ICD-10-PCS Overview with Examples from Utah’s Top Procedures

1. ICD-10-PCSOverview with Examplesfrom Utah’s Top Procedures Utah Health Information Management Association Spring Conference May 18, 2012

2. ICD-10-PCS is unique to the United States, and is not used by any other country. The final rule to adopt ICD-10-CM and ICD-10-PCS was passed by HHS on January 16, 2009 (Federal Register 45 CFR part 162 [CMS—0013—F])

3. CMS is the agency officially charged with maintaining and updating ICD-10-PCS The code set is currently in the draft phase and should not be used until the system is officially implemented, currently to occur October 1, 2013 (A later date is under consideration)

4. ICD-10-PCS (Procedure Classification System) Replaces ICD-9-CM Volume 3 Although ICD-10-PCS is totally different than ICD-9 . . .

5. Don’t be afraid! ICD-10-PCS

6. Most coders with a minimal amount of training like ICD-10-PCS, and many coders can’t wait to get started on the new system

7. ICD-10-PCS Organized like CPT, and includes virtually everything that is in the CPT coding system with the exception of E/M Service codes. The original intent was for PCS to replace CPT

8. However, The American Medical Association which owns CPT is a very powerful lobbyist. We will continue to have two systems for procedure coding.

9. System Organization Both CPT and ICD-10-PCS are organized by: type of service, then body system, then type of procedure

10. ICD-9-CM In ICD-9-CM, each digit within the procedure code is loosely interrelated to the other digits, and may have totally different meanings in different body systems and organs. This limits the number of available codes.

11. ICD-10-PCS ICD-10-PCS uses multi-axial codes, meaning each digit or character acts independently of the other characters, with each individual character retaining its meaning over the broadest possible range of codes.

12. ICD-10-PCS • In addition to the multi-axial properties of the new codes, there were three other goals in the development of ICD-10-PCS: • Completeness–There should be a unique code for all substantially different procedures.

13. ICD-10-PCS • In addition to the multi-axial properties of the new codes, there were three other goals in the development of ICD-10-PCS : • Expandability– As new procedures are developed, a unique code should be able to be assigned.

14. ICD-10-PCS • In addition to the multi-axial properties of the new codes, there were three other goals in the development of ICD-10-PCS : • Standardized Terminology – Each term should be assigned a specific meaning, with no multiple meanings for the same term.

15. ICD-10-PCS 1 2 3 4 5 6 7 • Each ICD-10-PCS always has seven characters or digits. • If a particular character is not needed for a particular code, the letter “Z” is inserted as a placeholder. • Each character has a potential of 34 different alphanumeric characters that can be used: • Numbers 0-9 • Letters A-Z except I and O to avoid confusion with the numbers 1 and 0.

16. ICD-10-PCS 1 2 3 4 5 6 7 • Section: 0-Medical and Surgical 8-Other procedures 1-Obstetrics 9-Chiropractic 2-Placement B-Imaging 3-Administration C-Nuclear medicine 4-Measurement/Monitoring D-Radiation Oncology 5-Extracorp. assistance/performance F-Physical rehab/diag. audiology 6-Extracorp. therapies G-Mental Health 7-Osteopathic H-Substance Abuse Treatment

17. ICD-10-PCS 1 2 3 4 5 6 7 • Body system: 0-Central Nervous System 1-Peripheral nervous system 2-Heart & great vessels 3-Upper arteries 4-Lower arteries 5-Upper veins 6-Lower veins 7-Lymphatic & Hemic systems 8-Eye 9-Ear, nose, sinus B-Respiratory system C-Mouth & throat D-Gastrointestinal system F-Hepatobiliary & pancreas G-Endocrine system H-Skin and breast J-Subcutaneous tissue & fascia K-Muscles L-Tendons M-Bursae & ligaments N-Head & facial bones P-Upper bones Q-Lower bones R-Upper joints S-Lower joints T-Urinary system U-Female reproductive system V-Male reproductive system W-Anatomical regions, general X-Anatomical regions, upper extremities Y-Anatomical Regions, lower extremities

18. ICD-10-PCS 1 2 3 4 5 6 7 Root Operations: 0-Alteration 1-Bypass 2-Change 3-Control 4-Creation 5-Destruction 6-Detachment 7-Dilation 8-Division 9-Drainage B-Excision C-Extirpation D-Extraction F-Fragmentation G-Fusion H-Insertion J-Inspection K-Map L-Occlusion M-Reattachment N-Release P-Removal Q-Repair R-Replacement S-Reposition T-Resection V-Restriction W-Revision U-Supplement X-Transfer Y-Transplantation MEMORIZE!

19. ICD-10-PCS 1 2 3 4 5 6 7 Body Part – The specific organ or body part within the body system (2nd character) on which the procedure is performed. This includes tubular body parts, which are defined as hollow body parts that provide a route of passage for solids, liquids or gasses.

20. ICD-10-PCS 1 2 3 4 5 6 7 • Approach. This includes terms such as: • Open • Percutaneous • Percutaneous endoscopic • Via natural or artificial opening • Via natural or artificial opening, endoscopic • Open with percutaneous endoscopic assistance • External

21. ICD-10-PCS 1 2 3 4 5 6 7 • Device– Used only to specify devices that remain after the procedure is completed. These include: • Biological or synthetic material that takes the place of a body part (such as skin grafts and joint prosthetics) • Biological or synthetic material that assists or prevents a physiological function (such as IUD) • Therapeutic material that is not absorbed by, eliminated by or incorporated into a body part (e.g., radioactive implants) • Mechanical or electronic appliances used to assist, monitor, take the place of, or prevent a physiological function (pacemakers, orthopedic pins/plates, etc.)

22. ICD-10-PCS 1 2 3 4 5 6 7 • Qualifier • The qualifier contains unique values for individual procedures. For example, the qualifier can be used to identify the destination site in a bypass, or whether a skin excision is diagnostic (biopsy) or surgical. Qualifiers do not have the same meaning from table to table. • Frequently, since there is no qualifier needed, the placeholder “Z” is used.

23. ICD-10-PCS has its own set of Coding Guidelines which are currently in the draft form and are detailed in the front of the ICD-10-PCS book. Some important guidelines include:

24. Guideline A6 The purpose of the alphabetic index is to locate the appropriate table, that contains all information necessary to construct a procedure code. The PCS Tables should always be consulted to find the most appropriate valid code.

25. Guideline A7 It is not required to consult the index first before proceeding to the tables to complete the code. A valid code can be chosen directly from the tables.

26. 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.

27. 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 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.

28. There are guidelines specific to the Medical and Surgical Section and the Obstetrics Section. Some of these will be discussed later in this presentation.

29. ICD-9 Index Patient receives a PTCA with drug-eluting stent in a single vessel. ICD-9-CM allows us to use almost any relevant procedural term to find codes in the index and refer the coder to the correct code in the Tabular List.

30. ICD-10-PCS Index Patient receives a PTCA with drug-eluting stent in a single vessel. In ICD-10-PCS, we should learn to use the standardized terminology. Referencing a term that is not a root operation, such as “angioplasty,” will often redirect the coder to the appropriate term.

31. ICD-10-PCS Index Patient receives a PTCA with drug-eluting stent in a single vessel. In some cases, the index listing may refer the coder to the wrong section or table. In the case of “angiography,” not all angiography is of the heart. This is more like the CPT index than ICD-9.

32. ICD-10-PCS Index Patient receives a PTCA with drug-eluting stent in a single vessel. We have already learned from Guideline A6 that the only purpose of the Index is to locate the appropriate table for the coder to use. For this purpose, the first three characters are all that are needed.

33. If we follow the guidance of the Index to “see Dilation, Heart and Great Vessels,” there is no such entry in the Index. The coder is being referred to the correct table, not another entry in the index. We can reference “Dilation, Artery, Coronary, One Site 0270,” but we still do not have a complete code (all PCS codes are always seven characters). We are being referred to Table 027.

34. All of the Tables are arranged in the order of the first three characters. There is no information in the index that cannot be found in the Tables. As skills improve, coders can go straight to the appropriate Table without using the Index.

35. The first three characters of the code are printed at the top of the Table. This is also the Table number, and the Tables are printed in order, based on these three characters. The next Table is 028.

36. A table may be very small, like Table 028, or it may be several pages long. The 4th-7th characters are obtained from the body of the table. Notice that the complete description of the root operation is also printed at the top.

37. The 4th character of the code for a PTCA is in the first column on the left. Since we are coding a single PTCA with a drug-eluting stent, we know the 4th character must be 0. So far, our code is “0270.”

38. Next, we code the approach from the Approach column. Coders should always work the tables from left to right. As coders, we know that a PTCA is percutaneous, so our next character is “3.” So far, we have 02703.

39. The physician’s documentation specified he used a drug-eluting stent, so the 6th character is “4” from the Device column.

40. There is no documentation in this coding scenario to indicate the PTCA with stent was placed in a vessel bifurcation. When there is no specific correct choice, the default is “Z.” The correct complete code is 027034Z. What if the PTCA were only done by balloon catheter with no stent?

41. Notice the horizontal lines running through the Table? Coders should never cross over the lines when selecting characters for their code. Never select characters from different groupings within the Tables.

42. Guideline B4.4 The coronary arteries are classified as a single body part that is further specified by number of sites treated and not by name or number of arteries. Separate body part values are used to specify the number of sites treated when the same procedure is performed on multiple sites in the coronary arteries.

43. Guideline B4.4 Example A: Angioplasty of two distinct sites in the left anterior descending coronary artery with placement of two stents is coded as Dilation of Coronary Arteries, Two Sites, with Intraluminal Device Example B: Angioplasty of two distinct sites in the left anterior descending coronary artery, one with stent and one without, is coded separately as Dilation of Coronary Artery, One Site with Intraluminal Device, and Dilation of Coronary Artery, One Site with no device.

44. PTCA at two sites, each with stent, code 02713DZ. PTCA at two sites, one with stent, one without, code 02703DZ and 02703ZZ

45. CABG with both saphenous vein and LIMA graft Root Operation Definition: Bypass – Altering the route of passage of the contents of a tubular body part

46. CABG with both saphenous vein and LIMA graft Guideline B3.6a Bypass procedures are coded by identifying the body part bypassed “from” and the body part bypassed “to.” The fourth character body part specifies the body part bypassed from, and the qualifier specifies the body part bypassed to.

47. CABG with both saphenous vein and LIMA graft Guideline B3.6b Coronary arteries are classified by number of distinct sites treated, rather than number of coronary arteries or anatomic name of a coronary artery (e.g., left anterior descending). Coronary artery bypass procedures are coded differently than other bypass procedures as described in the previous guideline. Rather than identifying the body part bypassed from, the body part identifies the number of coronary artery sites bypassed to, and the qualifier specifies the vessel bypassed from.

48. CABG with both saphenous vein and LIMA graft Guideline B3.6c If multiple coronary artery sites are bypassed, a separate procedure is coded for each coronary artery site that uses a different device or qualifier. Example: Aortocoronary artery bypass and internal mammary coronary artery bypass are coded separately.

49. CABG with both saphenous vein and LIMA graft Guideline B3.9 If an autograft is obtained from a different body part in order to complete the objective of the procedure, a separate procedure is coded. Example: Coronary bypass with excision of saphenous vein graft, excision of saphenous vein is coded separately.

50. CABG Story Problem A patient is admitted with a known history of CAD, now with unstable angina. The surgeon performs a triple bypass graft consisting of a right greater saphenous vein graft from the aorta to RCA, aorta to 1st diagonal, and LIMA to LAD. The saphenous vein was excised through an open approach.