Q: I've heard that in ICD-10-PCS, certain imaging procedures will require documentation of the specific type of contrast used. Is this true?
A: Yes, many imaging procedures do require coders to capture the specific type of contrast used during the procedure. Option types include the following:
- High osmolar
- Low osmolar
- Other contrast
The fifth character of the PCS code for imaging procedures denotes this information. For example, the fifth character '0' in ICD-10-PCS code B00B0ZZ denotes a spinal cord plain radiography using high osmolar contrast. The fifth character '1' in ICD-10-PCS code B210110 denotes a heart fluoroscopy via a single coronary artery using low osmolar contrast and an intraoperative laser. The type of contrast must documented in order for coders to be able to assign a PCS code.
Imaging procedures in PCS category B00-BY4 include plain radiography, CT scans, MRIs, ultrasonography, and fluoroscopy. Providers can perform these procedures on various body parts as defined in ICD-10-PCS. Most-but not all-procedures do require specification of the type of contrast used. It's important for coders to review this category of codes to determine which ones require this information and which ones simply offer 'none' (character Z) as the only option in the fifth character position of the PCS code.
Kim Carr is an AHIMA-approved ICD-10 CM/PCS trainer and clinical documentation director, HRS.