Take the Right Approach to ICD-10-PCS Coding
Don’t let procedural coding intimidate you; it may turn out to be your preferred code set.
I admit it: I was very intimidated at the thought of using a procedural coding system (PCS), at first. Prior to Oct. 1, 2015, I coded inpatient procedures using ICD-9-CM Volume 3 codes, which were three to four numeric characters. Then, ICD-10-PCS was implemented, and I was faced with a code set using seven alphanumeric characters. The new code set seemed very difficult and confusing, and I didn’t think I’d ever get used to it. Two years later, I prefer PCS coding to both ICD-9-CM Volume 3 and CPT® coding. The key is to understand the approach.
Get More Specific
There are a few reasons why I prefer PCS coding. One is because CPT® codes are rarely as specific as PCS codes: For any given procedure, CPT® generally offers one or two codes compared to the multiple codes PCS offers.
For example, as shown in Figure A, a total abdominal hysterectomy with bilateral salpingo-oopherectomy (TAHBSO) in CPT® is coded 58150 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s); which is not specific as to whether one or both ovaries and fallopian tubes were removed.
In PCS, as shown in Figure B, a TAHBSO is four codes (0UT90ZZ, 0UTC0ZZ, 0UT20ZZ, 0UT70ZZ), allowing you to specify the uterus and cervix were completely removed, as well as bilateral ovaries and bilateral fallopian tubes, and that it was an open procedure, not laparoscopic. There are different codes for when only one ovary or fallopian tube is removed, and they are also specific to laterality.
Codes Are Composed Intuitively
PCS codes are composed of seven alphanumeric characters that account for:
- Body system
- Root operation
- Body part
As shown in Figure C, each character represents an aspect of the performed procedure and helps to build a code that clearly describes it.
ICD-10-PCS codes are organized into tables, as shown in Figure D. These tables are further organized into rows that specify a valid combination of characters to comprise a complete code.
For a PCS code to be valid, it must be built from the same PCS table, with characters four through seven in the same row of the table. You cannot choose one character from one row and another character from a different row. As shown in Figure E, 0JHT3VZ is a valid code and 0JHW3VZ is not.
Tip: Be careful not to mix up the number zero “0” character and the letter “O”. They are not interchangeable.
Tables Lead You to the Right Approach
Approach is the fifth character of a PCS code and is the “technique” the physician
used to reach the site of the procedure. There are seven approaches to choose. Not all
approaches are available for each procedure. As shown in Figure F, the procedure
tables note the available approach options for the given procedure, as well as the device and qualifier options.
The seven approach options available and definitions for each are:
External approach – The procedure is performed directly on the skin or mucous membrane and performed indirectly by the application of external force through the skin or mucous membrane.
Open approach – Cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure.
Percutaneous approach – Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and/or any other body layers necessary to reach the site of the procedure.
Percutaneous endoscopic approach – Entry, by puncture or minor incision, through the skin or mucous membrane and/or any other body layers necessary to reach and visualize the site of the procedure.
Natural or artificial opening endoscopic – Entry of instrumentation through a natural or artificial external opening to reach and visualize the site of the procedure.
Natural or artificial opening – Entry of the instrumentation through a natural or artificial external opening to reach the site of the procedure.
Natural or artificial opening endoscopic with percutaneous endoscopic assistance – Entry of instrumentation through a natural or artificial external opening and entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to aid in performing a procedure.
Less Need to Query
Sometimes it’s a challenge to determine which approach is used for a procedure. The physician doesn’t have to change their documentation verbiage to specifically say open, percutaneous, endoscopic, etc.
It’s appropriate for you to determine what PCS definition equates to the documentation in the medical record. It’s not necessary to query the provider when the correlation between the documentation and the defined PCS term is clear (per coding guidelines).
Example: When the physician documents “partial resection,” you can independently correlate “partial resection” to the root operation “excision” without asking the physician for clarification.
Be sure to follow guidelines for multiple procedures. During the same operative episode, multiple procedures are coded if:
A. The same root operation is performed on different body parts as defined by distinct values of the body part character.
Examples: Diagnostic excision of liver and pancreas are coded separately.
Excision of lesion in the ascending colon and excision of lesion in the transverse colon are coded separately.
B. 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.
Examples: Excision of the sartorius muscle and excision of the gracilis muscle are both included in the upper leg muscle body part value, and multiple procedures are coded.
Extraction of multiple toenails is coded separately.
C. Multiple root operations with distinct objectives are performed on the same body part.
Example: Destruction of sigmoid lesion and bypass of sigmoid colon are coded separately.
D. The intended root operation is attempted using one approach, but it’s then converted to a different approach.
Example: Laparoscopic cholecystectomy converted to an open cholecystectomy is coded as percutaneous endoscopic inspection and open resection (two PCS codes).
Look Up Codes More Easily
The simplest way to use the index in PCS is to first look up the defined root operation. From there, it’s easy to find what options are available for that procedure. If you start with the section or even the body system, it’s more difficult and takes more time.
Example: Laparoscopic cholecystectomy.
Look up the root operation Resection (the entire gallbladder is being removed). Then search for the body part, Gallbladder (0FT4). Next, determine whether the approach was laparoscopic/percutaneous endoscopic or open. There is no device or qualifier available for this procedure, so No Device (Z) and No Qualifier (Z) are the only choices.
Some encoders will let you just start with “cholecystectomy” and lead you into Excision – Cutting out or off, without replacement, a part/portion of the body part vs. Resection – Cutting out or off, without replacement, all of a body part, then Open vs. Laparoscopic. As shown in Figure G, the valid code for laparoscopic cholecystectomy is 0FT44ZZ.
The tables show you what options are available for the approach, as well as other characters (body part, device, qualifier) for a given operation (excision, resection, etc.), per the body part the surgery is performed on. For the gallbladder resection, you can see in Figure H, the options for Via Natural or Artificial Opening and Via Natural or Artificial Opening Endoscopic are grayed out, as they are not available approaches for that body part and procedure.
There is no reason to feel overwhelmed when it comes to ICD-10-PCS coding. If you familiarize yourself with the PCS coding guidelines, particularly with previous inpatient coding knowledge and pursue continued education, you’ll find assigning PCS codes easier than expected.
ICD-10-PCS code book
AHA Coding Clinic for ICD-10-PCS, first quarter 2015