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Basic ICD-10-CM/PCS Coding 2013 Edition

Basic ICD-10-CM/PCS Coding 2013 Edition. Chapter 2: Introduction to ICD-10-PCS. Learning Objectives. Review the chapter’s learning objectives and the key terms included in the chapter A thorough understanding of the basic concepts of the ICD-10-PCS procedure coding system is important

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Basic ICD-10-CM/PCS Coding 2013 Edition

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  1. Basic ICD-10-CM/PCS Coding2013 Edition Chapter 2: Introduction to ICD-10-PCS

  2. Learning Objectives • Review the chapter’s learning objectives and the key terms included in the chapter • A thorough understanding of the basic concepts of the ICD-10-PCS procedure coding system is important • Other chapters in this book will include instruction on coding of procedures performed in specific body systems

  3. ICD-10-PCS References • The Centers for Medicare and Medicaid Services website for the ICD-10-PCS home page • Files of the ICD-10-PCS codes and essential references • Guidelines • Current version, code tables, index, code titles • Article on the development of ICD-10-PCS • ICD-10-PCS Reference Manual • Most recent addendum • PCS Slides • General Equivalence Mappings (GEMS) • Reimbursement Mappings

  4. Characteristics of the ICD-10 Procedure Coding System • In 1992, CMS began the process of replacing ICD-9-CM Volume 3 by funding a research project to design a new procedure coding system • In 1995, CMS award 3M Health Information Systems a three-year contract to complete the development of a new procedure coding system • The new system is the International Classification of Diseases, Tenth Revision, Procedure Coding System or ICD-10-PCS

  5. Characteristics of the ICD-10 Procedure Coding System • Multiaxial seven-character alphanumeric code structure • Unique code for all substantially different procedures • Allows new procedures to be easily incorporated as new codes • Exclusively designed for United States • Initially released in 1998 and updated several times • Scheduled to be implemented with ICD-10-CM on October 1, 2014

  6. Design Considerations for ICD-10-PCS • Completeness • There should be a unique code for all substantially different procedures • Expandability • The structure should allow a code for new procedures to be easily identified • Multiaxial • Ability of the nomenclature to express the meaning of a concept across several axes • Each individual axis retains its meaning across broad ranges of codes as much as possible

  7. Design Considerations for ICD-10-PCS • Standardized Terminology • Definitions of the terminology are included • Each term has a specific meaning or definition • Only limited options for “not elsewhere classified” (NEC) procedures • When a new device is used in a procedure and there is not a device value for that particular procedure, the coder can use the value of “other device” until a possible update for that device can be added when the coding system is updated on an annual basis

  8. General Design Principles • There is no diagnosis included in the ICD-10-PCS code description • The reason for the procedure being performed is not important for coding of the procedures • The procedure code identifies what procedure is performed according to the objective of the procedures, the approach, the device used and other factors

  9. General Design Principles • A single principle was to limit the “not otherwise specified” NOS codes available • Coder needs the facts about the procedure to code it • The operative report must provide, at a minimum, the objective of the procedure, the body system, the body part involved, and the approach used to perform the procedure

  10. General Design Principles • There is no need for an NEC code in ICD-10-PCS. • NEC values in the PCS tables are identified as the “other” specified types • Value for Other Device • Value for Other Contrast • Value for Other Equipment • Finally, the system allows for all procedures to be coded • Each variation of a procedure can be identified with the specific values available for the body part involved, the approach used, any devices left in place, and such. Some of the combination of values may not be performed frequently or even at all.

  11. Code Structure • Codes are constructed using the Alphabetic Index and the Code Tables • Process of constructing codes is intended to be logical and consistent and uses individual letters and numbers called “values” to occupy the seven digits or letters of the code. • The seven digits or letters of a code are called “characters”

  12. Code Structure • Each character has one of 34 possible values • A value can be a number from 0 to 9 • A value can be a letter A to H, J to N and P to Z. Letters O and I are not used so they are not confused with numbers zero (0) and one (1) • Each code is constructed by choosing a specific value for each of the seven characters

  13. Code Structure • All ICD-10-PCS codes are seven characters long • Character 1 = Section of ICD-10-PCS • Character 2 = Body System • Character 3 = Root Operation • Character 4 = Body Part • Character 5 = Approach • Character 6 = Device • Character 7 = Qualifier

  14. The ICD-10-PCS Format: Index and Tables • Index is an alphabetic listing of procedure titles • Entries are based on: • general type of procedure, such as excision or resection • commonly used procedure titles, such as cholecystectomy • Index specifies the first three or four values of the code • Table identifies the first three values of the code and is used to obtain the complete codes by specifying the last four values

  15. The ICD-10-PCS Format: Index and Tables • Each Table is composed of rows that specify the valid combinations of code values • The upper portion of each Table specifies the values for the first three characters • In the Medical and Surgical section, the first three characters are the section, the body system, and the root operation • The coder needs to selects the fourth, fifth, sixth and seventh characters to complete the code

  16. The ICD-10-PCS Code • All codes in the ICD-10-PCS have seven characters • Each character represents an aspect of or a fact about the procedure • Each of the characters have a defined meaning • Character 1: Section • The first character of a code determines the broad procedure category or section where the code is located • Character 2: Body System • The general physiological system or anatomical region involved

  17. The ICD-10-PCS Code • Character 3: Root Operation • The objective of the procedure being performed in the medical and surgical section while in other sections the root operation is known as the root type of procedure. Each of the root operations are defined. • Character 4: Body Part • Specific anatomical site where the procedure was performed • Character 5: Approach • The surgical technique used to reach the operative site with seven different approach values used in Medical-Surgical

  18. The ICD-10-PCS Code • Character 6: Device • Defines the device left in place at the end of the procedure but not all procedures have one left in place • Character 7: Qualifier • Specifies an additional attribute of the procedure. In each section the qualifier has a unique meaning and even a unique meaning within different root operations in a section

  19. The ICD-10-PCS Code • If a given character does not have a value assigned, the Z value is used. This is particularly frequent for the sixth and seventh characters, which generally represent the device and the qualifier. • In summary, the first through fifth characters are always assigned a specific value, but the device (sixth) and the qualifier (seventh) characters are not applicable to all procedures. • The value Z is used for the sixth and seventh characters to indicate that a specific device or qualifier does not apply to the procedure.

  20. Overall Organization of ICD-10-PCS • ICD-10-PCS is composed of 16 sections, represented by the numbers 0 through 9 and the letters B through D and F through H. • The 16 sections are contained in three main areas: • The Medical and Surgical section • The Medical and Surgical-related sections • The Ancillary sections • The first section, Medical and Surgical, begins with the section value of 0 and contains the majority of procedures typically reported in an inpatient setting

  21. Overall Organization of ICD-10-PCS • Sections with values 1 through 9 of the ICD-10-PCS comprise the Medical and Surgical-related sections. • The sections include the following section values • 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

  22. Overall Organization of ICD-10-PCS • Codes in sections 1 through 9 are structured like the Medical and Surgical section with a few exceptions. • For example, in sections 5 and 6, the fifth character is defined as the duration instead of the approach. The sixth character represents the substance, the function or the method applicable to the specific procedure. • Sections B through D and F through H comprise the Ancillary section which can be described as follows: • B = Imaging • C = Nuclear Medicine • D = Radiation Oncology • F = Physical Rehabilitation and Diagnostic Audiology • G = Mental Health • H = Substance Abuse Treatment

  23. The Medical and Surgical Section (0) • The Second Character represents the general body system. • The definition of a body system is a bit different than the usual meaning of the term. Some customary body systems are given multiple body-system values. • There are 31 body system values • Central Nervous; Peripheral Nervous; Heart and Great Vessels • Upper Arteries, Lower Arteries, Upper Veins, Lower Veins • Lymphatic and Hemic, Eye, Ear-Nose-Sinus, Respiratory, Mouth-Throat • Gastrointestinal, Hepatobiliary-Pancreas, Endocrine, Skin-Breast • Subcutaneous-Fascia, Muscles, Tendons, Bursae-Ligaments • Head-Facial bones, Upper Bones, Lower Bones, Upper and Lower Joints • Urinary, Female Reproductive, Male Reproductive • Anatomical Regions: General, Upper Extremities and Lower Extremities

  24. The Medical and Surgical Section (0) • The Third Character is the root operation. • There are 31 root operations each representing a specific objective • The 31 root operations are divided into nine groups of similar attributes • Procedures that take out some/all of a body part • Procedures that take out solids/fluids/gases from a body part • Procedures involving cutting or separation only • Procedures that put in/put back or move some/all of a body part • Procedures that alter the diameter/route of a tubular body part • Procedures that always involve a device • Procedures involving examination only • Procedures that define other repairs • Procedures that define other objectives

  25. The Medical and Surgical Section (0) • The Third Character is the root operation. • Each component of the procedure is define separately • The third, fourth and fifth characters are used to describe the objective of the procedure • The third character is the root operation that defines the objective of the procedure • The fourth character identifies the body part upon which the procedure was performed • The fifth character describes the approach and further contributes to describing the procedure’s objective • The procedure coded is the procedure that was actually performed • When the intended or anticipated procedure is changed or discontinued, the root operation is coded based on the actual procedure that was performed.

  26. The Medical and Surgical Section (0) • Multiple Procedures • If multiple procedures are performed that are defined by distinct objectives during a single operative episode, then multiple procedure codes are used.

  27. The Medical and Surgical Section (0) • Multiple procedures are coded if: • The same root operation is performed on different body parts that have distinct body part values. • For example, a biopsy or diagnostic excision is performed on the duodenum and rectum. • The same root operation is repeated on different body sites that are included in the same body part value. • For example, a biopsy is performed on the scalene muscle and the platysma muscles which are both included in the neck muscle body part • Distinctive procedures with multiple root operations are performed on the same body part. • For example, biopsy of the pancreas and partial pancreatectomy is performed • The intended procedure cannot be accomplished and is converted to a different approach. • For example, a laparoscopic nephrectomy is attempted but is converted to an open nephrectomy. The laparoscopic portion is coded as an inspection and the open procedure is coded as a resection for the nephrectomy.

  28. The Medical and Surgical Section (0) • Redo of Procedures • If a procedure is a complete or partial redo of a previous procedure, the root operation used is the root operation that identifies what was the actual procedure performed. • The term of “redo” is not always a revision procedure according to the definition of the root operation of “revision.” • For example, a complete redo of a knee replacement procedure which requires putting in a new prosthesis, is coded to the root operation of Replacement instead of Revision.

  29. The Medical and Surgical Section (0) • Redo of Procedures • The correction of complications arising from the original procedure other than device complications as defined in the root operation Revision are also coded to the procedure performed. • For example, a procedure to add mesh to the abdominal wall to repair a postoperative ventral hernia is coded to Supplement rather than Revision.

  30. The Medical and Surgical Section (0) • The fourth character is the body part. • The value chosen for this character represents the specific part of the body system (character 2) on which the surgery was performed. • Body parts may specify laterality • Example of the body parts in the Endocrine body system are the pituitary gland, pineal body, adrenal gland, thyroid gland and parathyroid gland. • Some body part value is either the whole body part or for nerve and vessels, the body part value is coded to the closest proximal branch.

  31. The Medical and Surgical Section (0) • The fifth character is the approach used to reach the site of the procedure. • For procedures performed on internal organs, the access location specifies the external site through which the internal organ is reached. Access locations are skin or mucous membrane and external orifices • The method specifies how the external access location is entered for procedures performed on an internal body part. An open approach means there was cutting through the skin, mucous membrane and other body layers to expose the site. • Specialized equipment or instrumentation is used to perform a procedure on an internal body part.

  32. The Medical and Surgical Section (0) • The fifth character is the approach used to reach the site of the procedure. • Another approach, external, is used when procedures are performed directly on the skin or mucous membrane. • In total, there are seven approaches defined: • Open • Percutaneous • Percutaneous endoscopic • Via Natural or Artificial Opening • Via Natural or Artificial Opening Endoscopic • Via Natural or Artificial Opening Endoscopic with Percutaneous Endoscopic Assistance • External

  33. The Medical and Surgical Section (0) • The sixth character specifies devices that remain after the procedure is completed. • A device can be one of the following four objects left in the patient’s body at the conclusion of the procedure: • Grafts and Prostheses • Implants • Simple or Mechanical Appliances • Electronic Appliances • There is a device Key in Appendix D that includes brand names and generic names of devices. • The Device Aggregation Table assists the coder in correctly reporting the device used during a procedure.

  34. The Medical and Surgical Section (0) • The sixth character specifies devices that remain after the procedure is completed. • Devices can be removed from the body but some cannot be removed without being replaced with another nonbiological appliance or another substitute for the body part. • The following root operations may or may not have specific devices as part of the procedure: • Alteration, Bypass, Creation • Dilation, Drainage • Fusion, Occlusion • Reposition, Restriction

  35. The Medical and Surgical Section (0) • The sixth character specifies devices that remain after the procedure is completed. • The following root operations must have specific devices as part of the procedure: • Change • Insertion • Removal • Replacement • Revision

  36. The Medical and Surgical Section (0) • The sixth character specifies devices that remain after the procedure is completed. • The Insertion root operation is used when the procedure’s objective is to put in a device • If there is another objective for a procedure but it includes the use of a device, then the root operation defining the underlying objective of the procedure is used instead. The device used is still reported in the sixth character. • Material incidental to a procedure such as clips, ligatures, and sutures are not what is meant by a device and are not specified in the device character.

  37. The Medical and Surgical Section (0) • The seventh character is the qualifier which can add more information to describe the procedure. • Individual procedures have unique values for the qualifier. • The qualifiers may have a narrow application to a specific root operation, body system, or body part. • For example, a qualifier can be used to identify the destination site in a bypass procedure. • Other qualifiers identify the type of transplant performed. • A common qualifier is X for Diagnostic which is used, for example, to identify when a biopsy procedure is performed.

  38. ICD-10-PCS Appendices • The OptumInsight printed versions of the ICD-10-PCS system include several appendices available for the coder’s use to completely and accurately assign a procedure code. • Appendix A contain the root operation definitions • Appendix B is a comparison of medical and surgical root operations organized into nine groups that describe related procedures • Appendix C is the body part key which is a handy reference of anatomical terms with the corresponding PCS description that is used for the body part values. • Appendix D is the device key and aggregation table that helps the coder translate a specific trade name or generic name of a device to the equivalent PCS description used for the device character value.

  39. ICD-10-PCS Appendices • The OptumInsight printed versions of the ICD-10-PCS system include several appendices available for the coder’s use to completely and accurately asign a procedure code • Appendix E contains the type and type qualifier definitions for procedures coded in Sections B through H. The largest number of type qualifiers and the definitions of each are from the Physical Rehabilitation and Diagnostic Audiology section • Appendix F is a one-page summary of the components of the medical and surgical approach definitions • Appendix G is a list of character meanings for section and body system • Appendix H contains the answers to the coding exercises that the publisher, OptumInsight has included in their edition of the PCS code book

  40. Assigning an ICD-10-PCS Code • An ICD-10-PCS code is constructed by assigning values for each of the characters. • The procedure term is referenced in the Index using either the root operation phrase or a common procedure term. • The Index usually provides the first three characters with the final seven characters identified by accessing the code Tables that appear following the Index. • The Alphabetic Index occasionally provides the complete seven-character code, which must still be confirmed by accessing the applicable code table.

  41. Assigning an ICD-10-PCS Code • As an example, to code a laparoscopic total cholecystectomy, the coder would • Access the term “resection” as the root operation in the Index and find • Resection, Gallbladder, 0FT4 • As an alternative, the coder would access the term “cholecystectomy” in the Index and find • Cholecystectomy, see Excision, Gallbladder 0FB4 or see Resection, Gallbladder 0FT4 • The coder must decide whether to use the term excision or resection. In this example, resection would be used as it is defined as cutting out or off, without replacement, all of a body part. • The next step is to access the 0FT code table. The remaining four characters are assigned based on this table. The values for each of the characters must be from the same row.

  42. Assigning an ICD-10-PCS Code • Using the OFT code Table, the seven characters for the ICD-10-PCS procedure code for a laparoscopic total cholecystectomy would be 0FT44ZZ: • 0 = Medical and Surgical Section • F = Hepatobiliary system and pancreas body system • T = Resection root operation • 4 = Gallbladder body part • 4 = Percutaneous endoscopic approach (laparoscopic) • Z = No device • Z = No qualifier

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