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If you are a physician, your eyes may glaze over instantaneously whenever you hear someone speak of ICD-10. Physicians, as well as most clinicians (speaking of myself), are generally not accustomed to change. Rightfully so for the last 30-plus years (and technically since 1979), hospitals have been reporting inpatient surgical procedures with Volume 3 (procedure systems) of ICD-9-CM.

Much to our dismay, however, beginning Oct. 1, 2014, ICD-9-CM will be replaced with ICD-10-PCS, a coding system that is more robust, flexible in structure, and unlike anything we have seen in the past! OK, enough of the scare tactics. It is important for all physicians to know that the implementation of ICD-10 will not change physicians’ reporting requirements for surgical services.

Now and after Oct. 1, 2014, physicians will continue to be required to report CPT/HCPCS codes identifying surgical procedures. ICD-10 will affect reporting of inpatient procedures in hospitals using ICD-10-PCS, and hospital outpatient services will continue to be reported using CPT/HCPCS codes. So if you’re a physician, practitioner, or in charge of a physician practice(s), should you stop reading this article? Not a chance – and here’s why:

Should physicians learn the ins and outs of ICD-10-PCS? Well, physicians do not need to know precisely how the system works, but the importance of operative report documentation is vital! Coders will need to translate the clinical information from the physician’s operative report into the new ICD-10-PCS system. In most cases, the process will be transparent to physicians. However, incomplete documentation will result in queries, thus delaying the billing process. Each seven-character ICD-10-PCS code reflects the objective of a given procedure (root operation). Each character has a specific meaning, and each code also indicates the body part that is the focus of the procedure, the operative approach, the device and the qualifier.

A recent audit study of documentation in operative reports revealed a lack of required documentation, specifically related to the body parts on which procedures were performed. The following summary outlines common problem areas.

What is Missing From Operative Reports?

Harvesting Saphenous Vein

ICD-10-PCS provides detailed descriptions for body parts. For example, saphenous veins are commonly used conduits for surgical revascularization of coronary arteries. During coronary artery bypass grafting, a healthy saphenous vein is grafted around the blocked portion of a coronary artery. In ICD-10-PCS, there is a choice to be made between Greater Saphenous and Lesser Saphenous. Without this piece of documentation, a coder cannot select the correct code. Even if it is obvious to the surgeon, documentation should state the exact vein that was excised or resected.


Under ICD-9-CM, a biopsy of the colon is assigned a code based on technique (open or closed). In ICD-10-PCS, all procedures of the colon, whether resection, biopsy or otherwise, are assigned a code based on the exact site. For example, was the biopsy of the ascending, descending, sigmoid or transverse colon?

Omentum (Greater or Lesser)

If the objective of the procedure involves the omentum, coders will need to know if it is the lesser or greater omentum. The omentum (peritoneal folds) has distinct anatomical locations; therefore, separate entries in the ICD-10-PCS system.

Cervix Resected

In ICD-10-PCS, a separate code is assigned for resection of the cervix. Although the cervix frequently is removed during a hysterectomy procedure, this documentation often is not found in the operative report but is reflected in the pathology report.



Challenges Ahead

ICD-10-PCS will require coding professionals to apply new definitions, guidelines and master root operations. In addition, the new coding system requires enhanced knowledge of anatomy and surgical techniques. The role of the coder is clearly defined in ICD-10-PCS Guideline A11:

“Many of the terms used to construct PCS codes are defined within the system. It is the coder’s responsibility to determine what the documentation in the medical record equates to in the PCS definition. The physician is not expected to use the terms used in PCS code descriptions, nor is the coder required to query the physician when the correlation between the documentation and the defined PCS terms is clear. Example: When the physician documents ‘partial resection,’ the coder can independently correlate ‘partial resection’ to the root operation Excision without querying the physician for clarification.”

In other words, this guideline states that use of the query process is not a proper substitute for genuine knowledge and skill when using the ICD-10-PCS system. Now would be a good time to review a selection of inpatient operative reports, to assign appropriate ICD-10-PCS codes and to determine the need for documentation improvement. This type of audit also will help coding professionals practice their new skills and evaluate knowledge gaps.

It is important to plan and coordinate a strategy for ICD-10 PCS implementation. For healthcare facilities, tackling your 10-20 most frequently performed surgical inpatient procedures first and holding a weekly coding roundtable discussion to communicate findings should be part of the plan.

The outcomes of these activities can be used to help establish a communication plan with physicians as well as to evaluate the need for coding training sessions.  Such a communication plan can include monthly articles in newsletters as well as inviting surgeons to the coding roundtables. So for all you physicians, practitioners and practice managers out there, take a deep breath, listen to your organization’s leaders, and take the time to digest and learn from the results of all documentation reviews.

There are many resources available to help pave the way to success and achieve successful ICD-10 PCS implementation!

About the Author

Maria T. Bounos, RN, MPM, CPC-H, is the Business Development Manager for Regulatory and Reimbursement software solutions for Wolters Kluwer.  Maria began her career at Wolters Kluwer as a product manager, responsible for product development, maintenance, enhancements and business development and now solely focuses on business development.  She has more than twenty years of experience in healthcare including nursing, coding, healthcare consulting, and software solutions.

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