ICD-10-PCS Beginning The Journey

ICD-10-PCS – Structure ICD-9-CM ICD-10-PCS ICD-9-CM has 3-4 characters All characters are numeric All codes have at least 3 characters ICD-10-PCS has 7 characters Each can be either alpha or numeric Numbers 0-9; letters A-H, J-N, P-Z Alpha characters are not case-sensitive Each code must have 7 characters The letters O and I are not used in ICD 10 PCS to avoid confusion with the numbers 0 and 1. ICD-10 AHIMA

ICD-10-PCS - Structure ICD-9-CM . 1 X X 2 4 X X 3 All procedure codes in ICD 10 PCS will have 7 characters. There are no decimal points. The PCS code is alpha numeric. ICD-10-PCS 3 X 1 D E X B H X 5 X F 8 8 7 X Z X 3 4 X Z X ICD-10 AHIMA

WHAT IS A ROOT OPERATION???? THE OBJECTIVE OR ACTION OF THE PROCEDURE

31 MEDICAL & SURGICAL ROOT OPERATIONS There is a specific definition for each one of these roots ICD-10-PCS uses terminology that coders are not accustomed to seeing on a chart The purpose of this training is to help the coder smoothly transition to the new root operation and their meanings

SURGICAL & MEDICAL ROOT OPERATIONS (31) Alteration Division Inspection Reposition Bypass Drainage Map Resection Change Excision Occlusion Restriction Control Extirpation Reattachment Revision Creation Extraction Release Supplement Destruction Fragmentation Removal Transfer Detachment Fusion Repair Transplantation Dilation Insertion Replacement

ICD-10-PCS - Structure Characters (Med/Surg) 2 3 4 5 6 7 Root Operation Qualifier Section Approach Body System Body Part Device ICD-10 AHIMA

First Character of the Procedure Code -Section 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 B – Imaging C – Nuclear Medicine D – Radiation Oncology F – Physical Rehabilitation and Diagnostic Audiology G – Mental Health H – Substance Abuse Treatment There are 16 sections in ICD 10 PCS which is the first character of the code.

Medical and Surgical section Largest of the 16 sections Same definition or meaning Section B–D and F-H comprise the Ancillary section of ICD-10-PCS

Sec Second Character- Body System General physiological system or anatomical region involved Body System Value Central Nervous Peripheral Nervous 1 Heart and Great Vessels 2

Third Character – Root Operation Objective of the procedure 31 Root Operations Examples of Root Operations Bypass Resection Excision Removal

Fourth Character – Body Part Defines the body part or specific anatomical site where the procedure was performed This is different from character 2 which provides the general Body System There are 34 possible body part values in each body system Examples of Body Parts are: Liver Kidney Ascending Colon Optic Nerve

Fifth Character - Approach Defines the approach, or the technique used to reach the procedure site There are seven different approach values in the Medical and Surgical section Through Skin or mucous membrane Through an orifice External Open Natural or Artificial Opening Percutaneous Natural or Artificial Opening Endoscopic Percutaneous Endoscopic Natural or Artificial Opening with Percutaneous Endoscopic Assistance

Sixth Character - Devices Identified devices that remain after the procedure is completed Remember that all codes require seven characters The default value to indicate that NO device was involved is Z Examples of Device Values Drainage Device Radioactive Element Extraluminal device Intraluminal device Autologous tissue substitute Synthetic substitute

Seventh Character - Qualifier Qualifier for the code that provides additional information about a specific attribute of the procedure These qualifiers may have a narrow application, to a specific root operation, body system or body part Most procedures will not have an applicable qualifier. The default value for NO qualifier is a Z Examples of Qualifiers Type of Transplant Second site for a bypass Diagnostic excision (biopsy)

EXAMPLE CODE 0LB50ZZ Excision of right lower arm and wrist tendon, open” 0 = Section – Medical and Surgical L = Body Section - Tendons B = Root Operation- Excision 5 = Body Part – Lower arm and wrist tendon, right 0 = Approach - Open Z = Device – No Device Z = Qualifier – No Qualifier

CODERS MUST LEARN NEW TERMINOLOGY It is the coder’s responsibility to determine which root operation the documentation in the medical record equates to in the PCS definitions Physicians will continue to use the same terminology they have always used in describing an operative procedure. For example, the surgeon will document a thrombectomy and not an “extirpation”. That is why it is important to learn and understand the 31 root operations.

PHYSICIAN TERMINOLOGY MAY NOT CHANGE The physician is not expected to use the root terms provided in PCS code description Nor Is the coder required to query the physicians when the correlation between the documentation and the defined PCS term is clear.

EPONYMS ARE GONE IN ICD 10 PCS Billroth I procedure equates to anastomosis

QUESTIONS