beginning the journey. icd-9-cm icd-10-pcs 2 icd-9-cm has 3-4 characters all characters are...

Beginning The Journey

ICD-9-CM ICD-10-PCS

2

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

3

.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

4

THE OBJECTIVE

OR

ACTION OF THE PROCEDURE

5

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

6

Alteration Division Inspection Reposition

Bypass Drainage Map Resection

Change 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

8

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

9

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

2

Objective of the procedure 31 Root Operations

Examples of Root Operations

Bypass

Resection

Excision

Removal

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:

Liver

Kidney

Ascending Colon

Optic 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 Device

Radioactive Element

Extraluminal device

Intraluminal device

Autologous tissue substitute

Synthetic 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 Transplant

Second site for a bypass

Diagnostic 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

18

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.

19

Billroth I procedure equates to anastomosis

20