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The fact that we now have procedural coding guidelines is the first hint that procedural coding with ICD-10 is more complex than with ICD-9. Learning these guidelines and how to apply the information is the first step to becoming proficient in ICD-10-PCS. The guidelines are intended to complement the official conventions and instructions provided within ICD-10.

ICD-10-PCS Official Guidelines for Coding and Reporting, 2015

The first section of the guidelines summarizes conventions and details the required components of a valid ICD-10-PCS code. It is here we find specific information about indexing in PCS and using the tables correctly. A critical component to using the PCS tables is that the code must be constructed with a combination of value choices within the same row of the table.

A coder cannot combine values from different rows of the same table and come up with a valid code. This section of the guidelines also assigns coders the responsibility to translate the physician documentation to the correct PCS definition. It lets the coder know that the physician does not have to document using PCS terminology; the coder can make the correlation between the clinical documentation and a defined PCS term without having to query the physician. For example, the physician is not required to document the root operation “extirpation” in an operative report in order for coder to assign extirpation as a root operation. This guideline is specific to procedural coding and cannot be applied to clinical documentation and diagnosis coding.

The bulk of the guidelines come in the second section, detailing Medical and Surgical Section guidelines. These begin by further defining terminology within the body system, letting us know that “upper” or “lower” specifies body parts located above or below the diaphragm. There are also 16 root operation-explicit instructions. These include how the coder determines if multiple procedures are being coded for the same operative episode, what to do if a procedure is discontinued, and how to code overlapping body parts, just to name a few examples.

This Medical and Surgical Section continues by providing instruction related to body parts, letting us know that the coronary arteries are classified as a single body part that is further specified by number of sites treated (not by number of arteries). This section concludes with additional approach and device guidelines, including the provision that a device is coded only if the device remains in place after the procedure is completed. 

The Obstetrics Section guidelines outline the difference between procedures performed on the products of conception versus procedures performed on the pregnant female. Procedures performed on the products of conception are coded in the Obstetrics section of ICD-10-PCS. If a procedure is performed on the pregnant female, the procedure is coded in the Medical and Surgical Section of PCS.

The last section of the ICD-10 PCS Official Guidelines for Coding and Reporting detail the selection of principal procedure.

In the event that a coder has utilized the conventions and guidelines for ICD-10 PCS and is still uncertain of code selection, here are several suggestions that we have found to be extremely helpful:

  • The ICD-10-PCS Reference Manual can be found on the Centers for Medicare & Medicaid Services (CMS) ICD-10 website.
    • This instruction manual provides examples, additional definition explanations, and assistance in understanding PCS for coders.
  • Utilize the index in PCS; although not required, sometimes a coder can strike gold and find a direct reference to the procedure or body part he or she is attempting to code.
  • Attempt to narrow down root operation options based on the type of procedure.
    • If a coder knows that a procedure involves a certain device, there are only six root operations that always involve a device to choose from (rather than all 31 root operations).
    • If procedure is a biopsy, the ICD-10-PCS guidelines state biopsy procedures are coded using root operations of excision, extraction, or drainage.
  • In certain circumstances, attempting to work backwards in PCS table can be helpful in narrowing your body part choices.
    • Not all approaches or all devices apply to all body part choices, so working backwards can eliminate some of your options.
    • For example: Table 0BH (medical/surgical, respiratory system, insertion) has a body part value for the tracheobronchial tree and also for main bronchus, upper lobe bronchus, and lower lobe bronchus; however, looking at the device character, a radioactive element is found only in the row for tracheobronchial tree, so this can assist coder in ruling out other potential body part choices if he or she is not sure if the body part should be coded as tracheobronchial tree or bronchus.
  • The body part key and device key tables are invaluable tools for coders to provide clarification; don’t forget to use those as a first reference before spending time researching other sources.
    • For example: supraclavicular nerve, use cervical plexus
    • For example: SAPIEN transcatheter aortic valve, use zooplastic tissue in heart and great vessels

ICD-10-PCS demands a completely different thought process for coding professionals than that which was demanded by ICD-9 procedural coding. Therefore, the ICD-10- PCS guidelines are available to provide direction for assigning PCS codes, allowing for consistency in code assignment throughout the country. It is imperative that as coding professionals, we take the initiative to learn and apply the guidelines appropriately.   

About the Author

Lisa Roat, RHIT, CCS, CCDS is manager of HIM Services for Nuance Healthcare.   She has more than 23 years of experience and expertise within the healthcare industry specializing in clinical documentation improvement, coding education, reimbursement methodologies and healthcare quality for hospitals.  Lisa is an American Health Information Management (AHIMA)- Approved ICD-10 CM/PCS Trainer and Ambassador.  Lisa has worked extensively with the development of ICD-10 education and services for Nuance Healthcare. 

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