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ICD-10 Transition tips and tools

Coding ICD-10

Key documentation tips for PCS procedures.

So far, the International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS) is still on track for mandated  use in inpatient settings starting Oct. 1, 2015 under the Health Insurance Portability and Accountability Act (HIPAA). Similar to how CPT codes identify procedures done in the office and in the outpatient setting, ICD-10-PCS captures procedures done in the hospital. 

Clinical terms are translated by coding professionals into the terms used in ICD-10-PCS to identify and differentiate the scope and intent of various types of inpatient procedures. Coders must look for documentation describing 31 specifically defined root operations. Providers are not required to use these specific ICD-10-PCS terms, but their documentation must provide enough detail for coders to equate the documentation to the specific PCS definitions. It is important to note that if the coder is not able to correlate documentation to defined PCS terms, the provider may be queried.

SEE ALSO: ICD-10 Benefits Beyond Coding

ICD-10-PCS procedure codes must be built using the specific information for each procedure, so there are key documentation tips for coding procedures including the following: 

  • Coding ICD-10Describe the procedure. Eponyms are no longer used (e.g., Whipple procedure). Documentation must describe each component.
  • Be as specific as possible when documenting the body system or body part (e.g., the vessel, bone, nerve, or lobe of the lung).
  • Provide the laterality as this information is necessary to identify the specific site.
  • Specify when the same operation is performed on different body parts and specifically identify each body part.
  • Distinguish when different procedures are performed on the same body part for different reasons (e.g., excision of a colonic lesion and creation of a colostomy site).
  • State when and why a procedure was converted from a laparoscopic surgical procedure to an open procedure.
  • Document when a diagnostic biopsy is performed prior to an open procedure, rather than as a component of a definitive treatment, if performed to determine the medical necessity to proceed with the open procedure.
  • Indicate the sites "to" and "from" for bypass procedures.
  • Define the type of grafts and material used for instance, skin and blood vessel.

Remember, all medical and surgical procedures that are performed in the inpatient setting must have an associated diagnosis that describes the medical necessity of the procedure and supports the need for the procedure to be done in the inpatient setting.  Medical necessity is a regulatory word that simple asks "why" -- why did you need to do the procedure and why did the patient need to be admitted?

There are several great resources available to coders such as the ICD-10-PCS Official Guidelines for Coding and Reporting, ICD-10-PCS Reference Manual, and the various appendices that assist coders in assigning appropriate body parts and devices. For example, if a procedure is done on the abductor hallucis muscle, using the Body Part Key, the coder can determine that this is a right or left foot muscle for coding purposes. The Device Key can tell the coder that if an AbioCor Total Replacement Heart was used, the device for coding purposes is "synthetic substitute." The Substance Key helps the coder know to assign Recombinant Bone Morphogenetic Protein for the substance character when rhBMP-2 is used.

Lastly, the Device Aggregation Table tells a code that if a procedure to place a cardiac lead for a pacemaker is being performed, then the root operation is Insertion of the Heart and Great Vessels using the character "M" for the cardiac lead.  ICD-10-PCS coding is new to all of us, using this documentation tips and the tools available will help the process of assigning a code ensure accuracy and maintain productivity.

Deborah Neville is director of Revenue Cycle, Coding and Compliance for Elsevier Clinical Solutions.

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siva kumar,  coding,  codesNovember 30, 2015
chennai, IN

I find it interesting how the US is actually behind on the coding books where Europe is on ICD-11-CM and we're just now converting over to ICD-10-CM. However, any help for the coders of today who are used to ICD-9-CM I'm sure will be appreciated. How is this affecting everyone in the coding and billing profession? Are you going to use other resources to help you learn the new text?

Shaila Ritz,  Student,  Brown Mackie CollegeSeptember 09, 2015
Salina, KS


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