ICD-10 PCS Coding procedures common to all facilities

1. 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

2. 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.

3. 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.

4. Objectives • Review structure of PCS codes • Code common procedures from various sections of ICD-10-PCS

5. ICD-10-PCS Procedure Classification System

6. 6

7. 7 Structures and Features Comparison

8. *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.

9. *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.

10. 10 Structures and Features Comparison

11. 1 2 3 4 5 6 7 Section Structure and Features of ICD-10-PCS Character Meanings 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.

13. 1 2 3 4 5 6 7 Section Body System • 2nd Character • Body Systems (#31)

14. 1 2 3 4 5 6 7 Section Body System Root Operation 3rd Character Root Operation

15. 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.

16. 16 ICD-10 Procedure Coding SystemGlobal Root Operations (Section 0-9)

17. 17 Global Root Operations (Section 0-9)

18. 18 ICD-10 Procedure Coding SystemGlobal Root Operations (Section 0-9)

19. 19 Global Root Operations (Section 0-9)

20. 20 ICD-10 Procedure Coding SystemGlobal Root Operations (Section 0-9)

21. 21 ICD-10 Procedure Coding SystemGlobal Root Operations (Section 0-9)

22. 22 ICD-10 Procedure Coding SystemGlobal Root Operations (Section 0-9)

23. 23 ICD-10 Procedure Coding SystemGlobal Root Operations (Section 0-9)

24. 24 ICD-10 Procedure Coding SystemGlobal Root Operations (Section 0-9)

25. 1 2 3 4 5 6 7 Section Body System Root Operation Body Part 4th CharacterBody Part

26. 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.

27. 1 2 3 4 5 6 7 Section Body System Root Operation Body Part Approach 5th Character Approach (7 Options)

28. 28 ICD-10 Procedure Coding SystemMedical and Surgical Approaches

29. 1 2 3 4 5 6 7 Section Body System Root Operation Body Part Approach 29 Device 6th Character Device

30. Types of Devices Devices 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.

31. 1 2 3 4 5 6 7 Section Body System Root Operation Body Part Approach Device Qualifier • 7th Character - Qualifier • -Defines an additional attribute of the procedure performed, if applicable.

32. Medical and Surgical Section (0)

33. Medical and Surgical Section (0)

34. 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.

35. 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)

36. Medical and Surgical Section (0)Obstetrics Section (1)

37. 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)

38. 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

39. Placement • Packing of external ear canal _________________ • Splinting of right ankle _______________________

40. 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.

41. 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

43. 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.

44. Resource:Gray’s Anatomy Bookcan be found athttp://www.bartleby.com