Long Island Health Information Management Association

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1 PREPARATION IS THE KEY TO SUCCESS Long Island Health Information Management Association 2014 Annual Meeting-ICD-10-PCS Boot Camp April 2, 2014 John W. Ruth, MBA, RHIA Director, Health Industries Advisory PricewaterhouseCoopers, LLP 2014 ICD-10-PCS available at Code Tables and Index o ICD-10-PCS 2014 Tables o Definitions o Index 2014 ICD-10-PCS Reference Manual ICD-10-PCS 2014 Code Book 2 1

2 3 Guidelines ICD-10-PCS Draft Coding Guidelines (2014) appear in the ICD-10-PCS 2014 Code Book Four Sections of Guidelines A. Conventions B. Medical and Surgical Section C. Obstetrics Section D. Selection of Principal Procedure 4 2

3 Guidelines There are multiple guidelines documented within the AHIMA ICD-10-PCS workbook and Official Coding Guidelines We will focus on those guidelines which may be more prone to coding difficulties Today s discussion will include the first 3 Groups- Section, Body System, Root Operation, with most focus on Root Operation We will briefly discuss Body PartApproach, Device, Qualifier 5 Conventions ICD-10-PCS Code Book A.1 A.2 Code composition A.6 A.7 Alphabetic Index A.9 PCS Tables A.10 And A.8 and A.11 Documentation 6 3

4 Guideline A. 11. 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. 7 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 tables for the first three characters and they may cover multiple pages in the code book. 8 4

5 ICD-10-PCS Section The first character of a code determines the broad procedure category, or section, where the code is located. For example, 0 represents the Medical and Surgical section in the first character. 9 ICD-10-PCS Section 1 Section 2 Body System 3 Root Operation 4 5 All codes in PCS are seven characters Letters O and I not used in PCS o Numbers 0 and 1 used Each character has a meaning Meanings change by sections Section provides first character value 6 7 Body Part Approach Device Qualifier 10 5

6 ICD-10-PCS Section Sections: 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 11 ICD-10-PCS Section Sections: B Imaging C Nuclear Medicine D Radiation Therapy F Physical Rehabilitation and Diagnostic Audiology G Mental Health H Substance Abuse Treatment 12 6

7 ICD-10-PCS Sections Knowledge Challenge: Match the following procedures with the section of ICD-10-PCS where it is found: (Hint: The first character identifies the section.) 1. 0B110F4, Tracheostomy 2. 8E0H30Z, Acupuncture 3. F07L0ZZ, Manual physical therapy for range of motion and mobility, patient right hip, no special equipment 4. 3E1M39Z, Peritoneal dialysis via indwelling catheter 5. 4A02XM4, Cardiac stress test, single measurement 6. BW03ZZZ, Chest x-ray, AP/PA and lateral views 13 ICD-10-PCS Sections Knowledge Challenge-Answers 1. Answer: Medical and Surgical 2. Answer: Other Procedures 3. Answer: Physical Rehabilitation and Diagnostic Audiology 4. Answer: Administration 5. Answer: Measurement and Monitoring 6. Answer: Imaging 14 7

8 ICD-10-PCS Body Systems 15 ICD-10-PCS Body System 1 Section 2 Body System 3 Root Operation Body Part Approach Device Qualifier The second character defines the body system which is the general physiological system or anatomical region involved. Examples of body systems include Central Nervous System, Upper Arteries, Respiratory System, Tendons, Muscles, and Upper Joints. 16 8

9 Body System Body Part 17 Body System Guidelines B2.1a B2.1b Anatomical Regions Upper or Lower 18 9

10 Body System Guidelines The procedure codes in the general anatomical regions body systems should only 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 Example: Control of postoperative hemorrhage is coded to the root operation Control found in the General Anatomical Regions body systems. 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. 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. 19 Body System-Medical/Surgical The Medical and Surgical section is the largest of the 16 sections of ICD-10- PCS. Some of the procedures found in this section are: Thrombectomy Lithotripsy Inguinal hernia repair Gastrostomy tube change Cardiac mapping Insertion of central venous catheter 20 10

11 Body System-Medical/Surgical Knowledge Check 1. Which of the following body systems is assigned multiple body system values in ICD-10-PCS? a. Urinary system b. Respiratory system c. Musculoskeletal system d. Gastrointestinal system 2. Which of the following root operations does not share similar attributes with the other three root operations and therefore is not within the same group? a. Removal b. Excision c. Resection d. Destruction 21 Body System-Medical/Surgical Knowledge Check 3. True or false? The meaning of the second character in the Medical and Surgical section is body part. a. True b. False 22 11

12 Body System-Obstetrics The Obstetrics section follows the same conventions established in the Medical and Surgical section, with all seven characters retaining the same meaning. Obstetrics procedure codes have a first character value of 1 and the second character value for body system is Pregnancy. There are a total of 12 root operations in the Obstetrics section, 10 are in Medical/Surgical section. The Obstetrics section also includes two additional root operations unique to this section: Value Root Operation Description Definition A Abortion: Artificially terminating a pregnancy E Delivery: Assisting the passage of the products of conception from the genital canal 23 ICD-10-PCS Root Operations 24 12

13 ICD-10-PCS Root Operations Section Body System Root Operation Body Part Approach Device Qualifier Objective of procedure 31 root operations Arranged by similar attributes Multiple codes Examples of Root Operations: Bypass Drainage Reattachment Resection Inspection 25 Root Operation Guidelines B3.1a B3.1b Full definition Integral to procedure B3.2 Multiple procedures B3.3 Discontinued procedures B3.4a B3.4b Biopsy Procedures Biopsy followed by treatment B3.5 Overlapping body layers 26 13

14 ICD-10-PCS Body Part 27 ICD-10-PCS Body Part Section Body System Root Operation Body Part Approach Device Qualifier Fourth character Anatomical site for procedure 34 possible values per body system Examples of Body Parts: Liver Kidney Thalamus Ascending Colon Optic Nerve Tonsil 28 14

15 Body Part Guidelines B4.1a B4.1b Portion of body part Peri B4.2 Branches of body parts B4.3 Bilateral body part values 29 Body Part Guidelines B4.4 B4.5 B4.6 B4.7 B4.8 Coronary Arteries Tendons, Ligaments, Bursae, Fascia Near a Joint Skin, Subcutaneous Tissue, Fascia Overlying Joint Fingers and Toes Upper and Lower Intestinal Tract 30 15

16 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 Examples of Peripheral Nervous System: cervical nerve, ulnar nerve, radial nerve, thoracic nerve, tibial nerve, sciatic nerve, sacral plexus 31 ICD-10-PCS Approaches 32 16

17 ICD-10-PCS Approaches Section Body System Root Operation Body Part Approach Device Qualifier Fifth character approach or technique used to reach procedure Seven different approach values Approach may be 33 o Through skin or mucous membrane o Through orifice o External Approaches Skin or Mucous Membranes Open Percutaneous Percutaneous Endoscopic Through an Orifice Via Natural or Artificial Opening Via Natural or Artificial Opening Endoscopic Via Natural or Artificial Opening with Percutaneous Endoscopic Assistance 34 17

18 Note: When assigning the approach value, remember that the approach defines the technique used to reach the procedure site, not necessarily the instruments used. 35 Approaches 0 Open F X Percutaneous Percutaneous Endoscopic Via Natural/Artificial Opening Natural/Artificial Opening Endoscopic Natural/Artificial Opening with Percutaneous Endoscopic Assistance External 36 18

19 Approach Guidelines Endoscopic Assistance External Approach Percutaneous Procedure via Device B5.2 B5.3a B5.3b B ICD-10-PCS Devices 38 19

20 ICD-10-PCS Device 1 Section 2 Body System 3 Root Operation Body Part Approach Device Qualifier Sixth character Device must be left in place Review definitions of categories 39 ICD-10-PCS Device Four basic groups Grafts and Prostheses Implants Simple or Mechanical Appliances Electronic Appliances 40 20

21 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. Examples of Device Values: o Drainage device o Radioactive element o Autologous tissue substitute o Extraluminal device o Intraluminal device o Synthetic substitute o Nonautologous tissue substitute 41 NEC in Medical/Surgical Section Root Operation Value Q - Repair Device Value Y Other Device Coding Note: Materials incidental to a procedure, such as clips and sutures, are not considered devices

22 Coding Note: Appendix B Appendix B in the ICD-10-PCS Reference Manual discusses the distinguishing features of device, substance, and equipment as classified in ICD-10-PCS, to provide further guidance for correct identification and coding. 43 Device Guidelines General Drainage Device B6.1a Device must remain B6.1b Integral to procedure B6.1c Procedures performed on device B6.2 Separate procedure to put in drainage device 44 22

23 ICD-10-PCS Qualifier 1 Section 2 Body System 3 Root Operation Body Part Approach Device Qualifier Seventh character Provides additional information May have narrow application There are no specific guidelines for qualifiers. 45 ICD-10-PCS Qualifier Type of transplant Second site for a bypass Diagnostic excision (biopsy) 46 23

24 Coding Note: Most procedures will not have an applicable qualifier. The default value to indicate that NO qualifier is needed is Z. Z 47 Check Your Understanding Guideline Review

25 1. 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: a. 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) 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: b. 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

26 3. 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: a. 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) 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

27 5.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. Answer: a. True Rationale: If the prefix peri is combined with a body part to identify the site of the procedure, the procedure is coded to the body part named (Coding Guideline B4.1b). Example: A procedure site identified as perirenal is coded to the kidney body part True or false? Irrigation of a percutaneous nephrostomy tube is coded to the root operation Irrigation of indwelling device in the Administration section. Answer: a. True Rationale: Procedures performed on a device only and not on a body part are specified in the root operations Change, Irrigation, Removal, and Revision, and are coded to the procedure performed (Coding Guideline B6.1c). Example: Irrigation of percutaneous nephrostomy tube is coded to the root operation Irrigation of indwelling device in the Administration section

28 7. True or false? Body systems designated as upper or lower contain the body parts that are above or below the diaphragm respectively. Answer: a. True Rationale: 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. (Coding Guideline B2.1b). 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. 55 Check Your Understanding Root Operation Review

29 8. True or false? In ICD-10-PCS, when an entire lymph node chain is cut out, the appropriate root operation is Resection. Answer: a. True Rationale: When an entire lymph node chain is cut out, Resection is used. When a lymph node(s) is cut out, the root operation is Excision. Resection is defined as cutting out or off, without replacement, all of a body part (ICD-10-PCS Reference Manual p. 39) True or false? The root operation Detachment is used exclusively for amputation procedures. Answer: a. True Rationale: Detachment represents a narrow range of procedures, and it is used exclusively for amputations (ICD-10-PCS Reference Manual p )

30 10. True or false? Forceps removal of a foreign body is an example of an extirpation procedure. Answer: a. True Rationale: Extirpation represents a range of procedures where the body part itself is not the focus of the procedure. Instead, the objective is to remove solid material such as a foreign body, thrombus, or calculus from the body part (ICD-10-PCS Reference Manual p. 47) True or false? The root operation Restriction is coded when the objective of the procedure is to close off a tubular body part or orifice. Answer: b. False Rationale: Restriction is defined as partially closing an orifice or the lumen of a tubular body part. Occlusion is defined as completely closing an orifice or the lumen of a tubular body part (ICD-10-PCS Reference Manual p )

31 12. True or false? Typical Change procedures include exchange of drainage devices and feeding devices. Answer: a. True Rationale: Typical Change procedures include exchange of drainage devices and feeding devices (ICD-10-PCS Reference Manual p. 69) True or false? All codes in the ICD-10-PCS Administration section define procedures where a diagnostic or therapeutic substance is given to the patient, such as a platelet transfusion. Answer: a. True Rationale: The Administration section includes infusions, injections, and transfusions, as well as other related procedures, such as irrigation and tattooing. All codes in the section define procedures where a diagnostic or therapeutic substance is given to the patient (ICD-10-PCS Reference Manual p. 89)

32 14. True or false? In ICD-10-PCS, the term measurement refers to a series of levels obtained at intervals, while monitoring describes a single level taken. Answer: b. False Rationale: Measurement describes a single level taken, while Monitoring describes a series of levels obtained at intervals (ICD-10-PCS Reference Manual p. 90)

33 65 Nine Groups Arranged by Similar Attributes Root Operation Groupings Root Operations That Take Out Some or All of a Body Part Root Operations That Take Out Solids/ Fluids/Gases From a Body Part Root Operations Involving Cutting or Separation Only Root Operations That Put in/put Back or Move Some/All of a Body Part 66 33

34 Nine Groups Arranged by Similar Attributes Root Operation Groupings Root Operations That Alter the Diameter/Route of a Tubular Body Part Root Operations That Always Involve a Device Root Operations Involving Examination Only Root Operations That Define Other Repairs Root Operations That Define Other Objectives 67 Root Operations That Take Out Some or All of a Body Part 68 34

35 Excision (B) Excision B Definition Explanation Cutting out or off, without replacement, a portion of a body part The qualifier Diagnostic is used to identify excision procedures that are biopsies Examples Partial nephrectomy, liver biopsy, breast lumpectomy, breast reduction for medical reasons (for cosmetic reasons is Alteration), Excisional debridement (nonexcisional debridement is Extraction) 69 Excision Excision is coded when a portion of a body part is cut out or off using a sharp instrument. All root operations that employ cutting to accomplish the objective allow the use of any sharp instrument, including but not limited to: Scalpel Wire Scissors Bone saw Electrocautery tip 70 35

36 Coding Note: Bone Marrow and Endometrial Biopsies Bone marrow and endometrial biopsies are not coded to Excision. They are coded to Extraction, with the qualifier Diagnostic. 71 Resection (T) Resection T Definition Explanation Examples Cutting out or off, without replacement, all of a body part N/A Total nephrectomy, total lobectomy of lung, total mastectomy Resection is similar to Excision except Resection includes all of a body part, or any subdivision of a body part that has its own body part value in ICD-10-PCS, while Excision includes only a portion of a body part

37 Coding Note When an entire lymph node chain is cut out, the appropriate root operation is Resection. When a lymph node(s) is cut out, the root operation is Excision. 73 National Cancer Institute 74 37

38 Coding Note: Documentation There is an opportunity to provide physician education on the need for more complete documentation in the medical record on the following: Lymph node(s) versus the complete chain The complete body part removal versus a portion 75 Detachment (6) Detachment 6 Definition Explanation Examples Cutting off all or part of the upper or lower extremities 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 Below knee amputation, disarticulation of shoulder, amputation above elbow 76 38

39 Detachment = Amputation Detachment procedure codes are found only in body systems X, Anatomical Regions, Upper Extremities and Y, Anatomic Regions, Lower Extremities because amputations are performed on extremities across overlapping body layers and so could not be coded to a specific musculoskeletal body system such as the bones or joints. 77 Detachment Qualifiers The specific qualifiers used for Detachment are dependent on the body part value in the upper and lower extremities body systems. Definitions established for: Upper arm and leg Hand and foot Thumb, finger, toe Complete/partial High, Mid, Low 78 Example: Table 0X6 39

40 Coding Note: Documentation There is an opportunity to provide physician education on the need for more complete documentation in the medical record on the actual location of the amputation. According to the definition, the coding professional needs to know if the amputation is at the proximal middle, or distal portion of the shaft of the humerus, femur, radius/ulna, or tibia/fibula. Coding Note: Qualifier Value When a surgeon uses the word toe to describe the amputation, but the operative report says he extends the amputation to the midshaft of the fifth metatarsal, which is the foot, the qualifier is Partial 5 th Ray. Gray s Anatomy

41 Destruction (5) Destruction 5 Definition Explanation Examples Physical eradication of all or a portion of a body part by the direct use of energy, force or a destructive agent None of the body part is physically taken out Fulguration of rectal polyp, cautery of skin lesion, fulguration of endometrium 81 Destruction Destruction takes out a body part in the sense that it obliterates the body part so it is no longer there. Defines a broad range of common procedures, since it can be used anywhere in the body to treat a variety of conditions, including: o Skin and genital warts o Nasal and colon polyps o Esophageal varices o Endometrial implants o Nerve lesions 82 41

42 Extraction (D) Extraction D Definition Explanation Examples Pulling or stripping out or off all or a portion of a body part by the use of force The qualifier Diagnostic is used to identify extraction procedures that are biopsies Dilation and curettage, vein stripping, phacoemulsification without IOL implant (phacoemulsification with IOL implant is Replacement), non-excisional debridement (excisional debridement is excision), liposuction for medical reasons (liposuction for cosmetic reasons is Alteration) 83 Extraction Extraction is coded when the method employed to take out the body part is pulling or stripping. Minor cutting, such as that used in vein stripping procedures, is included in Extraction if the objective of the procedure is nevertheless met by pulling or stripping. Cutting used to reach the procedure site is specified in the approach value

43 TEACHING TIP: D&C is a procedure whose goal is to scrape and collect the PREPARATION endometrial tissue IS THE from KEY inside TO SUCCESS the uterus. The dilation--widening the and curettage--scraping walls of uterus. Two components: Dilation (D) is a widening of the cervix to allow instruments into the uterus. Curettage (C) is the scraping of the walls of the uterus. The cervical canal is widened with a metal rod, and then the curette is passed. A curette is described as an instrument with a metal loop on the end of a long, thin handle, or spoon shaped with sharp edges. This curette gently scrapes the endometrium. When coding a D&C in ICD-10-PCS, the Dilation is not separately coded because procedural steps necessary to reach the operative site and close the operative site are not coded separately (Coding Guideline B3.1b). 85 During liposuction, a small incision is made in the skin and a suction tube with a sharp end is inserted into the fat pockets. The instrument has been described as a long, thin, hallow shaft ending in a small, sharp-edged spoon. This is swept through the area between the skin layers and the deeper subcutaneous tissue, and then the vacuum pump suctions it out. In a vein stripping, two small incisions are made one above and one below the specified vein. These incisions are included in the Extraction root operation (see definitions above). A thin, flexible plastic wire is then threaded into the vein (at the top part) and guided toward the other cut. The vein is pulled out when the wire is pulled out through the lower cut. Hooks may also be used in the procedure. Visit MedlinePlus at the US National Library of Medicine National Institutes of Health to get information on these and other surgical procedures. Many excellent videos and tutorials are available

44 Coding Note: Documentation Be careful of documentation. It is important to convert common terminology to the appropriate root operation according to the intent of the procedure. For example, the procedure documentation may say removal, but in actuality, using PCS definitions, an extraction was performed. Removal of a thumbnail would be coded to Extraction. The root operation of Removal is not correct because by definition a Removal in ICD-10-PCS is defined as taking out or off a device from a body part. 87 Questions? 88 44