Tune in to this monthly online coding column from Melanie Endicott to learn about challenging areas and documentation opportunities for ICD-10-CM/PCS.
When educating physicians about ICD-10-PCS, the most important factor to be pointed out is that ICD-10-PCS will NOT be replacing CPT. Physicians will still need to report their services using CPT/HCPCS codes. However, physicians need to be aware of the nuances associated with ICD-10-PCS if they perform surgeries in the hospital inpatient setting, since they may receive queries for additional documentation/clarification from the hospital inpatient coder or clinical documentation improvement specialist at the facility. Accurate code assignment in ICD-10-PCS requires very specific documentation from physicians. To understand why this increased detail is needed, let’s take a look at the ICD-10-PCS code structure character by character.
The first character of an ICD-10-PCS code describes the section. There are 16 sections in ICD-10-PCS, with the most voluminous section being Medical and Surgical. The other sections include codes for other types of procedures, such as Obstetrics, Nuclear Medicine, and Administration. We will focus on the Medical and Surgical section of ICD-10-PCS from here on out since it is the largest section, with the most guidelines.
The second character of an ICD-10-PCS code in the Medical and Surgical section identifies the Body System (of which there are 31), such as Central Nervous System, Lower Veins, Endocrine System, and Upper Joints.
The third character describes the intent, or objective, of the procedure. These 31 Root Operations receive the most publicity in ICD-10-PCS due to their very specific definitions that must be mastered by coders in order to correctly assign procedure codes in ICD-10. Some examples of Root Operations are Excision, Resection, Extirpation, Supplement, and Replacement. An important note on this topic is that physicians DO NOT need to use these ICD-10-PCS terms in their documentation, but they must provide enough detail for the coder to select the correct Root Operation.
Body Part is the fourth character, which describes the exact location of the procedure. This requires precise documentation, such as the specific vein or artery, laterality, lobe of lung, or portion of intestine.
The fifth character identifies the Approach. There are only seven Approach values, but it can be one of the more difficult areas to decipher in cases of scanty documentation. The seven Approaches are:
- External (i.e., skin biopsy)
- Open (i.e., thoracotomy)
- Percutaneous (i.e., needle biopsy)
- Percutaneous Endoscopic (i.e., laparoscopy)
- Via Natural or Artificial Opening (i.e., removal of foreign body from ear)
- Via Natural or Artificial Opening Endoscopic (i.e., colonoscopy)
- Via Natural or Artificial Opening with Percutaneous Endoscopic Assistance (i.e., laparoscopic-assisted vaginal hysterectomy)
Devices are described with the sixth character in ICD-10-PCS. Some examples of devices are pacemakers, drainage devices, vascular access devices, and internal fixation devices. The key to coding the device character correctly is for the documentation to clearly state that the device is left in place after surgery. Temporary devices used during surgery are not coded, nor are devices that are inherent to the procedure, such as sutures and staples.
The last character of an ICD-10-PCS code is the Qualifier. The Qualifier can describe many things, such as the site of a bypass, whether the procedure was diagnostic (i.e., biopsy), or the thickness of a skin graft. Precise physician documentation is essential for assigning this character as well.
Example ICD-10-PCS Code
Let’s wrap this up by taking a look at an ICD-10-PCS code for an insertion of a dual chamber cardiac pacemaker into the subcutaneous tissue of the chest: 0JH606Z. Additional codes would be assigned for the placement of the electrodes to the atrium and/or ventricle.