Module 2 - Coding Guidelines HIM4726

Coding hierarchy in ICD-10-PCS

1. Conventions and instructions built into the PCS system (highest priority), 2. Official Coding Guidelines, 3. Advisory sources such as Coding Clinic. All coding advice must conform to this hierarchy.

Who approves the ICD-10-PCS Official Coding Guidelines

The Cooperating Parties: AHA, AHIMA, CMS, and NCHS.

Are the PCS guidelines optional

No. Adherence is required under HIPAA for inpatient hospital procedure reporting. They are published annually with the code set.

Six sections of the PCS Official Guidelines

A. Conventions, B. Medical and Surgical, C. Obstetrics, D. Radiation Therapy, E. New Technology, and selection of the principal procedure.

Where can the PCS guidelines be found

In the physical code book or downloaded from the CMS website.

How many guidelines are in the Conventions section

11 (A1 through A11). They cover how a PCS code is structured and built.

A1

ICD-10-PCS codes are composed of seven characters. Each character is an axis of classification that specifies information about the procedure. Within a defined code range, a character specifies the same type of information in that axis.

A1 example

The fifth axis specifies the approach in sections 0 through 4 and 7 through 9.

A2

One of 34 possible values can be assigned to each axis: numbers 0 through 9 and the alphabet except I and O. The number of unique values used in an axis differs as needed.

Why does PCS exclude the letters I and O

They are easily confused with the numbers 1 and 0. A code containing I or O is always marked incorrect.

A3

The valid values for an axis of classification can be added to as needed.

A3 example

If a significantly distinct type of device is used in a new procedure, a new device value can be added to the system.

A4

As with words in context, the meaning of any single value is a combination of its axis of classification and any preceding values on which it may depend.

A4 example

Body part value 0 in Central Nervous System means Brain, but body part value 0 in Peripheral Nervous System means Cervical Plexus. Body part meaning depends on body system.

A5

As the system is expanded to become increasingly detailed, over time more values will depend on preceding values for their meaning.

A5 example

In Lower Joints, device value 3 in root operation Insertion means Infusion Device, but device value 3 in Replacement means Ceramic Synthetic Substitute.

A6

The purpose of the alphabetic index is to locate the appropriate table that contains all information necessary to construct a procedure code. The PCS Tables should always be consulted to find the most appropriate valid code.

A7

It is not required to consult the index before proceeding to the tables. A valid code may be chosen directly from the tables.

A8

All seven characters must be specified to be a valid code. If documentation is incomplete for coding purposes, the physician should be queried.

A9

Within a PCS table, valid codes include all combinations of choices in characters 4 through 7 contained in the same row. You cannot jump rows.

A9 example

0JHT3VZ is valid; 0JHW3VZ is not valid because it crosses into another row.

A10

The word And in a code description means and/or, except when used to describe a combination of body parts for which separate values exist for each body part.

A10 examples

Lower Arm and Wrist Muscle means lower arm and/or wrist muscle. Skin and Subcutaneous Tissue are treated as separate parts because separate body part values exist.

A11

Many terms used to construct PCS codes are defined within the system. It is the coder's responsibility to determine what the documentation equates to in PCS definitions. The physician is not expected to use PCS terms, and the coder is not required to query when the correlation is clear.

A11 example

When the physician documents partial resection, the coder can independently correlate it to the root operation Excision without querying.

How is the Medical and Surgical guideline section organized

Into smaller subsections, each focusing on a single character of the code: B2 body system, B3 root operation, B4 body part, B5 approach, B6 device.

Why must you cite the full guideline identifier for subdivided guidelines

Some guidelines are divided into subparts a, b, c, d. B3.2 alone is not a valid guideline; you must cite B3.2a, B3.2b, B3.2c, or B3.2d.

Number of Body System guidelines

2: B2.1a and B2.1b.

Number of Root Operation guidelines

19: B3.1a through B3.19.

Number of Body Part guidelines

8: B4.1a through B4.8.

Number of Approach guidelines

3 numbered guidelines spanning B5.2a through B5.4 (subparts B5.2a, B5.2b, B5.3a, B5.3b, B5.4).

Number of Device guidelines

2: B6.1a through B6.2 (subparts B6.1a, B6.1b, B6.1c, B6.2).

B2.1a

Procedure codes in Anatomical Regions General, Anatomical Regions Upper Extremities, and Anatomical Regions Lower Extremities can be used when the procedure is performed on an anatomical region rather than a specific body part, or on the rare occasion when no information is available to support a specific body part.

Three anatomical region body systems

Anatomical Regions General, Anatomical Regions Upper Extremities, Anatomical Regions Lower Extremities.

B2.1b

Where the general body part values Upper and Lower are provided in Upper Arteries, Lower Arteries, Upper Veins, Lower Veins, and Muscles and Tendons, Upper or Lower specifies body parts located above or below the diaphragm respectively.

What is the line of demarcation for upper vs lower body part values

The diaphragm. Above is Upper, below is Lower.

B3.1a

In order to determine the appropriate root operation, the full definition of the root operation as contained in the PCS Tables must be applied. You cannot pick and choose parts of a definition.

B3.1b

Components of a procedure specified in the root operation definition or explanation are not coded separately. Procedural steps necessary to reach and close the operative site, including anastomosis of a tubular body part, are also not coded separately.

B3.1b example

After removing part of the sigmoid colon, the anastomosis is not coded separately because it closes the operative site. Sutures and access steps are also not coded.

B3.2

During the same operative episode, multiple procedures are coded in four situations (a through d).

B3.2a

The same root operation is performed on different body parts as defined by distinct values of the body part character.

B3.2b

The same root operation is repeated in multiple body parts, and those body parts are separate and distinct body parts classified to a single ICD-10-PCS body part value.

B3.2c

Multiple root operations with distinct objectives are performed on the same body part.

B3.2d

The intended root operation is attempted using one approach but is converted to a different approach. Both are coded.

B3.3

If the intended procedure is discontinued or not completed, code the procedure to the root operation performed. If discontinued before any other root operation is performed, code the root operation Inspection of the body part or anatomical region inspected.

B3.4a

Biopsy procedures are coded using the root operations Excision, Extraction, or Drainage with the qualifier Diagnostic.

B3.4b

If a diagnostic Excision, Extraction, or Drainage (biopsy) is followed by a more definitive procedure such as Destruction, Excision, or Resection at the same procedure site, both the biopsy and the more definitive treatment are coded.

B3.5

If root operations such as Excision, Extraction, Repair, or Inspection are performed on overlapping layers of the musculoskeletal system, the body part specifying the deepest layer is coded.

B3.6a

Bypass procedures are coded by identifying the body part bypassed from and the body part bypassed to. The fourth character body part specifies the part bypassed FROM, and the qualifier specifies the part bypassed TO.

B3.6a example

A bypass from the stomach to the jejunum: stomach is the body part (from), jejunum is the qualifier (to).

B3.6b

Coronary artery bypass is coded differently: the body part identifies the NUMBER of coronary arteries bypassed to, and the qualifier specifies the vessel bypassed FROM.

B3.6c

If multiple coronary arteries are bypassed, a separate procedure is coded for each coronary artery that uses a different device and/or qualifier.

B3.7

Control is defined as stopping, or attempting to stop, postprocedural or other acute bleeding. Control is coded when hemostasis techniques beyond what is integral to a procedure (cautery, application of substances or pressure, suturing, ligation, clipping of bleeding points) are used and no more specific root operation applies.

Which root operations override Control

Bypass, Detachment, Excision, Extraction, Reposition, Replacement, or Resection. If a more specific definition applies, code that instead of Control.

Key word in the Control definition

Acute bleeding. Control does not apply to chronic bleeding.

B3.8

PCS contains specific body parts for anatomical subdivisions such as lobes of the lung or liver and regions of the intestine. Resection of the specific body part is coded whenever all of that body part is cut out or off, rather than coding Excision of a less specific body part.

Excision vs Resection

Excision is partial removal of a body part or anatomical subdivision. Resection is complete removal of a specific body part or anatomical subdivision.

B3.8 example

Removal of an entire lobe of the lung is coded as Resection of that lobe, not Excision of the lung.

B3.9

If an autograft is obtained from a different procedure site to complete the objective of the procedure, a separate procedure is coded, except when the seventh character qualifier in the table fully specifies the site from which the autograft was obtained.

B3.10a

The body part coded for a spinal vertebral joint rendered immobile by spinal fusion is classified by the level of the spine (for example thoracic). There are distinct body part values for a single vertebral joint and for multiple vertebral joints at each spinal level.

B3.10b

If multiple vertebral joints are fused, a separate procedure is coded for each vertebral joint that uses a different device and/or qualifier.

B3.10c

Device value rules for spinal fusion when combinations of devices are used on the same vertebral joint.

B3.10c interbody fusion device rule

If an interbody fusion device is used to render the joint immobile (containing bone graft or bone graft substitute), code device value Interbody Fusion Device.

B3.10c bone graft only rule

If bone graft is the only device used to render the joint immobile, code device value Nonautologous Tissue Substitute or Autologous Tissue Substitute.

B3.10c mixture rule

If a mixture of autologous and nonautologous bone graft (with or without biological or synthetic extenders or binders) is used, code device value Autologous Tissue Substitute.

B3.11a

Inspection of a body part performed in order to achieve the objective of a procedure is not coded separately.

B3.11b

If multiple tubular body parts are inspected, the most distal body part (furthest from the starting point) is coded. If multiple non-tubular body parts in a region are inspected, the body part that specifies the entire area inspected is coded.

B3.11c

When both an Inspection and another procedure are performed on the same body part during the same episode, the Inspection is coded separately only if it uses a different approach.

B3.12

If the objective of an embolization procedure is to completely close a vessel, code Occlusion. If the objective is to narrow the lumen of a vessel, code Restriction.

B3.13

In the root operation Release, the body part value coded is the body part being freed, not the tissue being manipulated or cut to free the body part.

B3.14

If the sole objective is freeing a body part without cutting the body part, the root operation is Release. If the sole objective is separating or transecting a body part, the root operation is Division.

B3.15

Reduction of a displaced fracture is coded to the root operation Reposition, and application of a cast or splint in conjunction with Reposition is not coded separately. Treatment of a nondisplaced fracture is coded to the procedure performed.

B3.16

Putting in a mature and functioning living body part taken from another individual or animal is coded to Transplantation. Putting in autologous or nonautologous cells is coded to the Administration section.

B3.17

Transfer contains qualifiers to specify when a transfer flap is composed of more than one tissue layer, such as a musculocutaneous flap. Code the body part value that describes the deepest tissue layer in the flap, and use the qualifier to describe the other tissue layer(s).

B3.18

If an excision or resection of a body part is followed by a replacement procedure, code both procedures to identify each distinct objective, except when the excision or resection is considered integral and preparatory for the replacement.

B3.18 example both coded

Mastectomy followed by breast reconstruction is coded as Resection plus Replacement.

B3.18 example only one coded

Resection of a joint followed by joint replacement is coded only as Replacement, because the resection is integral to the replacement.

B3.19

Detachment contains qualifiers to specify the level where the extremity was amputated. Qualifiers depend on the body part value in the Upper Extremities and Lower Extremities body systems, and the procedure is coded to the body part value describing the site of the detachment.

Detachment qualifiers for upper arm, lower arm, upper leg, lower leg

High, Mid, and Low.

Detachment qualifiers for hand and foot

Dependent on which ray is removed and whether it is complete or partial.

Detachment qualifiers for thumb, finger, and toe

Complete, High, Mid, and Low.

B4.1a

If a procedure is performed on a portion of a body part that does not have a separate body part value, code the body part value corresponding to the whole body part.

B4.1b

If the prefix peri- is combined with a body part to identify the site and the site is not further specified, the procedure is coded to the body part named. This applies only when a more specific body part value is not available.

What does the prefix peri- mean

Around or near.

B4.1c

If a single vascular procedure is performed on a continuous section of an arterial or venous body part, code the body part value corresponding to the anatomically most proximal (closest to the heart) portion of that body part.

What does proximal mean in PCS vascular guidelines

Closest to the heart.

B4.2

Where a specific branch of a body part does not have its own body part value, code to the closest proximal branch that has a specific body part value. In cardiovascular body systems, if a general body part is available in the correct root operation table and coding to a proximal branch would require a different body system, use the general body part value.

B4.3

Bilateral body part values are available for a limited number of body parts. If the identical procedure is performed on contralateral body parts and a bilateral value exists, code a single procedure using the bilateral value. If no bilateral value exists, code each procedure separately.

B4.4

The coronary arteries are classified as a single body part further specified by number of arteries treated. One procedure code specifying multiple arteries is used when the same procedure is performed, including the same device and qualifier values.

B4.4 example one code

Angioplasty on two coronary arteries with a stent in each: one code, Dilation of Coronary Artery, Two Arteries, with Two Intraluminal Devices.

B4.4 example two codes

Angioplasty on two coronary arteries where one gets a stent and one does not: two codes, one for one artery with intraluminal device and one for one artery with no device.

B4.5

Procedures on tendons, ligaments, bursae, and fascia supporting a joint are coded to the body part in the respective body system that is the focus of the procedure. Procedures on the joint structures themselves are coded to the body part in the joint body systems.

B4.6

If a procedure is performed on skin, subcutaneous tissue, or fascia overlying a joint, code to the specified body part.

B4.6 shoulder

Coded to Upper Arm.

B4.6 elbow

Coded to Lower Arm.

B4.6 wrist

Coded to Lower Arm.

B4.6 hip

Coded to Upper Leg.

B4.6 knee

Coded to Lower Leg.

B4.6 ankle

Coded to Foot.

B4.7

If a body system does not contain a separate body part value for fingers, procedures on the fingers are coded to the body part value for the hand. If there is no separate value for toes, procedures on the toes are coded to the body part value for the foot.