the root operation definition and explanation are
not coded separately. Procedural steps necessary to reach the operative site and close the
operative site, including anastomosis of a tubular body part, are also not coded
separately.
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. Laparotomy
performed to reach the site of an open liver biopsy is not coded separately. In a
resection of sigmoid colon with anastomosis of descending colon to rectum, the
anastomosis is not coded separately.
CMS Official PCS Guidelines 2016
Medical and Surgical Section Guidelines (section 0)
Multiple procedures
B3.2
During the same operative episode,
multiple procedures are coded if:
a. The same root operation is performed
on different body parts
as defined by distinct
values of the body part character.
Example: Diagnostic excision of liver and pancreas are coded separately.
b. The same root operation is repeated
in multiple body parts
, and those body parts
are separate and distinct body parts classified to a single ICD-10 PCS body part value.
Example: Excision of the sartorius muscle and excision of the gracilis muscle are both
included in the upper leg muscle body part value, and multiple procedures are coded.
c. Multiple root operations
with distinct objectives
are performed on the same body
part.
Example: Destruction of sigmoid lesion and bypass of sigmoid colon are coded
separately.
d. The intended root operation is attempted using
one approach, but is converted to
a different approach.
Example: Laparoscopic cholecystectomy converted to an open cholecystectomy is coded
CMS Official PCS Guidelines 2016
Medical and Surgical Section Guidelines (section 0)
Biopsy procedures
B3.4a
Biopsy procedures are coded using the root operations Excision, Extraction, or Drainage and the qualifier Diagnostic.
The qualifier Diagnostic is used only for biopsies.
Examples: Fine needle
aspiration biopsy
of lung is coded to the root operation
Drainage
with the qualifier
Diagnostic.
Biopsy of bone marrow
is coded to the root operation
Extraction
with the qualifier Diagnostic
.
Lymph
node sampling
for biopsy is coded to the root operation
Excision
with the qualifier Diagnostic.
Biopsy followed by more definitive treatment
B3.4b
If a diagnostic Excision, Extraction, or Drainage procedure (biopsy) is followed by a more definitive procedure,
such as Destruction, Excision or Resection at the same procedure site,
both the biopsy and the more definitive
treatment are coded.
Example: Biopsy of breast followed by partial mastectomy at the same procedure site, both the biopsy and the partial
mastectomy procedure are coded.
CMS Official PCS Guidelines 2016
Medical and Surgical Section Guidelines (section 0)
Excision vs. Resection
B3.8
PCS contains specific body parts for anatomical
subdivisions of a body part, such as lobes of the lungs
or liver and regions of the intestine
. Resection of
the specific body part is coded whenever all of
the body part is cut out or off, rather than
coding Excision of a less specific body part.
Example: Left upper lung lobectomy is coded to
Resection of Upper Lung Lobe, Left rather than
Excision of Lung, Left.
Resection of a complete lobe vs. Resection of
a complete Lung
CMS Official PCS Guidelines 2016
Medical and Surgical Section Guidelines (section 0)
Inspection procedures
B3.11a
Inspection of a body part(s) performed in order to achieve the objective of a
procedure is not coded separately.
Example: Fiberoptic bronchoscopy performed for irrigation of bronchus,
only the irrigation procedure is coded.
B3.11c
When both an Inspection procedure and another procedure are performed on the same
body part during the same episode, if the Inspection procedure is performed using a
different approach than the other procedure, the Inspection procedure is coded
separately.
Example: Endoscopic Inspection of the duodenum is coded separately when
open Excision of the duodenum is performed during the same procedural
episode.
CMS Official PCS Guidelines 2016
Medical and Surgical Section Guidelines (section 0)
B5. Approach
Open approach with percutaneous endoscopic assistance
B5.2
Procedures performed using the open approach with percutaneous endoscopic assistance are coded to the approach
Open.
Example: Laparoscopic-assisted sigmoidectomy is coded to the approach Open. External approach
B5.3a
Procedures performed within an orifice on structures that are visible without the aid of any instrumentation are coded to the approach
External.
Example: Resection of tonsils is coded to the approach External.
B5.3b
Procedures performed indirectly by the application of external force through the intervening body layers are coded to the approach
External.
Example: Closed reduction of fracture is coded to the approach External.
Percutaneous procedure via device
B5.4
Procedures performed percutaneously via a device placed for the procedure are coded to the approach Percutaneous.
Example: Fragmentation of kidney stone performed via percutaneous nephrostomy is coded to the approach Percutaneous.
CMS Official PCS Guidelines 2016
Medical and Surgical Section Guidelines (section 0)
B6. Device
General guidelines
B6.1a
A device is coded only if a device remains after the procedure is completed. If no device remains, the device value No
Device is coded.
Drainage device
B6.2
A separate procedure to put in a drainage device is coded to the root operation Drainage with the device
value Drainage Device.
Transplantation vs. Administration
B3.16
Putting in a mature and functioning living body part taken from another individual or animal is coded to the root
operation Transplantation. Putting in autologous or nonautologous cells is coded to the Administration section.
Example: Putting in autologous or nonautologous bone marrow,
pancreatic islet cells or stem cells is coded to the Administration section.
DRG Shifts & PCS Impact for Root Operation and
Approach
Which PCS Codes Will Shift Surgical DRGs
MS
Major Chest Procedures
DRG 163 MAJOR CHEST
PROCEDURES W MCC
DRG 164 MAJOR CHEST
PROCEDURES W CC
DRG 165 MAJOR CHEST
PROCEDURES W/O CC/MCC
Other Respiratory System O.R.
Procedures
DRG 166 OTHER RESP SYSTEM
O.R. PROCEDURES W MCC
DRG 167 OTHER RESP SYSTEM
O.R. PROCEDURES W CC
DRG 168 OTHER RESP SYSTEM
O.R. PROCEDURES W/O CC/MCC
APR-DRG SOI Description
120 1 Major Respiratory & Chest Procedures
120 2 Major Respiratory & Chest Procedures
120 3 Major Respiratory & Chest Procedures
120 4 Major Respiratory & Chest Procedures
DRG SOI Description
121 1 Other Respiratory & Chest Procedures
121 2 Other Respiratory & Chest Procedures
121 3 Other Respiratory & Chest Procedures
Shift in DRGs for Surgical Procedures
Major Chest Procedures
DRG 165 MAJOR CHEST PROCEDURES W/O CC/MCC
Other Respiratory System O.R. Procedures
DRG 168 OTHER RESP SYSTEM O.R. PROCEDURES W/O CC/MCC
DRG= 165 MAJOR CHEST PROCEDURES W/O CC/MCC
0BBG0ZX = Excision left upper lobe
Open approach
DRG = 168 Other Resp system O.R. Procedures w/o CC/MCC
0BBG8ZX = Excision of left upper lobe
via natural orifice endoscopic
DRG = 168 Other Resp system O.R. Procedures w/o CC/MCC
0BBG4ZX = Excision left upper lobe
Percutaneous Endoscopic
Non –surgical impact
DRG = 198 - INTERSTITIAL LUNG DISEASE W/O CC/MCC
0BBG3zx = Excision of Left upper lobe
percutaneous approach
Excision of Partial Right Sided Pleura
43
MS-DRG : 197 – Interstitial Lung Disease w/cc
SIW 1.1209
Reimbursement $
16,127.19
Px Dx Sarcoidosis Lung
2
nd
DX UTI (cc impact)
0BBN0ZX – Excision of right Pleura,
Open approach,
Diagnostic
Affect of Approach assignment on DRG
44
DRG 197 Interstitial Lung Disease with CC
SIW 1.1209
Reimbursement
$16,127.19
0BBN0ZX Excision of right pleura,
Open Approach
,
Diagnostic-
does not impact as a significant procedure on the DRG
0BBN3ZX Excision of right pleura,
Percutaneous Approach
,
Diagnostic-
does not impact as a significant procedure on the DRG
Affect of Approach assignment on DRG
45
DRG 167 Other Respiratory System OR procedure w/cc
SIW 1.9144
Reimbursement
$27,268.58
0BBN0ZX Excision of right pleura,
Open Approach
, Diagnostic-
does not
impact as a significant procedure on the DRG
0BBN3ZX Excision of right Pleura,
Percutaneous Approach
,
Diagnostic-Does not impact as a significant procedure on the DRG
0BBN4ZX Excision of right pleura,
Percutaneous Endoscopic
Interventional Radiology Procedures
PleurX Pleuroperitoneal Shunt
A drain is placed into the pleural space and tunneled
to the peritoneal cavity. Pleural fluid then drains into the
peritoneum Requires the patient to provide
digital pressure over the valve multiple times per
day to pump the pleural fluid into the peritoneal
space
Therapeutic Procedures Involving more than One Body part –
Anatomic Region
US guided placement tunneled Pleuroperitoneal Drainage device:
Clinical history – 56-year-old man on hospice for Right upper lung neoplasm and recurrent malignant effusion.
The right posterior chest and central lower abdomen were prepped and draped in sterile fashion and
2% lidocaine administered for local anesthesia. An 18-gauge needle catheter was advanced into the pleural space and catheter secured. Placement of catheter confirmed and then attention placed to subcutaneous tissues in the anterolateral right lower quadrant under sonographic guidance and catheter advanced postero-medially with care to avoid epigastric artery.
Advance the needle tip into the peritoneal cavity under sonographic guidance. Spontaneous drainage
of straw-colored fluid was noted. A 0.035 superstiff guidewire was advanced into the peritoneal cavity followed by a 12 French dilator and then a 16 French peel-away sheath. A 16 French multi-sidehole Denver pleurX catheter was advanced through the peel-away sheath into the peritoneal cavity
The catheter cuff was positioned in the subcutaneous tissues near the skin entrance site. Vacuum
aspiration was performed yielding 600 cc of straw-colored fluid. Additional fluid was not aspirated at this time. The catheter was secured to the skin with 3-0 silk and a sterile dressing applied. The
catheter was capped. The patient tolerated the procedure well.
PleurX Drainage Device Insertion
51
MS-DRG : 181 – Respiratory Neoplasms w/cc
SIW 1.1520
Reimbursement $
17,926.62
Px Dx Malignant Pleural Effusion
2
nd
DX Inoperable Colon Cancer (cc impact)
PleurX Drainage Device Insertion
52
MS-DRG : 181 – Respiratory Neoplasms w/cc
SIW 1.1520
Reimbursement $
17,926.62
Px Dx Malignant Pleural Effusion
2
nd
DX Inoperable Colon Cancer (cc impact)
0B9N30Z= Insertion pleural drainage device right pleural cavity Does not impact the DRG
0W9G00Z = Insertion peritoneal drainage device peritoneal space Does not impact as a Significant
PleurX Drainage Device Insertion
53
DRG 167 – Other Respiratory System OR procedure w/cc
SIW 1.9144
Reimbursment
$27,268.58
Px Dx Malignant Pleural Effusion
2
nd
DX Inoperable Colon Cancer (cc impact)
0B9N30Z= Insertion pleural drainage device right pleural cavity, percutaneous approach Does not
impact the DRG
0W9G30Z = Insertion peritoneal drainage device peritoneal space, percutaneous approach - Does not
impact the DRG
•
0BBF4ZZ = Excision of right lower lung lobe, percutaneous endoscopic approach (OR
Key documentation for PCS
Know and understand the
objective of the procedure
Identify the targeted body
part/tissue/structure
(laterality and bilateral)
Utilize all of the parts of the
medical chart to interpret the
root operation, body part,
approach, device, other
qualifiers
Review and reference Coding
Clinic, CM and PCS guidelines
for complete code capture,
and proper sequencing
Query when the details are
not clearly assignable with
Key Points for Take Away
Designate a central resource – person for monitoring and disseminating Coding
Clinic Guidelines/Documentation requirements, and verify updates are utilized by
responsible staff for those changes
Ongoing education for targeted provider (s) & CDI Training/Assessment/
Reassessment
Concurrent CDI review workflow redesign yearly as PCS Codes update and New
Technology Codes are expanded for Surgical DRGs or Non-Surgical DRGs
Policy and procedure for escalating identified problems to responsible party
Expansion of provider documentation education needs for identified targeted
areas
Evaluate coding reliability at key intervals to include accuracy of PCS coding
Cross auditing of documentation to include all relevant documentation for
significant procedures
