icd-10 pcs coding procedures common to all facilities presented by ahima-approved icd-10-cm/pcs...
TRANSCRIPT
ICD-10 PCSCODING PROCEDURES COMMON TO ALL FACILITIES
Presented by
AHIMA-Approved ICD-10-CM/PCS Trainers :Deb Selland, RHIT, CCS
Sue Roehl, RHIT, CCS
Instructors • Sue Roehl, RHIT, CCS
Sue is a Manager and Health Care Consultant with Eide Bailly LLP in Fargo, ND. She has more than thirty years of health care experience, with an emphasis in coding, health information and quality management. She provides ICD-9-CM and CPT coding, documentation, and compliance reviews for hospitals throughout the country. She also provides coding support for inpatient and outpatient accounts.
Sue specializes in assisting hospital medical records coding staff, physicians, business services and ancillary departments with appropriate reimbursement. In addition, Sue offers onsite educational sessions and coding validation studies to determine if providers are assigning correct diagnosis and procedure codes for reimbursement and compliance.
Sue completed the AHIMA ICD-10-CM/PCS training in 2009. She has twice served as President for the North Dakota Health Information Management Association, along with various other Board offices.
• Deb Selland, RHIT, CCS
Deb is employed by Blue Cross Blue Shield of North Dakota as the Reimbursement Coding Coordinator and is responsible for performing DRG Validation coding audits on all North Dakota participating facilities. She has been employed in the Health Information industry for over thirty years.
Deb completed the AHIMA ICD-10 CM/PCS Academy certification in 2010. She has formerly served as President and Education Director for NDHIMA.
2
Disclaimer• The presenters have made every reasonable effort to
ensure accuracy of the information provided in this material.
• The presenters make no guarantee the information compiled or presented is error-free.
3
Objectives• Review structure of PCS codes• Code common procedures from various sections of
ICD-10-PCS
4
ICD-10-PCS
Procedure Classification System
5
ICD-10-PCS
(Procedures)Used in inpatient hospital setting
Replaces Volume 3
Maintained by CMS
6
6
Structures and Features Comparison
ICD-9-CM Volume 3
Procedures
ICD-10-PCS
Procedures-3 or 4 characters (numeric)
-Always 7 characters per procedure (alphanumeric)
-Digits 0-9 used
-Letters A-H, J-N, P-Z
(no I or O because of confusion with numbers 1 and 0)
7
7
*Documentation Alert
• ICD-10-PCS Coding Guideline:• 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.
8
*Documentation Alert• ICD-10-PCS Coding Guideline:
• A11: Many of the terms used to construct PCS codes are defined within the system. It is the coder’s responsibility to determine what the documentation in the medical record equates to in the PCS definition. 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.
9
Structures and Features Comparison
ICD-9-CM Volume 3
(Procedures)
ICD-10-PCS
(Procedures)
Consists of:
-Index
-Tabular
Consists of:-Index
Provides first 3 or 4 values of the code
- Tables
Must be used to build complete code
10
10
Structure and Features of ICD-10-PCS
Character Meanings
1 2 3 4 5 6 7
Section
Sections (#16)0 Medical & Surgical · For procedures in the Medical & Surgical section the first character will always be zero (0).
Sections 1-9 comprise the Medical & Surgical-related sections such as obstetrical procedures and extracorporeal therapies, while sections B-D and F-H contain the Ancillary sections including procedures such as imaging and nuclear medicine.
11
12
1 2 3 4 5 6 7
Section Body System
2nd Character Body Systems (#31)
13
1 2 3 4 5 6 7
Section Body System Root
Operation
3rd CharacterRoot Operation
14
ICD-10 PCS CODING 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.
15
ICD-10 Procedure Coding SystemGlobal Root Operations (Section 0-9)
Alteration Definition-Modifying the anatomic structure of a body part without affecting the function of the body part
Explanation-Principal purpose is to improve appearance
Examples-Face lift, breast augmentation
Bypass Definition-Altering the route of passage of the contents of a tubular body part
Explanation-Rerouting contents around an area of a body part to another distal (downstream) area in the normal route; rerouting the contents to another different but similar route and body part; or to an abnormal route and another dissimilar body part. It includes one or more concurrent anastomoses with or without the use of a device such as autografts, tissue substitutes and synthetic substitutes.
Examples-Coronary artery bypass, colostomy formation
Change Definition-Taking out or off a device from a body part and putting back an identical or similar device in or on the same body part without cutting or puncturing the skin or a mucous membrane.
Explanation- All Change procedures are coded using the approach External
Examples-Urinary catheter change, gastrostomy tube change
Control Definition-Stopping, or attempting to stop, postprocedure bleeding
Explanation-The site of the bleeding is coded as an anatomical region and not to a specific body part.
Examples-Control of post-prostatectomy hemorrhage, control of post-tonsillectomy hemorrhage 16
16
Global Root Operations (Section 0-9)
17
Creation Definition-Making a new genital structure that does not take over the function of a body part
Explanation-Used only for sex change operations
Examples-Creation of vagina in a male, creation of penis in a female
Destruction Definition-Physical eradicating 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
Detachment Definition-Cutting off all or a portion of an upper or lower extremity
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
Dilation Definition-Expanding an orifice or the lumen of a tubular body part
Explanation-The orifice can be a natural orifice or an artificially created orifice. Accomplished by stretching a tubular body part using intraluminal pressure or by cutting part of the orifice or wall of the tubular body part.
Examples-Percutaneous transluminal angioplasty, pyloromyotomy
Division Definition-Cutting into a body part without draining fluids and/or gases from the body part in order to separate or transect a body part
Explanation-All or a portion of the body part is separated into two or more portions
Examples-Spinal cordotomy, osteotomy
17
ICD-10 Procedure Coding SystemGlobal Root Operations (Section 0-9)
Drainage Definition-Taking or letting out fluids and/or gases from a body part
Explanation-The qualifier DIAGNOSTIC is used to identify drainage procedures that are biopsies.
Examples-Thoracentesis, incision and drainage
Excision 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
Extirpation Definition-Taking or cutting out solid matter from a body part
Explanation-The solid matter may be an abnormal byproduct of a biological function or a foreign body. The solid matter is imbedded in a body part, or is in the lumen of a tubular body part. The solid matter may or may not have been previously broken into pieces. No appreciable amount of the body part is taken out.
Examples-Thrombectomy, choledocholithotomy
Extraction Definition-Pulling or stripping out or off all or a portion of a body part
Explanation-The body part is pulled or stripped from its location by the use of force (e.g., manual, suction). The qualifier DIAGNOSTIC is used to identify extraction procedures that are biopsies.
Examples-Dilation and curettage, vein stripping
18
18
Global Root Operations (Section 0-9)
Fragmentation Definition-Breaking solid matter in a body part into pieces.
Explanation-The solid matter may be an abnormal byproduct of a biological function or a foreign body. Physical force (e.g., manual, ultrasonic) applied directly or indirectly through intervening body parts is used to break the solid matter into pieces. The pieces of solid matter are not taken out, but are eliminated or absorbed through normal biological functions.
Examples-Extracorporeal shockwave lithotripsy, transurethral lithotripsy
Fusion Definition-Joining together portions of an articular body part rendering the articular body part immobile.
Explanation-The body part is joined together by fixation device, bone graft, or other means.
Examples-Spinal fusion, ankle arthrodesis
Insertion Definition-Putting in a non-biological appliance that monitors, assists, performs or prevents a physiological function but does not physically take the place of a body part.
Explanation- None
Examples-Insertion of radioactive implant, insertion of central venous catheter
Inspection Definition-Visually and/or manually exploring a body part.
Explanation-Visual exploration may be performed with or without optical instrumentation. Manual exploration may be performed directly or through intervening body layers.
Examples-Diagnostic arthroscopy, exploratory laparotomy19
19
ICD-10 Procedure Coding SystemGlobal Root Operations (Section 0-9)
Map Definition-Locating the route of passage of electrical impulses and/or locating functional areas in a body part
Explanation-Applicable only to the cardiac conduction mechanism and the central nervous system
Examples-Cardiac mapping, cortical mapping
Occlusion Definition-Completely closing an orifice or the lumen of a tubular body part
Explanation-The orifice can be a natural orifice or an artificially created orifice
Examples-Fallopian tube ligation, ligation of inferior vena cava
Reattachment Definition-Putting back in or on all or a portion of a separated body part to its normal location or other suitable location
Explanation-Vascular circulation and nervous pathways may or may not be reestablished
Examples-Reattachment of hand, reattachment of avulsed kidney
Release Definition-Freeing a body part from an abnormal physical constraint by cutting or by use of force
Explanation- Some of the restraining tissue may be taken out but none of the body part is taken out
Examples-Adhesiolysis, carpal tunnel release
20
20
ICD-10 Procedure Coding SystemGlobal Root Operations (Section 0-9)
Removal Definition-Taking out or off a device from a body part
Explanation-If the device is taken out and a similar device is put in without cutting or puncturing the skin or mucous membrane, the procedure is coded to the root operation CHANGE. Otherwise, the procedure for taking out the device is coded to the root operation REMOVAL and the procedure for putting in the new device is coded to the root operation performed.
Examples-Drainage tube removal, cardiac pacemaker removal
Repair Definition-Restoring, to the extent possible, a body part to its normal anatomic structure and function
Explanation-Used only when the method to accomplish the repair is not one of the other root operations
Examples-Herniorrhaphy, suture of laceration
Replacement Definition-Putting in or on biological or synthetic material that physically takes the place of all or a portion of a body part
Explanation-The biological material is non-living, or the biological material is living and from the same individual. The body part may have been previously taken out, previously replaced, or may be taken out concomitantly with the Replacement procedure. If the body part has been previously replaced, a separate Removal procedure is coded for taking out the device used in the previous replacement.
Examples-Total hip replacement, free skin graft21
21
ICD-10 Procedure Coding SystemGlobal Root Operations (Section 0-9)
Reposition Definition-Moving to its normal location or other suitable location all or a portion of a body part
Explanation-The body part is moved to a new location from an abnormal location, or from a normal location where it is not functioning correctly. The body part may or may not be cut out or off to be moved to the new location.
Examples-Reposition of undescended testicle, fracture reduction
Resection Definition-Cutting out or off, without replacement, all of a body part.
Explanation-None
Examples-Total nephrectomy, total lobectomy of lung
Restriction Definition-Partially closing an orifice or the lumen of a tubular body part
Explanation-The orifice can be a natural orifice or an artificially created orifice.
Examples-Esophagogastric fundoplication, cervical cerclage
Revision Definition-Correcting to the extent possible a malfunctioning or displaced device
Explanation-Revision can include correcting a malfunctioning or displaced device by taking out or putting in components of the device such as a screw.
Examples-Adjustment of pacemaker lead, adjustment of hip prosthesis 22
22
ICD-10 Procedure Coding SystemGlobal Root Operations (Section 0-9)
Supplement Definition-Putting in or on biological or synthetic material that physically reinforces or augments the function of a body part
Explanation-The biological material is non-living, or living and from the same individual. The body part may have been previously replaced. If the body part has been previously replaced, the Supplement procedure is performed to physically reinforce and/or augment the function of the replaced body part
Examples-Herniorrhaphy using mesh, free nerve mitral valve ring annuloplasty, put a new acetabular liner in a previous hip replacement
Transfer Definition-Moving, without taking out, all or a portion of a body part to another location take over the function of all or a portion of a body part
Explanation-The body part transferred remains connected to its vascular and nervous supply.
Examples-Tendon transfer, skin pedicle flap transfer
23
23
ICD-10 Procedure Coding SystemGlobal Root Operations (Section 0-9)
Transplantation Definition-Putting in or on all or a portion of a living body part taken from another individual or animal to physically take the place and/or function of all or a portion of a similar body part
Explanation-The native body part may or may not be taken out, and the transplanted body part may take over all or a portion of its function
Examples-Kidney transplant, heart transplant
24
24
4th CharacterBody Part
1 2 3 4 5 6 7
Section Body System Root Operation
Body Part
25
Comparing ICD-9-CM and ICD-10-PCS:Release Carpal Tunnel Release, Percutaneous
In the ICD-9-CM Alphabetic Index locate the main term “release,” followed by subterm “carpal tunnel (for nerve decompression)” which identifies code 04.43, Release of carpal tunnel.
In ICD-10-PCS, the main term entry of “release” requires the coder to select the body part being released. It is necessary to know that the median nerve is released during a carpal tunnel release. The body part value assigned is the structure released (median nerve) and not the structure cut (carpal ligament) to obtain the release. The subterm “nerve, median” below the main term “release” leads to 01N5. The 01N table is then accessed to construct the remainder of the code. The code assigned for a percutaneous release of the median nerve is 01N53ZZ.
26
Approach
1 2 3 4 5 6 7
Section Body System Root Operation
Body Part
5th CharacterApproach (7 Options)
27
ICD-10 Procedure Coding SystemMedical and Surgical Approaches
1 Open Cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure Example: Abdominal hysterectomy
2 Percutaneous Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach the site of the procedure Example: Needle biopsy of liver
3 Percutaneous Endoscopic
Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach and visualize the site of the procedure Example: Arthroscopy
4 Via natural or artificial opening
Entry of instrumentation through a natural or artificial external opening to reach the site of the procedure Example: Endotracheal intubation
5 Via natural or artificial opening endoscopic
Entry of instrumentation through a natural or artificial external opening to reach and visualize the site of the procedure Example: Sigmoidoscopy
6 Via natural or artificial opening endoscopic with percutaneous endoscopic assistance
Entry of instrumentation through a natural or artificial external opening and entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to aid in the performance of the procedure Example: Laparoscopic-assisted vaginal hysterectomy
7 External Procedures performed directly on the skin or mucous membrane and procedures performed indirectly by the application of external force through the skin or mucous membrane Example: Closed fracture reduction
28
28
Device
1 2 3 4 5 6 7
Section Body System Root Operation
Body Part Approach
6th CharacterDevice
29
Types of DevicesDevices that remain after the procedure is completed
• 4 general types of devices:• Biological or synthetic material that takes the place of all or a portion of
a body part (i.e., skin graft, joint prosthesis)• Biological or synthetic material that assists or prevents a physiological
function (i.e., IUD)• Therapeutic material that is not absorbed by, eliminated by, or
incorporated into a body part (i.e., radioactive implant)• Mechanical or electronic appliances used to assist, monitor, take the
place of, or prevent a physiological function (i.e., cardiac defibrillator, orthopedic pin)
• Materials such as sutures, ligatures, radiological markers, and temporary post-operative wound drains are considered integral to the procedure and
are not coded as devices.
30
1 2 3 4 5 6 7
Section Body System Root Operation
Body Part Approach Device
7th Character - Qualifier-Defines an additional attribute of the procedure performed, if applicable.
Qualifier
31
Medical and Surgical Section (0)
ICD-9 Volume 3 ICD-10-PCS
81.91 Arthrocentesis Arthrocentesis, right knee, diagnostic, no device0S9C3ZX
51.23 Laparoscopic cholecystectomy 0FT44ZZ
51.22 Open cholecystectomy 0FT40ZZ
54.91 Percutaneous abdominal drainage Not diagnostic, no device0W9F3ZZ
03.31 Spinal tap Diagnostic009U3ZX (spinal canal) 009Y3ZX (lumbar spinal cord)_Spinal canal appears more appropriate
32
Medical and Surgical Section (0)
ICD-9 Volume 3 ICD-10-PCS
86.04 Incision and drainage skin Left upper arm, diagnostic0H9CXZX
54.51 Laparoscopic lysis of peritoneal adhesions
0DNW4ZZ
54.59 Open lysis of adhesions Greater omentumADN50ZZ
34.04 Insertion chest tube Left, percutaneous with device0W9B30Z
64.0 Circumcision 0VTTXZZ
33
Obstetric Section
• The obstetric section includes procedures performed on the products of conception only. Procedures on the pregnant female are coded in the Medical & Surgical section (e.g., episiotomy).
• The term “products of conception” refers to all physical components of a pregnancy, including the fetus, amnion, umbilical cord, and placenta. There is no differentiation based on gestational age.
• The specification of the products of conception as a zygote, embryo or fetus, or the trimester of the pregnancy is not part of the procedure code but can be found in the diagnosis code.
34
Obstetric Section
• Character 1 - Section - always 1• Character 2 - Body System - Pregnancy
• Character 3 - Root Operation• Vaginal Delivery and Cesarean are both Extraction
• Character 4 - Body Part • Products of Conception• Products of Conception, retained• Products of Conception, ectopic
• Character 5 - Approach• Character 6 - Device (Fetal Monitor electrodes)
• Character 7 - Qualifier (type of extraction, type of Cesarean Section, or type of fluid taken out)
35
Medical and Surgical Section (0)Obstetrics Section (1)
ICD-9 Volume 3 ICD-10-PCS
73.6 Episiotomy 0W8NXZZ Episiotomy10E0XZZ Delivery
74.1 Low cervical cesarean section 10D00Z1
73.09 AROM 10907ZC (Amniotic fluid is considered a product of conception)
75.4 Manual removal placenta 10D17ZZ
72.79 Vacuum extraction 10D07Z6 (Extraction – vacuum is the qualifier)
36
Obstetric Section
• Vaginal delivery, vacuum:• Extraction: Extraction of Products of Conception, Vacuum, Via
Natural or Artificial Opening
• Vaginal delivery with episiotomy:• Extraction: Delivery of Products of Conception, External Approach • Division of Female Perineum, External Approach
• Cesarean Section• Extraction: Extraction of products of conception, low cervical, open
approach (Low cervical Cesarean section)
37
Placement (2)
• Character 1 – Section Always 2• Character 2 – Anatomical Region
• Anatomical Region or:• Anatomical Orifices
• Character 3 – Root Operation• No incision or puncture• Compression ;Dressing: Immobilization; Packing; and Traction are
root operations in the Placement Section
• Character 4 – Body Region/Orifice• Character 5 – Approach - Always External• Character 6 – Device – almost always a device• Character 7 – Qualifier - always No Qualifier
38
Placement
• Packing of external ear canal: 2Y42X5Z
• Splinting of right ankle: 2W3LX1Z
39
Administration (3)
• Administration section codes represent procedures for putting in or on a therapeutic, prophylactic, protective, diagnostic, nutritional, or physiological substance. The section includes transfusions, infusions, and injections, along with other similar services such as irrigation and tattooing.
40
Administration Section (3)
• Character 1 - Section - always 3• Character 2 - Body System
• Indwelling Device• Physiological System and Anatomical Regions• Circulatory System (transfusion procedures)
• Character 3 - Root Operation• Introduction• Irrigation• Transfusion
• Character 4 - Body System/Region• Character 5 - Approach
• Percutaneous injection, insertion of catheter to introduce contrast
• Character 6 - Substance• Character 7 - Qualifier
41
ICD-9 Volume 3 ICD-10-PCS
96.04 Endotracheal intubation Not endoscopic0BH17EZ
96.71 Mechanical ventilation <96 consecutive hours
Less than 24 hours5A1935Z
99.15 TPN 2 codes (upper vein)05HY33Z3E0336Z
73.4 Medical induction labor (IV Oxytocin)
3E033VJ (intro, peripheral vein, hormone)
99.04 Packed cell transfusion 30233N1
75.34 External fetal monitoring 4A1HXCZ
42
Extracorporeal Assistance and Performance Section (5)• In Extracorporeal Assistance and Performance
procedures, equipment outside the body is used to assist or perform a physiological function. The section includes procedures performed in a critical care setting, such as mechanical ventilation and cardioversion; it also includes other services such as hyperbaric oxygen treatment and hemodialysis.
43
Resources:Comprehensive Anatomy and Physiology for ICD-10-CM and -PCS Coding (Softbound) - www.optumcoding.com($149.95)
http://www.freebookcentre.net/medical_books_download/Gray's-Anatomy.html
http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/icd10
44