Tackling the ICD-10-PCS Approaches

Tune in to this monthly online coding column to learn from AHIMA’s coding experts about challenging areas and documentation opportunities for ICD-10-CM/PCS.


 

There are only seven approach values in ICD-10-PCS, so one would think that selecting the correct approach value would be simple, but it’s not! Let’s take a closer look at these seven approaches and then walk through some challenging cases.

 

Open (0)

  • Definition: Cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure
  • Example: Abdominal hysterectomy

Percutaneous (3)

  • Definition: Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and/or any other body layers necessary to reach the site of the procedure
  • Example: Needle biopsy of liver

Percutaneous Endoscopic (4)

  • Definition: Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and/or any other body layers necessary to reach and visualize the site of the procedure
  • Example: Knee arthroscopy

Via Natural or Artificial Opening (7)

  • Definition: Entry of instrumentation through a natural or artificial external opening to reach the site of the procedure
  • Example: Foley catheter placement

Via Natural or Artificial Opening Endoscopic (8)

  • Definition: Entry of instrumentation through a natural or artificial external opening to reach and visualize the site of the procedure
  • Example: Sigmoidoscopy

Via Natural or Artificial Opening Endoscopic with Percutaneous Endoscopic Assistance (F)

  • Definition: Entry of instrumentation through a natural or artificial external opening and entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to aid in the performance of the procedure
  • Example: Laparoscopic-assisted vaginal hysterectomy

External (X)

  • Definition: Procedures performed directly on the skin or mucous membrane and procedures performed indirectly by the application of external force through the skin or mucous membrane
  • Example: Closed fracture reduction
Case 1

Assign the code for an endobronchial ultrasound (EBUS) guided transbronchial biopsy of an intrathoracic lymph node.

ICD-10-PCS Approaches Table 1

Let’s build our code from the table above.

  • Section: 0, Medical and Surgical
  • Body System: 7, Lymphatic and Hemic Systems
  • Root Operation: B, Excision
  • Body Part: 7, Lymphatic, Thorax
  • Approach: 4, Percutaneous Endoscopic
  • Device: Z, No Device
  • Qualifier: X, Diagnostic

Final Code: 07B74ZX

Rationale: The coder may be looking for the approach value 8, Via Natural or Artificial Opening Endoscopic, for this procedure; however, it is not present in this table. Careful review of the definition of approach value 8 reveals that procedures performed using this technique are performed within the orifice or tubular body part, without passing the lumen wall to get to a different body part. Since the wall of the bronchus is punctured and the scope is passed through the wall to reach the intrathoracic lymph node, the correct approach is 4, Percutaneous Endoscopic. A similar case was published in the AHA Coding Clinic for ICD-10-CM and ICD-10-PCS in 4th Quarter 2013, pages 111-112.

Case 2

A melanoma is widely excised to the depth of the subcutaneous tissue and fascia of the right upper leg.

ICD-10-PCS Approaches Table 2

 

Using the above table, we will construct our code.

  • Section: 0, Medical and Surgical
  • Body System: J, Subcutaneous Tissue and Fascia
  • Root Operation: B, Excision
  • Body Part: L, Subcutaneous Tissue and Fascia, Right Upper Leg
  • Approach: 0, Open
  • Device: Z, No Device
  • Qualifier: Z, No Device

Final Code:  0JBL0ZZ

Rationale:  The coder may be looking for a device value of X, External, for this procedure; however, the definition of the External approach states that the procedure is performed on the skin and mucous membranes. Since the subcutaneous tissue and fascia is excised, using a wide excision, the correct approach value is 0, Open.

References

AHA. AHA Coding Clinic for ICD-10-CM and ICD-10-PCS. 4th Quarter 2013, pages 111-112.

CMS. 2015 Code Tables and Index. http://cms.hhs.gov/Medicare/Coding/ICD10/2015-ICD-10-PCS-and-GEMs.html.

Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA, is senior director of HIM practice excellence, coding and CDI products development at AHIMA. She has over 15 years experience in HIM and coding, with her most recent focus being in ICD-10-CM/PCS, and has presented numerous times at the regional, state, and national levels on HIM and coding topics. She was previously a director of HIM practice excellence, focusing on coding products, resources, and education, at AHIMA. Melanie is an AHIMA-approved ICD-10-CM/PCS trainer and an ICD-10 Ambassador.

1 Comment

  1. Thank you for this! This was extremely helpful with clear definitions and concepts! Much needed clarification for new coders!

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