Basic ICD 10 CMPCS and ICD9 CM Coding
Basic ICD 10 -CM/PCS and ICD-9 -CM Coding, 2015 Edition Chapter 2: Procedure Coding in ICD-9 -CM and ICD-10 -PCS © 2014
Learning Objectives • Review the chapter’s learning objectives • A thorough understanding of the basic concepts of the ICD-9 -CM procedure coding system is important • Other chapters in this book will include instruction on coding of procedures performed in specific body systems 2
ICD-9 -CM Volume 3: Procedures • • 3 ICD-9 -CM classifies procedures in Volume 3 Includes Alphabetic Index and Tabular List Same format as Volumes 1 and 2 ICD-9 -CM procedures used for the coding of inpatient hospital procedures
Volume 3: Procedures (continued) • Hospital inpatient procedures coded in range of procedure codes in categories 00– 86 • Chapter 16 codes (87– 99) may be used selectively for inpatient procedure coding according to hospital or facility coding policy 4
Volume 3: Procedures (continued) • Hospital outpatient departments, physicians’ offices and other ambulatory care facilities use CPT-4 and HCPCS codes for procedures 5
Tabular List • 17 chapters in ICD-9 -CM Volume 3 o 16 chapters describe operations on specific body systems (codes 00– 86) o One chapter includes miscellaneous diagnostic and therapeutic procedures (codes 87– 99) 6
Tabular List (continued) • Format of ICD-9 -CM Volume 3 o Numeric codes only o 3 - or 4 -digit codes o 2 digits followed by a decimal point and one or two additional digits o 3 rd or 4 th digits provide further information about the site, procedure, or diagnosis 7
ICD-9 -CM Volume 3 Alphabetic Index • Listing of procedures, studies, tests, operations, therapies, and so on • Entries in the Alphabetic Index are more comprehensive than terms listed in the Tabular List • Trust the Alphabetic Index 8
ICD-9 -CM Volume 3 Main Terms • Terms listed in boldface type • Identify the type of procedure performed with subterms indented in alphabetic order • Main terms can include o o Titles of operations Procedure names Nouns Verbs • Main terms for procedures indicate an action performed, not a diagnosis or reason for the procedure
ICD-9 -CM Volume 3 Subterms • Subterms describe essential differences in the site, diagnosis, or surgical technique • Subterms may have subterms beneath • Verify all codes in the Tabular List—do not skip this step!
ICD-9 -CM Volume 3 Connecting Words • Subterms are used to reflect an instruction or an associated procedure • Subterms may begin with the words “as, ” “by, ” or “with” • Alphabetic subterms follow the connecting terms
Eponyms in ICD-9 -CM Volume 3 • Surgical procedures may be identified by eponyms, or names for their originators • May be indexed three ways: o Under the eponym o Under the main term “operation” or “procedure” o Under a main term or subterm describing the operation in terms of the action performed 12
Conventions Used in ICD-9 -CM Volume 3 • Code also o The phrase “code also” reminds the coder that additional procedure(s) must be coded when they are performed in addition to primary procedure o May reflect individual components of an operation or procedures performed together o May describe special adjunctive procedures or equipment 13
Conventions Used in ICD-9 -CM Volume 3 (continued) • Omit code o The phrase “omit code” is found only in volume 3 in both Alphabetic Index and Tabular List o This instruction indicates that no code is assigned, usually for exploratory part of procedure, operative approach, typical lysis of adhesions, or the closure of the procedure 14
Conventions Used in ICD-9 -CM Volume 3 (continued) • Omit code for the operative approach o When a definitive procedure (therapeutic or diagnostic) is performed, the operative approach is considered part of the procedure and is not coded o Coder knowledge of operative techniques is essential o If only an exploratory procedure is performed, the operative approach is used to describe it 15
Endoscopic Procedures in ICD-9 -CM Volume 3 • Open = Procedures that require an incision • Endoscopic = A less invasive procedure may be performed with a scope through tiny incisions into a cavity or joint and uses videoscopic guidance 16
Endoscopic Procedures (continued) • If an endoscopic procedure is performed as the approach so that a more definitive procedure can be performed, the endoscopic portion is not coded as it is the “approach” 17
Endoscopic Procedures (continued) • If an endoscopic procedure is unsuccessful, the surgeon may complete the procedure through an “open” approach. • If this is the case, only the “open” procedure is coded. • Diagnosis code V 64 category explains the “conversion” from endoscopic to open. 18
Endoscopic Procedures (continued) • Main term “endoscopy” or the more specific term describing the procedure may be used for the Alphabetic Index • Specific procedure codes exist to describe various endoscopic procedures 19
Endoscopic Procedures (continued) • If the endoscope is passed through more than one body cavity, the code for the endoscopy should identify the most distant site only 20
Slanted brackets [ ] in ICD-9 -CM Volume 3 • Slanted brackets found in the Alphabetic Index or in the Tabular List indicate that two codes for closely related procedures are required • This convention means both codes must be used and sequenced as listed 21
Aborted Surgery or Procedure in -9 -CM Volume 3 ICD • When a procedure was started but not completed, code the procedure to the extent it was performed • Coding rule = “Code as far as it goes” • Cavity entered = code exploratory procedure • Incision made = code incision only • No procedure = add V 64 diagnosis code for the reason the procedure was not completed 22
Incomplete Procedures in ICD-9 -CM Volume 3 • When a planned procedure is started but not completed, code to the following principles: o If cavity/space entered, code to exploration of site o If endoscopic approach is used but no definitive procedure performed, code the endoscopy only o If only an incision made, code to incision of site o When the procedure does not involve an incision, no procedure code is assigned 23
Failed Procedures in ICD-9 -CM Volume 3 • Some procedures are considered to have failed if the procedure did not achieve the desired outcome or result • This does not influence code assigned • The procedure performed is the procedure coded 24
Biopsy and Surgery in ICD-9 -CM Volume 3 • If a biopsy is performed and is followed by a more extensive surgery during the same operative episode, code the surgical procedure that is the more extensive surgery first, followed by the biopsy code • An “open” biopsy requires an incision—the open biopsy code includes the incision 25
Closed Biopsy Procedure in ICD-9 -CM Volume 3 • A closed biopsy is performed percutaneously, endoscopically, or through the use of a needle • If a needle or percutaneous biopsy is performed via an open procedure, code both the open procedure and the needle biopsy 26
Endoscopic Biopsies in ICD-9 -CM Volume 3 • When ICD-9 -CM provides one code to identify both the biopsy and the endoscopy, use this one code • When ICD-9 -CM does not provide a code to identify both the biopsy and the endoscopy, assign two codes, listing first the endoscopy code 27
Bilateral Procedure Coding in -9 -CM Volume 3 ICD • ICD-9 -CM may provide a single code to identify that a bilateral procedure was performed (A bilateral procedure code is used only once) • However, when ICD-9 -CM does not provide a code for a “bilateral” procedure, the code for the procedure is listed twice 28
Basic Steps for ICD-9 -CM Volume 3 Procedure Coding 1. Identify all main terms included in the procedural statement 2. Locate each main term in the Alphabetic Index 3. Refer to any subterms indented under the main term 29
Basic Steps for ICD-9 -CM Volume 3 Procedure Coding (continued) 4. Follow cross-reference instructions if the needed code is not located under the first main entry 5. Verify the code selected from the Index in the Tabular List—do not skip this step! 30
Basic Steps for ICD-9 -CM Volume 3 Procedure Coding (continued) 6. Read and be guided by all instructional terms 7. Continue coding until all procedures are identified 8. When the same procedure is performed bilaterally and ICD-9 -CM does not identify the code as a bilateral procedure, assign the code for the procedure twice 31
ICD-9 -CM Volume 3 Procedure Coding Guidelines • Each healthcare facility should specify in its coding policies what procedures will be assigned codes. • Some healthcare facilities do not assign codes to many diagnostic and nonsurgical procedures. 32
Selection of Principal Procedure using ICD-9 -CM Volume 3 • Following instructions should be applied in the selection of the principal procedure • Coding Clinic Fourth Quarter 2012 provided this information as well as clarification on the importance of the relation of the principal procedure to the principal diagnosis when more than one procedure is performed 33
Selection of Principal Procedure using ICD-9 -CM Volume 3 continued • Procedure performed for definitive treatment of both principal diagnosis and secondary diagnosis o Sequence procedure performed for definitive treatment most related to the principal diagnosis as the principal procedure 34
Selection of Principal Procedure using ICD-9 -CM Volume 3 continued • Procedure performed for definitive treatment and diagnostic procedure performed for both principal diagnosis and secondary diagnosis o Sequence procedure performed for definitive treatment most related to principal diagnosis as principal procedure 35
Selection of Principal Procedure using ICD-9 -CM Volume 3 continued • A diagnostic procedure was performed for the principal diagnosis and a procedure is performed for definitive treatment of a secondary diagnosis o. Sequence diagnostic procedure as principal procedure, since the procedure most related to the principal diagnosis takes precedence 36
Selection of Principal Procedure using ICD-9 -CM Volume 3 continued • No procedures performed that are related to principal diagnosis; procedures performed for definitive treatment and diagnostic procedures were performed for secondary diagnosis. o. Sequence procedure performed for definitive treatment of secondary diagnosis as principal procedure, since there are no procedures (definitive or nondefinitive treatment) related to principal diagnosis. 37
Introduction to ICD-10 -PCS • Inpatient procedure coding replacing Volume 3 of ICD-9 -CM on October 1, 2015 • ICD-10 -PCS is unique to United States • Developed by 3 M Health Information Systems under contract with CMS • Initially released in 1998 with updates the following years
ICD-10 -PCS • Designed and developed to meet healthcare needs for a procedure code system • Codes constructed from flexible code components (values) using tables; each individual number of letter is known as a value • Codes are alphanumeric • All codes are seven characters long
The ICD-10 -PCS Code • • Seven Characters, Alphanumeric 1 – section of ICD-10 -PCS 2 – body system 3 – root operation 4 – body part 5 – approach 6 – device 7 – qualifier
ICD-10 -PCS Code • Each of the 7 characters have a defined meaning • Character 1: Section – first character determines the broad category or section where the code is located. In the first section, Medical and Surgical, all begin with 0 or zero • Character 2: Body System – defines the body system which is the general physiological system or anatomic region involved
ICD-10 -PCS Code • Character 3: Root Operation – the objective of the procedure being performed • Character 4: Body Part – the body part of specific anatomical site where the procedure is performed
ICD-10 -PCS Code • Character 5: Approach – the technique used to reach the operative site, 7 approaches defined • Character 6: Device – depending on the procedure there may or may not be a device left in place at the end of the procedure • Character 7: Qualifier – defined for a particular code, an additional attribute of the procedure
ICD-10 -PCS Classification System • ICD-10 -PCS is composed of 16 sections with section values using o Numbers 0 through 9 o Letters B through D and Letters F through H • 16 sections contained within three main sections: o Medical and Surgical section o Medical and Surgical related section o Ancillary section 44
ICD-10 -PCS • First section, Medical and Surgical section, contains the majority of procedures typically performed in an inpatient setting. • First Character o All procedures begin with the section value of 0 (zero) 45
ICD-10 -PCS • Second section, Medical and Surgical-related section, include procedures such as o Obstetrics, Placement, Administration, Measurement and Monitoring, Extracorporeal Assistance and Performance, Extracorporeal Therapies, Osteopathic, Other procedures, and Chiropractic o All procedures begin with the section value of 1 through 9 (numbers) 46
ICD-10 -PCS • Third section, Ancillary section, include procedures such as o Imaging, Nuclear Medicine, Radiation Oncology, Physical Rehabilitation and Diagnostic Audiology, Mental Health and Substance Abuse o All procedures begin with the section value of B through D and F through H (letters) 47
ICD-10 -PCS Medical-Surgical Section • First character = Medical Surgical Section (0) • Second character = Body System o 31 body systems identified o Some customary body systems have multiple-body system values, for example, circulatory and musculoskeletal have multiple values o Values of 0 -9, B, C, D, F, G, H, J, K, L, M, N, P, Q, R, S, T, U, V, W, X, Y, Z • Third character = Root Operations o 31 root operations, each representing the specific objectives of the procedure o Nine groups of procedures • See textbook for the nine groups and root operations within each group
ICD-10 -PCS Medical-Surgical Section • Fourth character = Body Part o Represents the specific part of the body system on which surgery is performed; may specify laterality. o Examples, Lower extremities (body system), Left foot (body part) • Fifth character = Approach o Technique used to reach the site of the procedure. o Seven different approaches o Open; Percutaneous endoscopic; Via Natural or Artificial Opening Endoscopic; Via Natural or Artificial Opening Endoscopic with Percutaneous Endoscopic Assistance; and External
ICD-10 -PCS Medical-Surgical Section • Sixth character = Device o Specifies the device that remains after the procedure is completed o Used with certain procedures o Four general types of devices: Biological or synthetic material that takes the place of all or a portion of a body part; Biological or synthetic material that assists or prevents a physiological function; Therapeutic material; Mechanical or electronic applicance • Seventh character = Qualifier o Used with certain procedures to define an additional attribute o Unique values for individual procedures as needed, for example, identify the destination site in a bypas
Objective of the Procedure – Operation (third character) Root • In ICD-10 -PCS, each component of a procedure is defined separately • Coder analyzes the operative report to identify the objective of the procedure • Procedure coded is the procedure performed • If an intended procedure is changed or discontinued, the root operation is based on the actual procedure performed 51
Coding Multiple Procedures with ICD 10 -PCS (Root Operation) • If multiple procedures are performed that are defined by distinct objectives during a single operative episode, then multiple procedure codes are used • For example, obtaining a vein graft used for coronary artery bypass surgery is coded as a separate procedure from the bypass itself 52
Coding Multiple Procedures with ICD 10 -PCS • Multiple procedures are coded if: o The same root operation is performed on different body parts that have distinct body part values in ICD-10 -PCS • For example, a biopsy or diagnostic excision is performed on the duodenum and rectum 53
Coding Multiple Procedures with ICD 10 -PCS continued • Multiple procedures are coded if: o The same root operation is repeated on different body sites that are included in the same body part value • For example, a biopsy is performed on the scalene muscle and the platysma muscle (both neck muscles) and the neck muscle is the body part 54
Coding Multiple Procedures with ICD 10 -PCS continued • Multiple procedures are coded if: o Distinctive procedures with multiple root operations are performed on the same body part • For example, a biopsy of the pancreas and partial pancreatectomy is performed 55
Coding Multiple Procedures with ICD 10 -PCS continued • Multiple procedures are coded if: o The intended procedure cannot be accomplished and is converted to a different approach • For example, a laparoscopic nephrectomy is attempted but must be converted to an open nephrectomy. The laparoscopic port of the procedure is coded as an inspection and the open procedure is coded as an open resection for the nephrectomy 56
Redo of Procedures using ICD-10 -PCS (Root Operation) • If the procedure performed is a complete or partial redo of a previous procedure, the root operation that identifies the “redo” procedure that was performed is what is coded and not the root operation of “revision. ” • The correction of complications arising from the original procedure other than device complications are coded to the procedure performed. 57
Body Part – Fourth Character of the ICD-10 -PCS Code • Value chosen represents the specific body part of the body system (character 2) on which the surgery was performed • Body parts may specify laterality 58
Body Part – Fourth Character of the ICD-10 -PCS Code • ICD-10 -PCS does not have a specific value for every body part o In those instances, the body part value selected would be either the whole body part value or body part value of the closest proximal branch (for example with nerves and blood vessels) 59
Body Part – Fourth Character of the ICD-10 -PCS Code • ICD-10 -PCS does not have a specific value for every body part o Code should look up the body part named in the Alphabetic Index to identify the value for a specific anatomical site o For example, there is an entry for “adductor brevis muscle” in the Index that refers the code to “use muscle, upper leg (right or left)” 60
Approach – Fifth Character of the ICD -10 -PCS Code • The approach is the technique used to reach the site of a procedure • Seven different approaches are used: • Open • Percutaneous endoscopic 61 • Via natural or artificial opening endoscopic with percutaneous endoscopic assistance • External
Approach – Fifth Character of the ICD -10 -PCS Code continued • The approach is composed of three components o Access location o Method o Type of instrumentation 62
Approach – Fifth Character of the ICD -10 -PCS Code continued • Access specific the external site through which the internal organ is reached o Through skin or mucous membrane • Incised or punctured • Open and percutaneous approaches o External orifices • External opening • Natural (mouth) or Artificial (nephrostomy stoma) 63
Approach – Fifth Character of the ICD -10 -PCS Code continued • Method is how the external access location is entered for procedure performed on an internal body part o Open method means there is cutting through skin or mucous membranes and other body layers o May include instrumentation through a puncture or minor incision 64
Approach – Fifth Character of the ICD -10 -PCS Code continued • Instrumentation is specialized equipment used to perform a procedure on an internal body part • May or may not be used to visualize the procedure site • “Endoscopic” is the term used in approach values when instrumentation permits a procedure site to be visualized 65
Approach – Fifth Character of the ICD -10 -PCS Code continued • External approach is used when procedure are performed directly on the skin or mucous membrane. • May be performed indirectly by the application of external force 66
Device – Sixth Character of the -10 -PCS Code • Specifies the device that remains after the procedure is completed. • Examples of devices are o o Drainage device Monitoring device Infusion device Autologous tissue substitute o o o o 67 ICD Extraluminal device Intraluminal device Synthetic substitue Nonautologous tissue substitute Artificial sphincter Stimulator lead Other Device No device
Device – Sixth Character of the -10 -PCS Code continued ICD • Four general types of devices o Grafts and Prostheses that take the place of all or a portion of a body part • Example: Skin graft or Joint Prosthesis o Implants are therapeutic material that is not absorbed by, eliminated by, or incorporated into a body part • Example: Radioactive implant, Internal fixation device, Tissue expander 68
Device – Sixth Character of the -10 -PCS Code continued ICD • Four general types of devices o Simple or mechanical appliances that assist or prevent a physiological function • Example: Tracheostomy airway device, Vascular graft o Electronic appliances that assist, monitor, take the place of or prevent a physiological function • Example: Cardiac pacemaker generator, Cochlear implant hearing device, Neurostimulator 69
Device – Sixth Character of the -10 -PCS Code continued ICD • If the objective of the procedure is to put in a device, then the root operation is “insertion” • If the device is put in to meet an objective other than insertion, the root operation defining the underlying objective is used. For example, when a procedure is performed to replace a joint with a synthetic device, the root operation is “replacement” 70
Device – Sixth Character of the ICD-10 -PCS Code continued • Materials incidental to a procedure, such as clips, ligatures, and sutures, are not specified in the device characters • Specific device entries are included in the Index to allow the code to identify the appropriate device value. o For example, a Kirschner wire is referenced to use internal fixation device as the device value 71
Device – Sixth Character of the -10 -PCS Code continued ICD • The following root operations must have specific devices coded with these procedures: o Change o Insertion o Removal o Replacement o Revision o Supplement 72
Device – Sixth Character of the -10 -PCS Code continued ICD • All other root operations may or may not have devices as part of the procedure: o Alteration, bypass, creation, o Destruction, dilation, division, drainage o Excision, extirpation o Fragmentation, fusion, map, occlusion o Release, repair, reposition, resection, restriction o Transfer 73
Qualifier – Seventh Character of the ICD-10 -PCS Code continued • Qualifier adds more information to describe the procedure • Individual procedures have unique values for qualifiers in the seventh character position • Qualifiers may have a narrow application to a specific root operation 74
Qualifier – Seventh Character of the ICD-10 -PCS Code continued • A qualifier may identify the destination site in a bypass procedure • Other qualifiers identify the type of transplant performed, such as, allogeneic, syngeneic, and zooplastic • The most common qualifier expected to be used is the “X” for diagnostic to identify when a biopsy procedure is performed 75
ICD-10 -PCS Official Guidelines for Coding and Reporting • Guidelines developed by CMS and NCHS • Approved by the Cooperating Parties for ICD 10 -PCS (AHA, AHIMA, CMS, NCHS) • Guidelines accompany and assist in the interpretation of the official conventions and instructions within the ICD-10 -PCS • Conventions and instructions in ICD-10 -PCS take precedence over the guidelines 76
ICD-10 -PCS Official Guidelines for Coding and Reporting • Adherence to the guidelines is required under HIPAA as the ICD-10 -PCS codes are required for hospital inpatient healthcare settings under HIPAA • Current guidelines are the 2015 edition, included in the website provided by this publication or on the CMS website 77
ICD-10 -PCS Official Guidelines for Coding and Reporting continued • The guidelines consist of four parts o Convention o Medical and Surgical Section guidelines including directions for body system, root operations, body part, approach and device characters o Obstetric Section guidelines o Selection of the Principal Procedure 78
ICD-10 -PCS Official Guidelines for Coding and Reporting continued • The entire set of ICD-10 -PCS Guidelines for Coding and Reporting is required reading for coders. • Table in the textbook is intended to provide a synopsis of the information contained within the guidelines (Refer to the Textbook for review) 79
Assigning a ICD-10 -PCS Code • Procedure code is constructed by assigning values for each of the characters of the code • Procedural term is referenced in Alphabetic Index • Main terms in the Index can be root operation phrase with subterms (Resection, gallbladder) or a common procedure term (Cholecystectomy)
Assigning a ICD-10 -PCS Code continued • The purpose of the Alphabetic Index is to locate the appropriate table to construct an ICD-10 -PCS procedure code • The PCS tables should be consulted for the most appropriate valid code. • The coder does not have to use the Index before proceeding to the tables to construct a code
Assigning a ICD-10 -PCS Code • Example to code: laparoscopic total cholecystectomy • Coder may use the main term “resection, gallbladder” • Alternately, the coder may access the term “cholecystectomy” • Both entries would refer the coder to o Resection, gallbladder 0 FT 4 • Next step is to access the 0 FT code table
Assigning a ICD-10 -PCS Code • The remaining 4 characters are assigned based on the choices given on this table. • The values for each of the 4 characters must be from the same row of the table • Code for cholecystectomy performed through a laparoscopic approach would be 0 FT 44 ZZ
Assigning a ICD-10 -PCS Code • Each of the 7 characters in code 0 FT 44 ZZ describe the procedure: 0 = Medical and Surgical Section F = Hepatobiliary system and pancreas (body system) T = Resection (root operation) 4 = Gallbladder (body part) 4 = Percutaneous endoscopic (approach) Z = No device Z = No qualifier
Assigning a ICD-10 -PCS Code for laparoscopic cholecystectomy: 0 FT 44 ZZ • Alphabetic Index: Resection, Gallbladder gives coder first 4 characters – 0 FT 4 • Access the code table for first 3 characters - 0 FT • Find the row with the 4 th character “ 4 -gallbladder” • On that row, select value for 5 th character for approach – “ 4” for percutaneous endoscopic (laparoscopic) • Select value for 6 th character – no device (only choice) • Select value for 7 th character – no device (only choice)
ICD-10 -PCS Snapshot • Tabular List - Table o First Row • First three characters for procedure o Section of ICD-10 -PCS, Body System, Body Part o Four column table with varying number of rows • • Character 4 -body part Character 5 -approach Character 6 -device Character 7 -qualified
ICD-10 -PCS Snapshot • Tabular List - Table o First Row • First three characters for procedure o Section of ICD-10 -PCS, Body System, Body Part o Four column table with varying number of rows • Coder cannot make choices from multiple rows o First body part is located with the corresponding approach used for this particular procedure o Coder then must stay on that row to identify the applicable device or qualifier, characters that are not used for all codes o Character “z” is used as placeholder when device & qualified do not apply
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