ICD-10-PCS Training

1. ICD-10-PCS Training Lamon Willis

2. PCS Guidelines

3. PCS Guidelines • 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.

4. PCS Section of ICD-10

5. PCS Section of ICD-10 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 tablesfor the first three characters and they may cover multiple pages in the code book.

6. Medical & Surgical Section • All codes in PCS are seven characters • Letters O and I not used in PCS • Numbers 0 and 1 used • Each character has a meaning • Meanings change by sections • Section provides first character value • Sections of ICD-10-PCS listed in manual

7. Medical & Surgical Section • Second character • Body system, general physiological system, or anatomical region involved. What are the differences between Character 2 – Body System, and Character 4 – Body Part?

8. Medical & Surgical Section

9. Medical & Surgical Section • The body systems are unique to the Section - the 31 systems above are only for the Medical and Surgical Section. • For example, in the Obstetrics section the only body system is 0 = Pregnancy. • In the Administration section there is a Body System of E = Physiological Systems and Anatomical Regions.

10. Medical & Surgical Section What systems?

11. Medical & Surgical Section Thorax – Body System or Body Part?

12. Medical & Surgical Section

13. Medical & Surgical Section B2.1a Anatomical Regions B2.1b Upper or Lower

14. Medical & Surgical Section • B2.1a - The procedure codes in the general anatomical regions body systems can 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.

15. Medical & Surgical Section • Examples: • Control of postoperative hemorrhage is coded to the root operation Control found in the general anatomical regions body systems. • Chest tube drainage of the pleural cavity is coded to the root operation Drainage found in the general anatomical regions body systems. • Suture repair of the abdominal wall is coded to the root operation Repair in the general anatomical regions body system.

16. Medical & Surgical Section • B2.1b - 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.

17. Medical & Surgical Section • 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.

18. Medical & Surgical Section

19. Medical & Surgical Section

20. Medical & Surgical Section • What root operation does this procedure belong to? • Excision • Detachment • Drainage • Division • Extirpation • Release

21. Medical & Surgical Section • What root operation does this procedure belong to? • Extirpation

22. Medical & Surgical Section • What root operation does this procedure belong to? • Transplantation • Transfer • Release • Excision • Extirpation • Reposition

23. Medical & Surgical Section • What root operation does this procedure belong to? • Transfer

24. Medical & Surgical Section Examples of Body Parts: • Liver • Kidney • Thalamus • Ascending Colon • Optic Nerve • Tonsil Fourth character Anatomical site for procedure 34 possible values per body system

25. Medical & Surgical Section Marginal, right ventricle, posterior inter-ventricular, right coronary arteries

26. Medical & Surgical Section

27. Medical & Surgical Section

28. Medical & Surgical Section 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

29. Medical & Surgical Section Coding Note: Central Nervous System (0) vs. Peripheral Nervous System (1) • It is important to review anatomy regarding nerves. • Examples of Peripheral Nervous System: • cervical nerve, • ulnar nerve, • radial nerve, • thoracic nerve, • tibial nerve, • sciatic nerve, • sacral plexus

30. Medical & Surgical Section • Fifth character – approach or technique used to reach procedure • Seven different approach values • Approach may be • Through skin or mucous membrane • Through orifice • External

31. Medical & Surgical Section Approaches • Open • Percutaneous • Percutaneous Endoscopic Skin or Mucous Membranes Through an Orifice NOTE: Whenassigning the approach value, remember that the approach defines the technique used to reach the procedure site, not necessarily the instruments used. • Via Natural or Artificial Opening • Via Natural or Artificial Opening Endoscopic • Via Natural or Artificial Opening with Percutaneous Endoscopic Assistance

32. Open Medical & Surgical Section 0 • Percutaneous 3 Approaches • PercutaneousEndoscopic 4 • Via Natural/Artificial Opening 7 • Natural/Artificial Opening Endoscopic 8 • Natural/Artificial Opening with Percutaneous Endoscopic Assistance F • External X

33. Medical & Surgical Section Endoscopic Assistance B5.2 External Approach B5.3a B5.3b • Percutaneous Procedure via Device B5.4

34. Medical & Surgical Section

35. Four Basic Groups Medical & Surgical Section • Grafts and Prostheses • Implants • Simple or Mechanical Appliances • Electronic Appliances

36. 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 NO device was involved is Z. Medical & Surgical Section • Examples of Device Values: • Drainage device • Radioactive element • Autologous tissue substitute • Extraluminal device • Intraluminal device • Synthetic substitute • Nonautologous tissue substitute

37. Medical & Surgical Section • NEC in Medical/Surgical Section Coding Note: Materials incidental to a procedure, such as clips and sutures, are not considered devices.

38. General • B6.1a Device must remain • B6.1b Integral to procedure • B6.1c Procedures performed on device Medical & Surgical Section Drainage Device • B6.2 Separate procedure to put in drainage device

39. Medical & Surgical Section • Seventh character • Provides additional information • May have narrow application • There are no specific guidelines for qualifiers.

40. Medical & Surgical Section Examples of Qualifiers

41. Coding Note: Mostprocedures will not have an applicable qualifier. The default value to indicate that NO qualifier is needed is Z. Medical & Surgical Section Z

42. Test Your Knowledge • True or false? • A biological or synthetic material that takes the place of all or a portion of a body part such as a Joint Prosthesis would qualify as a device in ICD-10-PCS.

43. Test Your Knowledge • True or false? • A biological or synthetic material that takes the place of all or a portion of a body part such as a Joint Prosthesis would qualify as a device in ICD-10-PCS. Answer: 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).

44. Test Your Knowledge • 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.

45. Test Your Knowledge • 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: 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.

46. Test Your Knowledge • 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

47. Test Your Knowledge • 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: 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).

48. Test Your Knowledge • True or false? • Two codes would be assigned for this procedure: Resection of a joint with joint replacement.

49. Test Your Knowledge • 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.

50. Test Your Knowledge • True or false? • If the prefix peri is used with a body part to identify the site of the procedure, the procedure is coded to the body part named.