How Deep Do You Dig into ICD-10-PCS Coding?

By Karen Kostick, RHIT, CCS, CCS-P, and Gina Sanvik, RHIA

All coding professionals require the right clinical documentation at the right time in order to assign an accurate code. This article reviews just what that requirement entails for ICD-10-PCS coding.

ICD-10-PCS Scope of Work

On October 1, 2015, hospital inpatient procedures will be reported using the International Classification of Diseases Tenth Revision Procedure Coding System (ICD-10-PCS). The 2015 Draft ICD-10-PCS code set contains 71,924 procedure codes, compared to the 3,883 ICD-9-CM Volume 3 procedure codes.

Since almost all hospital inpatient admissions include procedures, the facility-specific ICD-10-PCS procedure requirements define which of the 71,924 procedure codes will be reported by the coding professional. Defining the facility-specific inpatient procedure scope of work indicates which of the ICD-10-PCS system sections (i.e., Medical and Surgical, Obstetrics, Administration, etc.) will be applied to report procedures.

The ICD-10-PCS coding system was developed to collect data, determine payment, and support the electronic health record for all inpatient procedures performed in the United States. One of the sources that hospital inpatient facilities use to define the facility-specific ICD-10-PCS procedure requirements is the Uniform Hospital Discharge Data Set (UHDDS) reporting criteria. The UHDDS guidelines are used by hospitals to report inpatient data elements in a standardized manner. The UHDDS guidelines state all significant procedures are to be reported and a significant procedure is defined as one that is:

1. Surgical in nature, or
2. Carries a procedural risk, or
3. Carries an anesthetic risk, or
4. Requires specialized training

It is important to note that the UHDDS is a minimum common core of data on individual hospital discharges and is not intended to serve the entire facility-specific inpatient procedural coded data requirement needs. Any additional ICD-10-PCS procedure coding requirements beyond the hospital inpatient UHDDS requirements are to be defined within facility health information management (HIM) coding compliance programs and facility-specific inpatient procedure coding policies.

Figure 1: ICD-10-PCS Character Code Structure

ICD-10-PCS Document Types

Although no federal requirements define the specific health record document types that must be present at the time of coding, the Office of Inspector General’s (OIG) Compliance Program Guidance for Hospitals indicates that “the documentation necessary for accurate code assignment should be available to coding staff.”¹

Within the hospital inpatient setting, facility HIM coding compliance plans support this OIG guidance through defining a core set of hospital inpatient procedure document types for ICD-10-PCS coding.

Also, based on ICD-10-PCS specificity and the facility provider’s procedure documentation practices, it may be necessary to review two procedure document types in order to assign an ICD-10-PCS code. For example, ICD-10-PCS codes to report the placement of a peripherally inserted central catheter (PICC line) infusion device specify where the inserted catheter resides.

The American Hospital Association’s (AHA’s) Coding Clinic indicates when the provider’s operative note documentation does not specify the end placement of the infusion device, the imaging report may be used to identify the required body part for the ICD-10-PCS code assignment. This scenario illustrates how the use of two procedure document types provide all the required documentation necessary for the accurate ICD-10-PCS code assignment and emphasizes the need for facilities to define all the appropriate procedure document types for ICD-10-PCS coding.

ICD-10-PCS Document Data Elements

In ICD-10-PCS, procedure codes consist of a seven character code structure, with each character code including specific values. ICD-10-PCS coding is applied at the procedure document type level where a code is assigned based on specific values for each of the seven characters (see Figure 1 above).

The coder should be guided by the procedure document report information. This information will drive the code assignment. For the coding professional, the depth of the ICD-10-PCS coding system is in the selection of the character code values for each of the seven characters, which is governed by the ICD-10-PCS system conventions, ICD-10-PCS coding guidelines, facility-specific procedure coding policies, and official advice from the AHA Coding Clinic for ICD-10-CM and ICD-10-PCS.

The following ICD-10-PCS coding example illustrates how one hospital inpatient primary procedure may include multiple ICD-10-PCS codes and require applying multiple ICD-10-PCS character code level governing rules and official guidance for code assignment.

ICD-10-PCS Coding Example

The procedure performed for the purposes of this example is an attempted percutaneous robotic-assisted laparoscopic total hysterectomy, converted to an open total abdominal hysterectomy.

The ICD-10-PCS code assignment for this example is:

• 0UT90ZZ, Resection of uterus, open approach (for the hysterectomy)
• 0UTC0ZZ, Resection of cervix, open approach (for removal of the cervix)
• 0UJD4ZZ, Inspection of uterus and cervix, percutaneous endoscopic approach (for the attempted laparoscopic hysterectomy)
• 8E0W4CZ, Robotic assisted procedure of trunk region, percutaneous endoscopic approach (for the attempted robotic-assisted surgery)

ICD-10-PCS codes 0UT90ZZ and 0UTC0ZZ are assigned based on the following Character 3 root operation coding guidelines and advice for this procedure: Medical and Surgical Section of the 2015 ICD-10-PCS Official Guidelines for Coding and Reporting:

• Multiple procedures B3.2a: During the same operative episode, multiple procedures are coded if the same root operation is performed on different body parts as defined by distinct values of the body part character. Example: Diagnostic excision of liver and pancreas are coded separately.
• Excision vs. Resection B3.8: ICD-10-PCS contains specific body parts for anatomical subdivisions of a body part, such as lobes of the lungs or liver and regions of the intestine. Resection of the specific body part is coded whenever all of the body part is cut out or off, rather than coding Excision of a less specific body part.
• AHA Coding Clinic for ICD-10-PCS, Third Quarter 2013 states that in ICD-10-PCS, when coding for a total (open) hysterectomy, two codes are reported to specify the resection of the uterus and the cervix. A total hysterectomy includes the removal of both the uterus and cervix.

ICD-10-PCS codes 0UJD4ZZ and 8E0W4CZ are assigned based on the following Character 5 root operation coding guidelines and advice for this procedure:

• Medical and Surgical Section of the 2015 ICD-10-PCS Official Guidelines for Coding and Reporting:
• Multiple procedures B3.2d: During the same operative episode, multiple procedures are coded if the intended root operation is attempted using one approach, but is converted to a different approach. Example: Laparoscopic cholecystectomy converted to an open cholecystectomy is coded as percutaneous endoscopic Inspection and open Resection.
• AHA Coding Clinic for ICD-10-PCS, First Quarter 2015 states: For an attempted robotic assisted laparoscopic hysterectomy, the AHA Coding Clinic emphasizes the need to apply the ICD-10-PCS guideline B3.2d when the intended root operation is attempted using one approach, but is converted to a different approach, the procedure(s) in the operative episode are coded to the approach ultimately used, and an Inspection procedure is coded using the approach value of the attempted approach.

Note

¹ Office of Inspector General. “Publication of the OIG Compliance Program Guidance for Hospitals.” Federal Register 63, no. 35 (February 23, 1998): 8,991. https://oig.hhs.gov/authorities/docs/cpghosp.pdf.

References

American Hospital Association. AHA Coding Clinic. Third quarter, 2014: 5-6.

American Hospital Association. AHA Coding Clinic for ICD-9-CM. July/August 1985: 3-8.

American Hospital Association. AHA Coding Clinic for ICD-10-PCS. First quarter, 2015: 33-34.

American Hospital Association. AHA Coding Clinic for ICD-10-PCS. Third quarter, 2013: 28.

Cassidy, Bonnie. “Defining the Core Clinical Documentation Set for Coding Compliance.” AHIMA Thought Leadership Series, 2012.

Centers for Medicare and Medicaid Services. “2015 Code Tables and Index.” 2015. www.cms.gov/Medicare/Coding/ICD10/2015-ICD-10-PCS-and-GEMs.html.

Centers for Medicare and Medicaid Services. “2015 ICD-10-PCS Reference Manual.” 2015. www.cms.gov/Medicare/Coding/ICD10/2015-ICD-10-PCS-and-GEMs.html.

Centers for Medicare and Medicaid Services. “ICD-10-PCS Official Guidelines for Coding and Reporting 2015.” 2015. www.cms.gov/Medicare/Coding/ICD10/2015-ICD-10-PCS-and-GEMs.html.

“The Uniform Hospital Discharge Data Set (UHDDS) Reporting of Inpatient Data Elements.” Federal Register 50, no. 147. July 1985.

Karen Kostick (Karen.Kostick@nuance.com) is senior technical business analyst, CLU and CAC content, and Gina Sanvik (Gina.Sanvik@nuance.com) is manager, CLU and CAC content, at Nuance Communications, Inc.