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ICD-10-PCS. Beginning The Journey. ICD-10-PCS – Structure. ICD-9-CM. ICD-10-PCS. ICD-9-CM has 3-4 characters All characters are numeric All codes have at least 3 characters. ICD-10-PCS has 7 characters Each can be either alpha or numeric Numbers 0-9; letters A-H, J-N, P-Z - PowerPoint PPT Presentation
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Beginning The Journey
ICD-9-CM ICD-10-PCS
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ICD-9-CM has 3-4 characters
All characters are numeric
All codes have at least 3 characters
ICD-10-PCS has 7 characters
Each can be either alpha or numeric
Numbers 0-9; letters A-H, J-N, P-Z
Alpha characters are not case-sensitive
Each code must have 7 characters
ICD-10AHIMA
ICD-9-CM
ICD-10-PCS
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.XX XX XX XX11 22 44 33
XX XX XX XXXX XX XX33 EE 00 44FF 88 0011 00 HH ZZ00 77 3300 DD BB XX55 88 ZZ
ICD-10-PCS - StructureICD-10-PCS - Structure
ICD-10AHIMA
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THE OBJECTIVE
OR
ACTION OF THE PROCEDURE
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There is a specific definition for each one of these roots
ICD-10-PCS uses terminology that coders are not accustomed to seeing on a chart
The purpose of this training is to help the coder smoothly transition to the new root operation and their meanings
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Alteration Division Inspection Reposition
Bypass Drainage Map ResectionChange Excision Occlusion Restriction
Control Extirpation Reattachment Revision
Creation Extraction Release Supplement
Destruction Fragmentation Removal Transfer
Detachment Fusion Repair Transplantation
Dilation Insertion Replacement
11 22 33 44 55 66 77
Body Body SystemSystem
SectionSection Root Root OperationOperation
Body PartBody Part
ApproachApproach
DeviceDevice
QualifierQualifier
7ICD-10AHIMA
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0 - Medical and Surgical1 – Obstetrics2 – Placement3 - Administration4 – Measurement and Monitoring5 – Extracorporeal Assistance and Performance6 – Extracorporeal Therapies7 – Osteopathic8 – Other Procedures9 – ChiropracticB – ImagingC – Nuclear MedicineD – Radiation OncologyF – Physical Rehabilitation and Diagnostic AudiologyG – Mental HealthH – Substance Abuse Treatment
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Largest of the 16 sections Same definition or meaning Section B–D and F-H comprise the
Ancillary section of ICD-10-PCS
General physiological system or anatomical region involved
Body System Value
Central Nervous 0
Peripheral Nervous 1
Heart and Great Vessels
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Objective of the procedure 31 Root Operations
Examples of Root OperationsBypassResectionExcisionRemoval
Defines the body part or specific anatomical site where the procedure was performed
This is different from character 2 which provides the general Body System
There are 34 possible body part values in each body system
Examples of Body Parts are:LiverKidneyAscending ColonOptic Nerve
Defines the approach, or the technique used to reach the procedure site
There are seven different approach values in the Medical and Surgical sectionThrough Skin or mucous membrane
Through an orifice
External
Open Natural or Artificial Opening
Percutaneous Natural or Artificial Opening Endoscopic
Percutaneous Endoscopic
Natural or Artificial Opening with Percutaneous Endoscopic Assistance
Identified devices that remain after the procedure is completed
Remember that all codes require seven characters
The default value to indicate that NO device was involved is ZExamples of Device Values
Drainage DeviceRadioactive ElementExtraluminal deviceIntraluminal deviceAutologous tissue substituteSynthetic substitute
Qualifier for the code that provides additional information about a specific attribute of the procedure
These qualifiers may have a narrow application, to a specific root operation, body system or body part
Most procedures will not have an applicable qualifier. The default value for NO qualifier is a ZExamples of Qualifiers
Type of TransplantSecond site for a bypassDiagnostic excision (biopsy)
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0LB50ZZ Excision of right lower arm and wrist tendon, open” 0 = Section – Medical and Surgical
L = Body Section - Tendons B = Root Operation- Excision 5 = Body Part – Lower arm and wrist
tendon, right 0 = Approach - Open Z = Device – No Device Z = Qualifier – No Qualifier
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It is the coder’s responsibility to determine which root operation the documentation in the medical record equates to in the PCS definitions
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The physician is not expected to use the root terms provided in PCS code description
Nor Is the coder required to query the
physicians when the correlation between the documentation and the defined PCS term is clear.
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Billroth I procedure equates to anastomosis
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