International Classification of Diseases Tenth Revision Procedure Coding

International Classification of Diseases Tenth Revision Procedure Coding System (ICD-10 -PCS): An Applied Approach 2012 Edition Chapter 3: Root Operations That Take Out All/Part of a Body Part or Take Out Solids/Fluids/Gases © 2012

Medical and Surgical Section • First and largest section • Seven characters • First character in Medical and Surgical Section is always 0 • 2 nd character for body system -31 body systems • 4 th character for body part -In context with the body system © 2012

Root Operations in the Medical and Surgical Section • 31 root operations • Divided into 9 groups based on similar attributes • See Appendix A for a complete list of the root operations • See Appendix A for the 9 groupings • Entire definition of the root operation must be used © 2012

Root Operations that Take Out Some or All of a Body Part • • • Excision Resection Detachment Destruction Extraction © 2012

Excision (B) • Cutting out or off, without replacement, a portion of a body part • Only a portion, not all, of the body part is removed • E. g. . Partial gastrectomy, removal of cysts, excision of lesions • If this is an excisional biopsy – X for the qualifier character - Diagnostic © 2012

Coding Guidelines for Excision • B 3. 4 o If the excision is for biopsy and the biopsy is followed by a more definitive procedure, code the biopsy and the definitive procedure • B 3. 9 o If an autograft is obtained from a different bod part in order to complete the objective of the procedure, a separate procedure is coded o Excision may be a component of another procedure © 2012

Resection (T) • Cutting out or off, without replacement, all of a body part • Contrast with Excision – ALL of the body part is removed • E. g. Total gastrectomy, total mastectomy • Body part values o May be as generally considered – e. g. appendix o May be subdivided in ICD-10 -PCS © 2012

Excision vs. Resection • B 3. 8 –PCS contains specific body parts for anatomical subdivisions of a body part, such as loves of the lungs or liver and regions of the intestine. Resection of the body part is coded whenever all of the body part is cut or off rather than Excision of a less specific body part • E. g. – removal of the lower lobe of the left lung is Resection since there is a specific body part © 2012

Lung Body Parts • • • C D F G H Upper lobe, Right Middle lobe, Right Lower lobe, Right Upper lobe, Left Lingula • • J Lower lobe, Left K Lung, Right L Lung, Left M Lung, Bilateral © 2012

Lymphatic Body Parts • A Lymph node chain is considered a body part • If a single or multiple lymph node(s) is removed – Excision • If the entire lymph node chain is removed Resection © 2012

Detachment (6) • Cutting off all or part of the upper or lower extremities • Amputations o E. g. – below the knee amputation • Only 2 body systems are applicable o X- Anatomical Regions, Upper Extremities • Code table 0 X 6 o Y- Anatomical Regions, Lower Extremities • Code table 0 Y 6 © 2012

Detachment – other characters • Body Part character – site of amputation -Forequarter – entire upper limb plus scapula and clavicle -Hindquarter – entire lower limb plus pelvic girdle and buttock • Approach character – only Open (0) applies • Device character – not applicable – Z © 2012

Detachment Qualifiers • Qualifier- specific portion of the body part amputated • Ray of the hand -metacarpal and phalanx associated with one finger • Ray of the foot – metatarsarsal and phalanx associated with one toe o o o 1 st ray, thumb or great toe 2 nd ray, index finger or 2 nd toe 3 rd ray – middle finger or 3 rd toe 4 th ray – ring finger or 4 th toe 5 th ray – little finger or little toe © 2012

Other Detachment Qualifiers • High- proximal portion • Mid- middle portion • Low- distal portion Referring to the shaft of the humerus, lower arm, femur, or lower leg or the phalanx of the thumb, finger or toe © 2012

Destruction (5) • Physical eradication of all or a portion of a body part by the direct use of energy, force, or a destructive agent • None of the body part is cut o Though some tissue may remain in instruments • Terms such as coagulation, cryotherapy, fulguration, coblation • Small nicks in the skin to accommodate instruments such as needles are coded as a percutaneous (not open) approach © 2012

Extraction (D) • Pulling or stripping out or off all or a portion of a body part by the use of force • Egg vein stripping, D&C, non-excisional debridement, cataract extractions (w/out IOL insertion • Minor cutting as in vein stripping is included in the Extraction procedure if the objective is met by pulling or stripping © 2012

Extraction Biopsies • If objective of the Extraction is to pull or strip out tissue for biopsy, X for diagnostic in the 7 th character Qualifier • Also coded as Extractions vs. Excisions o Bone marrow biopsies o Endometrial biopsies • Egg. D&C with biopsy © 2012

Root Operations that Take Out Solids/Fluids/Gases from a Body Part • Drainage • Extirpation • Fragmentation © 2012

Drainage (9) • Taking or letting out fluids and/or gases from a body part • E. g. incision and drainage, arthrotomy • Drainage procedures can be diagnostic biopsies or therapeutic procedures o If biopsy use X as the 7 th character qualifier to indicate Diagnostic © 2012

Extirpation (C) • Taking or cutting out solid matter from a body part • Solid matter may be -Abnormal byproduct of a biological function e. g. blood clot -Foreign body – e. g. piece of shrapnel © 2012

More on Extirpation • The body part is not the focus of the procedureremoving the solid matter is • The solid matter may or may not have been previously broken into pieces or fragmented • Providers do not have to use the PCS term • Coding Guideline A 11 o It is the coder’s responsibility to determine what the documentation in the medical record equates to in the PCS definitions © 2012

Fragmentation (F) • • Breaking solid matter in a body part into pieces Physical force either directly or indirectly Manual, ultrasound, other methods As with Extirpation, solid matter may be abnormal byproduct of a biological function or a foreign body • Material is broken up, but not removed © 2012

Percutaneous Approach • Coding Guideline B 5. 4 - Procedures performed percutaneously via a device placed for the procedure are coded to the approach Percutaneous o E. g. Fragmentation of kidney stone performed via percutaneous nephrostomy is coded to the approach Percutaneous © 2012

ICD-10 -PCS Guidelines • Specific guidelines for procedure coding • Subject to approval by the Cooperating Parties -AHA, AHIMA, CMS, NCHS • Organized into 3 sections -Conventions -Medical and Surgical Section -Obstetrics Section © 2012

Conventions Guidelines-A 1 • A 1 - All codes are 7 characters -Each character has an axis of classification that remains the same in a defined code range -May vary from Section to Section • E. g. . 5 th character is approach in Medical and Surgical Section and Duration in Extracorporeal Therapies section © 2012

Conventions Guidelines-A 2 and A 3 • A 2 - One of 34 potential values for each axis of classification -Numbers 0 -9 -All letters except I and O • Easily confused with 1 and 0 • A 3 -Values can be added as necessary -ICD-10 -PCS is easily expandable -For e. g. as new devices are developed, new values can be added © 2012

Conventions Guidelines- A 4 and A 5 • A 4 - meaning of a single value is a combination of it and preceding values -E. g. body part value (4 th character) is in context with the body system (2 nd character) • A 5 -as the system becomes more detailed, more values will depend on preceding values -E. g. Device value 4 • Heart and Great Vessels -Drug-eluting stent • Head and Facial Bones-Internal Fixation Device © 2012

Conventions Guidelines- A 6 and A 7 The Index • A 6 - The purpose of the index is to locate the appropriate table -The PCS Tables should always be consulted to find the most appropriate valid code • A 7 - It is not required to consult the index first to complete the code © 2012

Convention Guidelines-A 8 • A 8 – All 7 characters must contain valid values -Review documentation thoroughly -If necessary, query the physician for clarification -Cannot leave blank characters © 2012

Convention Guidelines – A 9 • A 9 - within a given table, codes are built from the same row • See Figure 2. 3 08 W table o Middle column for Body Part Lens, Right or Lens, Left only includes: • 3 percutaneous and X External for Approach • J synthetic substitute for Device © 2012

Conventions Guidelines- A 10 and A 11 • A 10 - and means and/or • A 11 - terms used to construct PCS codes are defined in the system -The coder determines the documentation that equates to the PCS definition -The physician does not have to use the PCS terms -Only query the physician when the documentation in relation to the definition is unclear © 2012

Body System Guidelines- B 2. 1 • B 2. 1 a- use the general anatomical regions body systems only when on a region vs. a body part or not enough information on body part • B 2. 1 b-the diaphragm divides the upper and lower body parts © 2012

Root Operation Guidelines- B 3. 1 • B 3. 1 a - Must use the entire definition of the root operation • B 3. 1 b-Components of a procedure specified in the root operation are not coded separately -Steps to reach and close the operative site are not coded separately © 2012

Multiple Procedures – B 3. 2 • B 3. 2 Multiple Procedures coded: -A. Same root operation on different body parts -B. Same root operation repeated at different body sites in the same body part -C. Multiple root operations with distinct objectives on the same body part -D. Intended root operation is attempted using one approach and converted to another approach © 2012

Discontinued Procedures • B 3. 3 If intended procedure is discontinued code root operation performed • If discontinued before any other root operation is performed, code Inspection of the body part or region inspected © 2012

Biopsy followed by Definitive Procedure and Overlapping Layers B 3. 4 • If a diagnostic Excision, Extraction or Drainage biopsy is followed by a more definitive procedure at the same site both are coded B 3. 5 • Excision, Resection or Inspection performed on overlapping layers of MS system coded to the body part of the deepest layer © 2012

Bypass Procedures • B 3. 6 a • Non-coronary Bypass procedures coded by identifying the body parts bypassed from and the body part bypassed to -4 th character for body part bypassed from -7 th character for body part bypassed to © 2012

Coronary Artery Bypass Procedures B 3. 6 b • Coronary arteries classified by the number of distinct sites treated rather than number or anatomical names of coronary arteries • Body part value represents the number of sites bypassed to • Qualifier specifies the vessel bypassed from B 3. bc –separate procedure codes if different device and/or qualifier (More in Chapter 11) © 2012

Control vs. more Definitive Root Operation • B 3. 7 Control – stopping, or attempting to stop, postprocedural bleeding. -If initial attempts are unsuccessful, and one of the following root operations is performed, that is coded rather than Control • Bypass * Reposition • Detachment * Replacement • Excision * Resection • Extraction -More in Chapter 6 © 2012

B 3. 8 Excision vs. Resection • PCS contains specific body parts for some subdivisions of body parts -E. g. lobes of the lung or liver, parts of intestine • Resection is ALL of the specific body part is removed • Rather than Excision of a less specific body part -More in Chapter 3 © 2012

Excision for Graft • B 3. 9 Separate procedure for harvest of an autograft to use in a procedure -E. g. - for coronary artery bypass graft with excision of the saphenous vein for use as a graft, the excision of the saphenous vein is coded separately © 2012